Providing a localised cervical cancer screening course for general practice nurses

Introduction

The World Health Organization’s 2020 call for countries to eliminate cervical cancer as a public health problem has resulted in multiple joint efforts in Australia, such as the national cervical screening program, national school-based HPV vaccination program and advertising campaigns. To aid in promotion, conversations by GPs or general practice nurses (GPNs) are needed to discuss the importance of screening and organising service delivery. In Australia, the Cervical Screening Test (CST), as part of the national cervical screening program, is essential for detecting precancerous changes among women or persons with a cervix aged between 25 and 74 (Department of Health and Aged Care (DHAC) 2024). GPNs are well placed due to their accessibility in primary health care, when provided with additional training and autonomy to undertake CSTs and support the objectives of the national screening program (Merrick 2013; Holmes et al. 2014). This forum paper explores the benefits of providing local training programs to enable nurses working in regional and remote general practices in Australia to become cervical screening providers to avoid travelling long distances for training.

Barriers to screening

Despite the reduction in mortality (due to the success in the detection and early treatment of disease), many barriers still exist to the uptake of cervical screening among the broader population (Cancer Council of Victoria, n.d.). Within Australia, some of the barriers include a lack of culturally appropriate service provision, difficulties gaining appointments or physical access, poor health literacy, emotional difficulties due to sexual trauma and socio-economic disadvantage (Department of Health and Aged Care (DHAC) 2022a). In addition, many women feel exposed and embarrassed when having this test and prefer it to be provided by a female health professional (Chorley et al. 2017; Ferdous et al. 2018; King and Busolo 2022; New South Wales Government 2022). As Australian society comprises many multicultural groups, including ethnic minorities, discussions around barriers to cervical screening reported in international studies (Marlow et al. 2015; Ferdous et al. 2018) are also often reflected in the Australian context. These additional barriers include a lack of awareness of the disease and terminology or the need for testing, as well as fear, embarrassment and shame (Marlow et al. 2015). For other ethnic groups, strong cultural and religious beliefs around sexual promiscuity as the cause for cervical cancer and the topic being taboo prevent a conversation around CSTs even being undertaken with a health professional (Ferdous et al. 2018).

In remote and very remote areas of Australia, under-screening rates are higher than in metropolitan areas resulting in higher rates of cervical cancer (Department of Health and Aged Care (DHAC) 2022a). In these areas, Aboriginal and Torres Strait Islander peoples make up 16% and 45% of the population (Australian Institute of Health and Welfare (AIHW) 2014), and these women have additional barriers to screening due to lack of services, mistrust of health care, poor health literacy and a lack of culturally appropriate care (Butler et al. 2022; DHAC 2022a). In fact, Aboriginal and Torres Strait Islander women have double the risk of a cervical cancer diagnosis and an almost quadruple risk of death due to cervical cancer compared to the general population (Butler et al. 2022; National Cancer Screening Register 2022).

In rural and remote areas of Australia, GPs are often transient, resulting in the community being unable to foster long-term trusted relationships with their health provider (Mills et al. 2012; Gippsland Primary Health Network (GPHN) 2021), which may also be a factor in low screening rates. Government initiatives to reduce the health workforce shortage in remote and very remote areas of Australia have had limited success, with full-time equivalent (FTE) medical practitioners (GPs) per 100,000 population ranging between 292 in inner regional areas to 264 in very remote areas, compared to the major cities being 437 FTE GPs per 100,000 population (Australian Medical Association (AMA) 2017; Australian Institute of Health and Welfare (AIHW) 2022a). The regional and rural areas of Gippsland, Victoria also show a disparity when compared to the whole of Victoria, as the GP FTE per 100,000 population in Victoria was 454 compared to Gippsland at 287, which is greater than a 25% lower rate of provision (GPHN 2021). Additionally, across Gippsland, which is predominantly classed as rural and remote (modified Monash model (MMM) 5 and 6), female GPs equated to 41.4% of the GP FTE provision (GPHN 2021), while in small rural towns (MMM5), remote (MMM6) and very remote communities (MMM7) the female GP FTE is 39.8%, 43.8% and 42.5% respectively (DHAC 2023a). This ratio per 100,000 population is much higher for FTE nurses and midwives compared to FTE GPs in remote (1187 compared to 309) and very remote areas (1202 compared to 223) (AIHW 2022a). Yet despite the high number of nurses in very remote areas, screening participation rates are the lowest compared to the other areas (AIHW 2022b) for reasons mentioned earlier. With the introduction of self-collection by the Australian Government in 2022 (DHAC 2022b), these figures may improve as the population becomes aware and comfortable with this new screening process and cultural and language barriers are addressed. Nevertheless, not all women may choose or be mentally or physically able to self-collect. Additionally, each woman still needs to have the test ordered by a GP or GPN, receive education on the self-screening procedure and be subsequently followed up (Zammit et al. 2023).

Benefits of GPNs conducting CSTs

Rennie et al. (2015) reported that 80% of doctors performed CSTs in Australia, whereas in the United Kingdom, female nurses conducted between 70 and 85% of tests, indicating an under-utilised resource in Australia (Holmes et al 2014). Considering women prefer female health professionals (GPs or GPNs) to perform sensitive screening tests (Chorley et al. 2017; Ferdous et al. 2018; King and Busolo 2022) and that female GPs in rural, remote and very remote areas of Australia equate to 39.8%, 43.8% and 42.5% respectively (DHAC 2023a), more female GPNs need to be trained to perform CSTs to reduce the levels of under-screening and impact the incidence of cervical cancer in Australia.

Pursuant to the Australian Primary Health Care Nurses Association’s (APNA) 2020 Workforce Survey, ‘52% of respondents expressed that they would like to undertake more complex clinical activities or extend their role in the workplace. Relating this data to sexual and reproductive health, approximately 26% of nurses surveyed indicated that they are trained in or are in the process of undertaking training in women’s health’ (Millard 2021, para. 21). These figures highlight an untapped potential for practice nurses to perform CSTs and at the same time address other issues around sexual and reproductive health (Mills et al. 2012; Holmes et al 2014; Millard 2021). As GPNs are known and trained to practice patient-centred care, collaborate with other team members and deliver care based on the latest evidence (Millard 2021) they are ideally placed to deliver quality women’s health care within general practice.

This is confirmed by Knapp (2020), who reported that CSTs conducted by female GPNs can improve access to care due to female delivery of care, which can reduce the power ratio and accommodate a greater time slot for appointments. In addition, GPNs undertaking CSTs and other women’s health appointments reduce a doctor’s workload, which may reduce doctor burnout (Knapp 2020). Despite the positive benefits to practice, personal work satisfaction of GPNs and community care service delivery, less than half of the GPNs who sought to increase their skill set in their general practice workplace felt supported to do so, according to an APNA workforce survey conducted in 2015 (Halcomb and Ashley 2017; Knapp 2020). Similar findings were presented by Birks et al. (2019), who also found over 88% of surveyed Australian nurses believed that seeking to expand their scope of practice was motivated by professional satisfaction and meeting the needs of patients. Yet one of the greatest barriers to expanding their scope of practice was not being recognised financially for their increase in skill. Some of these barriers may be addressed through the Practice Nurse Incentive Program delivered within the Stronger Rural Health Strategy (DHAC 2023b). This incentive is designed to support the cost of employing nurses, especially in rural and remote areas of Australia, remove the duplication of services and improve teamwork and access to care (DHAC 2023c). Additionally, it provides funding for GPNs to allow them to expand their scope of practice covering a broad range of services, not just women’s health.

Providing a local CST course for GPNs

An example of a regional area in Australia that has a low cervical screening rate is Gippsland, Victoria (GPHN 2021). As a result of the recommendations by the Hazelwood Mine Fire Inquiry Board in the Hazelwood Mine Fire Inquiry: Victorian Government Implementation Plan (2016) (State Government of Victoria 2023), the Victorian Government tasked the Gippsland Primary Health Network (GPHN) with implementing activities related to deliverables 69–77 of the Plan. One of the project’s objectives was to improve the health of the Latrobe community, with cervical cancer screening listed as one of the priorities. An increase in the number of GPNs certified to conduct CSTs was required to achieve this objective, which may also help reduce the impact of a somewhat transient medical workforce in the region. Gippsland is a large geographical area encompassing approximately 41,500 km². In order to undertake training and placements to become certified cervical screeners, GPNs working in outer regional and remote areas needed to drive up to 6 h to Melbourne and incur additional costs for accommodation, fuel and food, unless paid for by their employer.

The GPHN commissioned Family Planning Victoria (FPV) to deliver a training course in Gippsland, fully subsidised by the project which was the first of its kind in Gippsland. Two courses were offered as a pilot to registered nurses in 2019 and 2021.The objectives of the project were to build the capacity of GPNs who could perform cervical screening to increase participation in the program by women who were under-screened or marginalised. To gain certification, the registered nurses needed 100% attendance at the initial training, completion of online learning modules and assessment, performance of a minimum of five unassisted cervical screenings through clinical placements under the supervision of a FPV approved preceptor and completion of a final assessment.

Fifteen registered nurses from the Gippsland region attended the initial 3-day training course which was held face to face in November 2019 and had a period of 6-months to complete their placements. Unfortunately, due to the outbreak of the COVID-19 pandemic in 2020, many of the nurses experienced difficulty securing placements and completing the course requirements. From this cohort four registered nurses became certified to conduct CSTs by December 2020. By November 2022, a second cohort had completed the initial training and theory component. The training model organised through the local Primary Health Network was deemed very successful by FPV and the nurses who attended, and it was suggested by FPV that the course could be replicated in other regional or remote areas of Australia to enable GPNs to upskill. As GPNs need to maintain a minimum of 20 h per annum of continual professional development to maintain currency, training programs such as the one described would be beneficial to reduce time away from the practice and the cost of travelling to metropolitan areas (DHAC 2022c; Nursing and Midwifery Board of Australia (NMBA) 2022).

Conclusion

To increase participation rates in CSTs and due to the success of the training program, the model of providing a local CST course for GPNs could be replicated in other rural and regional areas of Australia to increase the nursing workforce’s ability to provide CSTs. This would be beneficial as female GPNs providing CSTs help reduce some of the physical, cultural and psychological barriers to screening, resulting in reduced rates of late cervical cancer diagnoses, especially in areas where there are GP shortages. Improving remuneration for the work that practice nurses undertake is needed, which the Australian Government’s Practice Nurse Incentive Program hopes to address.