Running head: COLONOSCOPY SCREENING

Clinical Question Paper

Kimberly McPike
Ferris State University
Abstract
As cancer prevention continues to play a vital role in promoting a healthy lifestyle, it is
important that the recommendations for cancer screening are promoted between people in the
community including: the indigent, uninsured, elderly, and disabled.
Colorectal Cancer is the third leading cause of deaths in men and women even though it is
preventable and treatable. Nurses serve as advocates to increase the awareness of the need for
prevention and screening through the knowledge of current evidence-based research. The
purpose of this literature review is to promote community awareness of the need for colorectal
cancer prevention and screening. A clinical question was developed and three peer reviewed
research articles were critiqued and analyzed to address the methods to promote and prevent
colorectal cancer. The results from the literature research suggest that educational workshops
were found to be successful in increasing awareness of colorectal cancer through healthy
lifestyle changes and adhering to the screening guidelines.

COLONOSCOPY SCREENING

2
Clinical Question Paper

Nursing is a profession that provides services to individuals, families, and communities in

attaining and maintaining optimal health and quality of life. Nursing care incorporates evidencebased practice that supports and guides nurses in making clinical decisions based on the health
care preferences of their patients by using the best research available (Nieswiadomy, 2012).
Colorectal cancer (CRC) is the third leading cause of deaths in men and women and accounts for
9% of cancer deaths (Nieswiadomy, 2012). The morbidity and mortality rate of this cancer can
be reduced, prevented, and treated with early intervention such as healthy lifestyle changes and
routine colonoscopy screening (Causey and Greenwald, 2011). The purpose of this paper is to
advocate nurses to increase the awareness of the need for prevention and screening of CRC to the
community through the knowledge of current evidence-based research.
Clinical Question
Preventative medicine is practiced to detect and treat possible diseases and cancers. The
advanced technology of today allows effective screening methods to be performed that assists
with health maintenance and cancer prevention. Colorectal cancer is one of the most common
and preventable cancer deaths that affect men and women (Causey and Greenwald, 2011). The
cancer can begin anywhere in the colon and starts with polyps which are mushroom-like growths
that are small and slow growing on the inner surface of the colon (Baxter et al, 2009). If the
polyps are not removed mutations in the genes grow and invade the colon thus causing CRC.
Experts recommend that inspecting the entire colon through a flexible tube (colonoscopy) is the
most accurate effective screening method, however , the process continues to be the most
inconvenient, expensive, and riskiest test to detect CRC (Baxter et. al, 2009). It is also
recommended that CRC screening begin at the age of 50 for average-risk adults who have no

COLONOSCOPY SCREENING
family or personal history of precancerous polyps (adenomas) or CRC, inflammatory bowel

disease, or high-risk genetic syndromes (Causey & Greenwald, 2011).

A clinical question was formed based on the evidence of nursing practice where an
increased rate of CRC diagnosis was noted due to the lack of knowledge and financial means in
individuals. A clinical issue was identified in finding methods to increase awareness of the need
for CRC prevention and screening. A clinical question can be formed by using a format that was
developed by Fineout-Overholt and Johnson. The acronym stands for (P) patient or population,
(I) intervention or interest area, (C) comparison intervention or current practice, (O) outcome(s)
desired, (T) time to achieve outcome (optional) (Nieswiadomy, 2013). The PICOT question that
was formed in answering the clinical issue is: Does community nursing education of the
importance of colonoscopy screening every five years versus screening every ten years in the
patient with a family history of colon cancer improve early detection of colon cancer?
The answer to this PICOT question can help to promote community awareness of the
need for CRC prevention and screening. There are millions of Americans who lack insurance
and are unable to receive preventative care but thanks to the Affordable Care Act this will enable
them to receive medical services and screenings. Nurses can be an advocate in the community
by raising awareness which will help to improve patient quality and safety that will aid in
promoting a healthy lifestyle.
Methodology
The methodology used to search for evidence to answer the PICOT question was via the
Ferris State University library home page. Three databases were searched using the Health and
Medical Resources that consisted of PubMed which generated ten results, the Cumulative Index
of Nursing and Allied Health Literature (CINAHL) which generated two results, and the

COLONOSCOPY SCREENING
Cochrane Database of Systematic Reviews which generated no results. The Agency for

Healthcare Research and Quality (AHRQ) data base generated twelve results but only 50% was
related to the clinical question. Search keywords that were used from the clinical question
included: colorectal cancer, colonoscopy, colorectal cancer screening, colon cancer, and
colonoscopy surveillance.
Nursing research adds to the unique body of knowledge that helps to build a scientific
foundation for the nursing profession. Nursing research ensures credibility of the nursing
profession and therefore is conducted by nurses. It provides accountability and promotes
evidence-based nursing practice in maintaining and providing safe and quality care to patients.
It is important for nurses to be aware of the levels of evidence which helps to identify the
strength of the evidence that is being presented. A level of evidence is a leveling or grading
system tool that is used to assist practitioners with reviewing the best evidence to guide their
clinical practice (Armola et al, 2009). The American Association of Critical Care Nurses
(AACN) developed a hierarchy system to grade the levels of evidence. The six levels begin with
A which is the highest with meta-analysis of qualitative studies and the lowest level M which is
manufactures recommendations only (Armola et al, 2009). The Quality and Safety in Nursing
(QSEN) also has a level of evidence that can be utilized to identify the strength of evidence from
the nursing search.
Discussion of Literature
Article One
The first article in this review is a peer reviewed nursing research article from a specialty
nursing journal that is authored by nurses and is specific to the nursing profession (Causey &
Greenwald, 2011). The impact factor for this journal is 0.469 (Baker, 2014). The study was

COLONOSCOPY SCREENING
ethically approved by the institutional review board (Causey & Greenwald, 2011). This is an

AACN Level B evidence article because it is from a well-designed case control study (Armola et
al, 2009). The purpose of the study was clearly identified to evaluate the effectiveness of a
health belief model (HBM)-based colorectal cancer (CRC) education session to increase
awareness of the need for CRC prevention and screening and to promote such discussions
between the participants and their doctors (Causey & Greenwald, 2011, p. 36).
This study was a convenient sample that consisted of 38 participants who attended
three 1-hour educational sessions on CRC prevention (Causey & Greenwald, 2011). The data
analysis was a composite means of the calculated Likert scores from the HBM survey. The
results revealed 31 of the participants were of screening age and only 23 had been advised by
their physicians to be screened for CRC. Bias was an internal threat to validity because some of
the participants in both studies knew the researchers (Causey & Greenwald, 2011).
Article Two
The second article in this review is a peer reviewed research article from a general
medical journal that is authored by physicians and is borrowed knowledge to the nursing
profession (Baxter, et al, 2009). The impact factor for this journal is 14 (Annals of Internal
Medicine, 2014). The study was ethically approved by the research ethics board of St. Michaels
Hospital, Toronto, Ontario, Canada (Baxter et al, 2009). This is an AACN Level B evidence
article because it is from a well-designed population-based, case control study, both randomized
and nonrandomized (Armola et al, 2009).
The purpose of the study was clearly identified to evaluate the association between colonoscopy
and CRC deaths (Baxter et al, 2009, p. 1).

COLONOSCOPY SCREENING
6
The study consisted of people age 52 to 90 years from the Ontario Cancer Registry who
received a CRC diagnosis from January 1996 to 2001 and died of CRC by December 2003. Data
analysis was performed using a conditional logistic regression and a Sensitivity analysis to
evaluate the association between colonoscopy and CRC deaths. The results revealed that
colonoscopy is associated with lower CRC mortality rates. Bias was an internal threat to validity
because the researchers could not detect exposure to colonoscopy before 1991 (Baxter et al,
2009).
Article Three
The third article in this review is a peer reviewed research article from a gastroenterology
journal that is authored by physicians and is borrowed knowledge to the nursing profession
(Manser et al, 2012). The impact factor for this journal is 5.210 (Eisen, 2014). The study was
ethically approved by the Institutional Ethic Committee of central Switzerland in Lucerne
(Manser et al, 2012). This is an AACN Level B evidence article because it is from a welldesigned population-based, closed cohort study (Armola et. al, 2009). The purpose of the study
was clearly identified to compare the incidence of and mortality from CRC among individuals
screened by colonoscopy and non-screened individuals (Baxter et al, 2009, p. 1).
The study involved 1912 screened and 20,744 control participants in a precisely defined
area with a low level of population migration. Data analysis was performed between the two
groups by using parametric or nonparametric methods and a P value of < 5% was considered
significant. The results revealed that the overall cancer incidence was significantly lower in the
screened group compared with the non-screened group. Bias was an internal threat to validity
because of the ethnicity and number of the participants, a non-randomized study (Baxter et al,
2009).

COLONOSCOPY SCREENING

7
Significance to Nursing

The evidence findings from the clinical question can be integrated into nursing practice to
improve quality and safety of the indigent, uninsured, elderly, and disabled populations. Health
professionals such as nurses need to be able to identify the competencies necessary to improve
the quality and safety of the health care systems in which they work. Nurses have the duty to
describe what constitutes good care, identify gaps among good and local care in their practices,
and close any gaps by knowing what activities they could initiate (Cronenwett et al, 2007).
QSEN competencies for nursing prepare graduates to be educated and competent in delivering
patient-centered care as an interdisciplinary team member with emphasis on evidence-based
practice (Cronenwett et al, 2007).
Nurses are bound to Standards of Professional Practices and the Standards of Professional
Performance that are developed by the American Nurses Association (ANA). The Standards of
Professional Practices represents a competent level of nursing care demonstrated through the
nursing process which represents a competent level of behavior in the professional nursing role
and the Standards of Professional Performance which represents a competent level of behavior in
the professional nursing role (ANA, 2010). Standard 9 and 10 supports the integration of
evidence and research findings into practice as the nurse participates in quality improvement
through activities such as: using indicators to monitor quality, safety, and effectiveness of nursing
practice, and collecting data to monitor quality, safety, and effectiveness of nursing practice
(ANA, 2010).
Colorectal Cancer is the third leading cause of deaths in men and women even though it
is preventable and treatable. The evidence findings of the literature review recommend that there
is a need to increase public awareness about new strategies and healthy lifestyles to promote

COLONOSCOPY SCREENING
primary and secondary prevention of CRC. It the responsibility of nurses and physicians to
advocate for legislation requiring coverage for tests that provide access to CRC screening and
treatment (Causey & Greenwald, 2011). The availability of insurance through the Affordable
Care Act and promoting awareness of the need for CRC prevention and screening can help to
remove major barriers by underserved populations. Nurses serve as advocates to increase the
awareness of the need for prevention and screening through the knowledge of current evidencebased research.

COLONOSCOPY SCREENING

9
References

American Nurses Association [ANA] (2010). Nursing: Scope and Standards of Practice (2nd
Ed.). Silver Spring, Maryland: Author
Annals of Internal Medicine. (2014). Retrieved from http://annals.org/public/authorsinfo.aspx
Armola, R. R., Bourgault, A. M., Halm, M. A., Board, R. M., Bucher, L., Harrington, L., &
Heafey, C. A. (2009). AACN Levels of Evidence: What's new? Critical Care
Nurse, 29(4), 70-73. doi: 10.4037/ccn2009969
Baker, K. (2014). Gastroenterology Nursing. Retrieved from
http://journals.lww.com/gastroenterologynursing/pages/default.aspx
Baxter, N. N., Goldwasser, M. A., Paszat, L. F., Saskin, R., Urbach , D. R., & Rabeneck, L.
(2009). Association of colonoscopy and death from colorectal cancer. Annals of Internal
Medicine,150(1), 1-8. doi: 10.7326/0003-4819-150-1-200901060-00306
Causey, C., & Greenwald , B. (2011). Promoting community awareness of the need for colorectal
cancer prevention and screening: A replication study. Gastroenterology Nursing, 34(1),
3440. doi: 10.1097/SGA.0b013e31820b22c5
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., & Warren, J.
(2007). Quality and Safety Education for Nurses. Nursing Outlook, 55(3), 122-131.
http://dx.doi.org/10.1016/j.outlook.2007.02.006
Eisen, G. (2013). Gastrointestinal Endoscopy. Retrieved from
http://www.journals.elsevier.com/gastrointestinal-endoscopy

Manser , C. N., Bachmann L.M., , L. M., Brunner , J., Hunold , F., Bauerfeind , P., & Marbet , U.
A. (2012). Colonoscopy screening markedly reduces the occurrence of colon carcinomas

COLONOSCOPY SCREENING
10
and carcinoma-related death: A closed cohort study .Gastrointestinal Endoscopy, 76(1),
110-117. doi: http://dx.doi.org/10.1016/j.gie.2012.02.040
Nieswiadomy, R. M. (2012). Foundations of Nursing Research (6th ed). Upper Saddle River,
New Jersey: Pearson Education.