Running head: SURVEY OF NURSE PRACTITIONER
Survey of Nurse Practitioner Provider Knowledge, Barriers, and Current Practice in
Referring High Risk Patients for Colorectal Cancer Screenings
Lecia Reardon, MSN, RN, FNP-BC
East Carolina University
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SURVEY OF NURSE PRACTITIONER KNOWLEDGE
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Survey of Nurse Practitioner Provider Knowledge, Barriers, and Current Practice
in Referring High Risk Patients for Colorectal Cancer Screenings
by
Lecia Reardon
APPROVED BY:
CHAIR OF
DNP SCHOLARLY PROJECT:______________________________________________
(Candace Harrington, DNP, APRN, AGPCNP-BC, ANP-C)
COMMITTEE MEMBER: __________________________________________________
(Carol Ann King, (DNP, FNP-BC, APRN)
COMMITTEE MEMBER: _________________________________________________
(Christopher Chad Kornegay, MD)
DIRECTOR OF THE DEPARTMENT
OF (DOCTOR OF NURSING PRACTICE): ____________________________________
(Bobby Lowery, PhD, MN, FNP
CC:
DNP Scholarly Project Committee Chair,
Student, DNP Program Office
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
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Abstract
Problem: Colorectal cancer (CRC) is the third leading cause of cancer and the second leading
cause of cancer deaths in the United States (National Cancer Institute, 2014). Evidence supports
preventive CRC screening, however, younger individuals at high-risk are often overlooked (Levin et al.,
2008). Screening rates remain suboptimal despite these recommendations (American Cancer Society,
2013). Nurse practitioners (NP) can positively influence the incidence of high-risk screening referrals
through knowledge and application of high-risk CRC screening guidelines. This knowledge when applied
will transform high-risk CRC screenings from tertiary prevention, to primary and secondary prevention in
CRC screenings and will improve health outcomes.
Purpose: The purpose of this scholarly project was to evaluate NP knowledge of high-risk CRC
screening guidelines, perceived barriers to CRC screening, and current NP screening practice patterns to
inform decisions supporting a paradigm shift from tertiary prevention to primary and secondary
preventive screening practices for those at high risk for CRC.
Methods: A 16-question internet Qualtrics® survey was sent via email to 2155 NPs listed as
primary care clinicians by the North Carolina Board of Nursing.
Results: One hundred eighty respondents (8.3%) completed the survey, with 104 (57.5%)
respondents rating themselves knowledgeable of high-risk CRC screening guidelines. The leading
screening barriers identified were uninsured, patient refusal to do bowel prep; fear of finding cancer; and
modesty concerns. The Chi Square test for independence of aggregate practice pattern questions
demonstrated a statistically significant between self-perceived knowledge of high-risk CRC
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guidelines and actual high-risk CRC screening practices (Χ = 4.1918, df = 1, p= .04).
Conclusion: Over half (57.8 %) of the respondents reported knowledge of high-risk CRC
guidelines with statistically significant relationship in aggregate practice patterns and perceived
knowledge of guidelines. Reduction of public and clinician screening barriers using targeted interventions
may improve health outcomes.
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
Key words: “high-risk colorectal cancer screening” ‘colorectal cancer high-risk factors,”
“nurse practitioner perceived high-risk colorectal cancer screening knowledge,” and “high-risk
colorectal cancer screening barriers”
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SURVEY OF NURSE PRACTITIONER KNOWLEDGE
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Acknowledgements
“I wish to express my sincerest appreciation to the following individuals in my educational journey
and accomplishment of this scholarly project:
East Carolina University College of Nursing Faculty, for your mentorship and guidance throughout
this journey. I would not have gone to any other university because I am a pirate nurse forever. An
individual note of thanks is expressed to Dr. Martha Engelke for IRB guidance, Dr. Mel Swanson for
statistical guidance, Ms. Kerry Browder for library resource assistance, and Mr. Scott Brinkley for writing
lab direction.
Funding: Thank you to Sigma Theta Tau and Proctor and Gamble Gastroenterology NP nonrestricted scholarship funding that funded education and project expenses.
A huge thanks is expressed to my scholarly project committee members. Dr. Candace Harrington,
chair; Your numerous hours of dedicated feedback and support of my educational and professional
development is forever appreciated. To Dr. Carol “Ann” King, for your mentorship and guidance with
project funding scholarship applications. To Dr. Christopher “Chad” Kornegay, for serving as
community committee member. You are an excellent mentor and colleague in rural healthcare to the
citizens of Duplin County.
Thanks to Mrs. Tara Mclamb MSN, ANP-C for testing the survey that practices in a
Gastroenterology practice. Thanks to Eastern Carolina Cancer Coalition and Dr. Suzanne Lea for
mentorship and support during this project.
My entire family for their diligent support and faith in my ability to succeed: My best friend and
husband Floyd, thank you for your much needed support! My son Allen, I am so proud of you! My
mother Nola, always there for me. I am also sending up a posthumous thank you to my late father
Edward L. Wooten, for encouraging me to “get you a good education.”
Last but truly first I thank you my Lord and Savior Jesus Christ, because you have taken me step by
step in life. Without all of your love and support, this journey would have been for naught.”
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Table of Contents
Project approval ….……………………………………………………………………………… 2
Abstract ……………………………………………………………………………………...........3
Acknowledgements…………………………………………………………………………. ……5
Problem .........…………………………………………………………………………………….8
Purpose ……………………………………………………………………………………………9
Theoretical framework………………………………………………………………………...…10
Clinical questions………………………………………………………………….………….….11
Review of evidence ……………………………………………………………………………...11
Disease burden………………………………………………………………………..….12
Healthy People 2020…………………………………………………………………..…17
Screening guidelines ……………………………………………………………….……17
Screening barriers…………………………………………………………………….….22
Knowledge and practice patterns…………………………………………………..…….24
Methodology………………………………………………………………………………….….25
Survey Design……………………………………………………………………...…….25
Participant Protection……….……………………………………………………………26
Population……………………………….……………………………………………….26
Inclusion Criteria……………………………………………………………………….. 27
Exclusion Criteria………………………………………………………………………. 27
Reliability and validity………………………………………………………………….. 28
Data protection………………………….………………………………………………..28
Process and Outcome Objectives……………………………………………………………….. 28
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Implementation…………………………………………………………………………………. 31
Results …………………………………………………………………………………………...31
Respondent Characteristics ……………………………………………………………...31
NP Perceived High-risk CRC Screening Knowledge…………………………………... 32
Perceived Colorectal Cancer Screening Barriers……………………………………….. 33
NP Screening Practice Patterns…………………………………………………………. 34
Categorical Analysis …………………………………………………………………….36
Discussion………………………………………………………………………………………. 37
Project Strengths………………………………………………………………………... 39
Project Limitations ………………………………………………………………………40
Significance to Advanced Nursing Practice …………………………………………….40
Recommendations……………………………………………………………………………….41
Conclusion ………………………………………………………………………………………41
Dissemination Plan……………………………………………………………………………... 42
References ……………………………………………………………………………………….45
Tables…………………………………………………………………………………………….50
Appendices ………………………………………………………………………………………52
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Survey of Nurse Practitioner Provider Knowledge, Barriers, and Current Practice
in Referring High-risk Patients for Colorectal Cancer Screenings
Colorectal cancer (CRC) is a significant health problem in the United States. In 2014, the
National Cancer Institute (NCI) reported 136,830 new cases (NCI, 2014). Although average
five-year survival rates improved from 48.5 to 65% from 1975 to 2009, CRC remains the second
leading cause of cancer deaths in the United States (NCI, 2014). Education, screening, and
prevention programs have reduced morbidity and mortality in the average risk population (ACS,
2013), but younger CRC patients (less than 50 years of age at diagnosis) have increased risk of
death from CRC, especially when it has advanced to a metastatic stage (Lieu et al., 2014). Highrisk persons tend to develop CRC under the age of 50 and CRC rates have increased in this group
by 1.8% per year (NCI, 2014). These individuals need to be identified for preventive CRC
screening and much earlier than average risk individuals.
Components of successful high-risk patient CRC preventive screening outcomes include
evidenced based CRC screening guidelines, well-defined risk factors, and screening
participation. The American Cancer Society, U.S. Multi-Society Task Force on Colorectal
Cancer (USMSTF), the American College of Radiology Colon Cancer Committee, the American
Cancer Society Colorectal Cancer Advisory Group, U.S. Preventive Services Task Force
Screening for colorectal cancer (USPSTF), and the American Gastroenterological Society,
concur that colonoscopy should begin earlier for higher risk individuals, depending on personal
and familial risk factors. Further, colonoscopy screenings can identify and remove precancerous
polyps if done at the appropriate time according to identified risk factors. The Centers for
Disease Control (CDC) reported despite this knowledge, “over 22 million people are still not upto-date with colorectal cancer screening.”(CDC, 2014). The existence of evidenced based high-
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risk CRC screening guidelines, the increased CRC rates and morbidity in younger patients, and
the suboptimal CRC screening rates are key health issues that need improved clinical outcomes.
Nurse practitioners are vital partners with patients and communities in health promotion
and illness prevention. The American Association of Nurse Practitioners (AANP) reports that
75% of the 192,000 practicing NPs in the United States practice in primary care settings (AANP,
2014). Advanced practice nurses have the opportunity to positively affect the incidence of highrisk CRC screening and improve health outcomes. Nurse practitioner knowledge and clinical
application of these high-risk CRC screening guidelines is essential to improve patient outcomes.
Purpose
The purpose of this scholarly project was to evaluate NP knowledge of high-risk CRC screening
guidelines, perceived barriers to CRC screening, and current NP screening practice patterns to inform
decisions supporting a paradigm shift from tertiary prevention to primary and secondary preventive
screening practices for those at high risk for CRC.
Theoretical Framework
Interventions aimed at preventing an illness or disease in the individual or community is a
key responsibility of NP practice and is necessary to improve healthcare outcomes. Health
promotion and disease prevention approaches to healthcare consistently reduce morbidity and
mortality more effectively than a secondary care approach of diagnosis and treatment of
established or advanced disease. “Prevention”, the central concept of Betty Neuman’s systems
model, provided the theoretical foundation for this scholarly project. Conceptual definitions
applicable to the scholarly project were “high-risk colorectal cancer screening”, “colorectal
cancer high-risk factors,” “nurse practitioner perceived high-risk colorectal cancer screening
knowledge,” and “high-risk colorectal cancer screening barriers.”
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Neuman’s system model of “wellness of the client system in relation to environment[al]
stressors and reaction to stressors,” included the model paradigm of person, environment, health,
and nursing, and application of the key construct of “prevention as intervention” and were used
to define the concepts of primary, secondary, and tertiary prevention of colorectal cancer in those
with high-risk factors.
For the purposes of this scholarly project, primary prevention “protecting [the] normal
line of defense or wellness”, refers to preventive colonoscopy screenings or education to eat a
high fiber diet to promote colorectal health (Neuman, as cited in Fawcett, 2000, p. 204).
Secondary prevention “relates to symptomatology following a reaction to stressors, appropriate
ranking of intervention priorities, and treatment to reduce their noxious effects” (Neuman, as
cited in Fawcett, 2000, p. 204). The concept “secondary prevention” referred to a screening
colonoscopy or a preventive polypectomy prior to cancerous transformation. Tertiary prevention
“relates to the adjective processes taking place as reconstitution begins, and maintenance factors
move the client back in a circular manner towards primary prevention” (Neuman, in Fawcett,
2000, p.204). An example of tertiary prevention is diagnosed CRC stages one to four, (early to
advanced or metastatic disease). Tertiary prevention measures are less efficacious since
treatment of current disease is associated with higher morbidity and mortality rates and is less
amendable to cure. A change in practice trends concerning late diagnosis and tertiary prevention
of CRC can be accomplished through earlier screening based on personal and family high-risk
factors. The goal of prevention as an intervention is to maintain health and prevent CRC through
primary prevention and secondary (early diagnosis) to achieve positive health outcomes.
The author defined “high-risk colorectal cancer screening” as screening tests that
included either structural examination of the colon or indirect testing through fecal occult blood
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sampling. For clarity, structural exams are defined as direct inspection of the colon to determine
presence of either healthy tissue, precancerous polyps, or presence of cancer. Indirect testing
methods are defined as fecal occult blood sampling. “Colorectal cancer high-risk factors” were
any of the increased risk factors such as family history (including genetic issues) or personal
history factors that increase risk for CRC and warrant earlier screening according to ACS (2014)
high-risk guidelines. “Nurse practitioner perceived high-risk colorectal cancer screening
knowledge” in this project pertained to the NP’s perceived or personal belief of knowledge of the
high-risk CRC screening guidelines. “High-risk colorectal cancer screening barriers” were
defined as any social, economic, or psychological barrier that prevents a patient from obtaining a
CRC screening. These barriers can range from no insurance coverage to personal refusal to
obtain screening for any reason.
Clinical Questions
Four clinical questions based on Neuman’s Systems theory guided the project design and
outcome objectives:
1) Are NPs knowledgeable about high-risk CRC guidelines?
2) Are there any perceived or identified barriers that exist in CRC screening referrals?
3) What are NP’s current high-risk CRC screening practice patterns?
4) Is there a relationship between NPs’ CRC screening practice patterns and NPs’ selfperceived knowledge of the guidelines?
Review of Evidence
An extensive evidence review was conducted for systematic reviews, summaries, clinical
guidelines, meta-analyses, research studies, and case studies to evaluate evidence for the
scholarly project concepts of high-risk CRC screening provider knowledge, barriers to CRC
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screening and CRC clinical practice patterns. The search included but was not limited to the East
Carolina University Laupus Library’s “One Search” with detailed review of “Cochrane”,
“PubMed”, and “Cinahl” databases. Hand searches of relevant internet webpages and
professional organizational websites, including the Centers for Disease Control (CDC), National
Cancer Institute (NCI), Healthy People 2020, American Gastroenterological Society (AGS),
American Gastroenterology Association (AGA), National Cancer Institute (NCI) and the
American Cancer Society (ACS) pages were completed to identify evidenced based practice
clinical guidelines, research studies, information pertinent to high-risk colorectal cancer, and
associated search terms. Additional data were located on the North Carolina Center for Vital
Statistics and the European Cancer Congress summit web pages.
Search terms were “colorectal cancer screening,” “high-risk colorectal cancer
screening,” “barriers to colorectal cancer screening,” “provider clinical practice patterns” and
“NP practice patterns.” Searches using “North Carolina (and) barriers to colorectal cancer
screening” were used. The MeSH term search of “colorectal neoplasm” was utilized general
search of databases. Evidence was chosen and sorted by strength and type as it related to disease
burden, provider knowledge, clinical practice patterns of high-risk CRC screening guidelines,
and gaps in the literature and guidelines.
Disease Burden
This author reviewed disease burden statistical data for North Carolina and surrounding
regions in NCI, CDC, and North Carolina Center for Vital Statistics databases. For this project,
high-risk, geographical CRC data, as well as morbidity and mortality data, were reviewed and
summarized.
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Colorectal cancer rates in NC from 2007-2011 were 43.4 per 100,000 population,
[M=45.35, SD= 0.243] (N.C. Center for Vital Statistics, 2014). A review of county data showed
higher rates in rural regions and lower rates of CRC in more urban settings. Twenty-eight
counties with highest reported CRC rates (average of 50 per 100,000 population or higher rates)
were reviewed and divided into eastern, central and western regions of the state. Results were as
follows: eastern region (14 counties), highest was Granville county (63.30 per 100,000
population rate), central region (seven counties), highest was Warren County (61.60 per 100,000
population), and Western region (seven counties), highest was McDowell county (58.00 per
100,000 population). All of these counties were in rural locations. McDowell was in the
Appalachia region and among seven counties listed in this region with higher incidence of CRC
per 100,000. The eastern region had the highest overall counties (n=14) with higher than average
CRC rates with a cluster in rural northeastern NC east of I-95 highway corridor to coastal regions
southeast of Virginia. The central region also had counties with higher incidences but these
seven counties were divided into four counties along the northern border of NC and the other
three counties were on the southern region of the state. These were all rural regions with noted
urban sparing in the data. (N.C. State Center for Health Statistics, 2014). Thus, there was
geographical disparity with worse disparity in rural northeastern NC, Appalachian (western)
regions, and southern and northern portions of central NC.
Naishadam et al. (2011) compared geographical regions by states to assess state-by-state
disparities in CRC mortality patterns. Based on their findings, rates in southern states showed the
least progress in CRC mortality reduction. Particularly high CRC mortality rate reported in
portions of Appalachian regions, which still have significantly high rates of CRC compared to
other regions in the country. Although the authors failed to identify the region used to define
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“Appalachia”, this author posits this area might include western NC, northern areas of Georgia
(GA), eastern or southeastern regions of Tennessee (TN), and/or southwestern Virginia (VA). In
addition, the authors noted a decrease in CRC mortality rates with uptake (acceptance) of and use
of CRC screening (Naishadam et al., 2011). These researchers conducted a secondary data and
trend analysis for periods 1990-1994, 2004-2007, and 2005-2007. Data extracted from Add the
original source of data here were used to analyze age-standardized CRC death rates for each state
and compared CRC screening rates. The results showed a statistically significant decrease in
CRC mortality rates in all states except Mississippi between 1990-1994 and 2004-2007, with the
highest CRC mortality rates shifting from the northeastern states during this time. From 19952007, North Carolina showed an annual percentage change -2.3% (22.0 to 17.3 per 100,000, p <
0.05) and a rate ratio 0.79 [0.72-0.81], CI 95%, p < 0.05 was noted during 1995-2007
(Naishadam et al., 2011). The states that saw most significant improvements annual percentage
changes over a two to seven year period ending in 2007 were in Connecticut (-5.1%) and
Colorado (-7.8%). The researchers found an inverse and high correlation between CRC
mortality rates and uptake of CRC screening (r -0.65, P < 0.0001) (Naishadam et al., 2011).
However, it is notable that in a secondary analysis, the high correlation was somewhat attenuated
(r -.59, P < 0.0003) when percentages of rural residents were taken into consideration
(Naishadam et al., 2011). Recommendations from this study highlighted the need for wider use
of CRC screenings.
Primary prognostic factors of CRC included stage of cancer, age at diagnosis, and
presence or absence of high-risk factors. Prognosis at CRC diagnosis depended upon the stage of
cancer. Five-year survival rates of localized CRC lesions are 90%, while regional lesions,
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distant metastatic lesions, and unstaged lesions have 70%, 12.5%, and 33.6% 5-year predicted
survivals respectively (National Cancer Institute, 2014).
Interestingly, Lieu et al. (2014) reported
High-risk persons tend to develop CRC under the age of 50 and CRC rates
have increased in this group by 1.8% per year” with “striking increases among
those age 20-29 years (men, 5.2% per year; women 5.6% per year. The
youngest patients experienced 19% (95% CI, 7% to 33%) increased risk of
death and 22% (95% CI, 10% to 35%) increased risk of progression. The
oldest patients experienced 42% (95% CI, 31% to 54%) increased risk of
death and 15% (95% CI, 7% to 24%) increased risk of progression or death.
(p. 2975)
In a secondary analysis of data in the Advanced Colorectal Cancer Database (ARCAD), a
database of over 18,000 patient data points from 24 colorectal cancer trials from 2004-2011, Lieu
et al. (2014) determined age was a strong prognostic indicator in overall survival (OS) or
progression-free survival (PFS) in patients with metastatic colorectal cancer (mCRC). The
researchers noted that age was prognostic for both overall all survival (p < .001). When
compared to middle age patients, the youngest patients experienced 19% (95% CI, 7% to 33%)
increased risk of death and 22% (95% CI, 10% to 35%) increased risk of progression. These data
show that younger patients have a significantly lower survival rates when compared to older
cohorts (Lieu et al., 2014). The authors speculate that these outcomes “may reflect differences in
biology compared to older counterparts, later diagnosis due to rarity of disease and/or less
surveillance in the age group” (Lieu et al., 2014, p. 2975). Given that younger patients generally
have fewer chronic illnesses and disabilities when compared to those over the age of 50, their
findings support the necessity of re-evaluation of current healthcare practice for screening based
on CRC high-risk factors.
The evidence provides overwhelming support for early screening and surveillance for
those with certain genetic diseases, genetic syndromes, and genetically associated CRC high-risk
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factors. Multiple sources support early screening and surveillance for conditions including,
familial adenomatous polyposis (FAP), Lynch syndrome (LS), hereditary non-polyposis colon
cancer (HNPCC), and MUYTH (mutY Homolog [E. coli]) genetic mutation carrier with history
of first degree relatives with colorectal cancer (Barrow et al., 2013; Sehgal et al., 2014; and Win
et al., 2014). Systematic reviews of registration and screening of high-risk CRC persons and
expert opinion evidence follows.
Sehgal et al. (2014) performed an updated literature review of genetics and screening of
Lynch syndrome in which the authors summarized the historical screening methods with the
assertion that standardization of high-risk Lynch clinics should be established. The authors
reported that Lynch syndrome accounted for up to 5% of CRCs, with 80 % lifetime risk for CRC
and other cancers at an average age of 46 years. The authors stressed this significant public
health impact especially in regards to patient selection for timely screening. Based on their
findings, the authors recommended that patients who have a confirmed MMR gene mutation for
Lynch syndrome should undergo colonoscopy every 1–2 years beginning at the age of 20–25, or
10 years before the earliest age of onset in the family, with voiced support to standardize
institutional high-risk/hereditary CRC clinics (p.48).
Additional evidence was sought by Win et al. (2014) for more intensive screening CRC
programs for high risk persons in a population based study of 2332 individuals out of 9504
relatives from 264 CRC cases in families also with MUTYH (mutY Homolog [E. coli]) genetic
mutation carrier status to determine CRC risk. MUTYH mutation was defined as a genetic
mutation associated with development of colorectal adenomas with the authors asserting
evidence of progression to cancer. Gender specific CRC risks for those with this mutation were
7.2% for males and 5.6% for females (Win et al., 2014). Win et al. (2014) performed MUTYH
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mutation DNA testing that revealed CRC mean age at diagnosis of colorectal cancer was 47.7
years (SD 10.0 years) in one type mutation (biallelic, a subtype of mutation) and 52.0 years (SD
11.9 years) years in other type mutation (monoallelic, a subtype of mutation). Win et al. (2014)
suggested, “Risks of CRC for carriers of mutations in MUTYH with a first-degree relative with
CRC are sufficiently high to warrant more intensive screening than for the general population”
(p.1208). The authors further asserted these individuals should be screened for CRC earlier and
more aggressively to reduce morbidity and mortality related to CRC high-risk factors (Win et al.,
2014). These studies provide evidence for early identification and earlier CRC screening in
persons identified a higher CRC risk from personal or familial risk factors.
Healthy People 2020
The Healthy People 2020 (2014) objectives include initiatives to reduce CRC morbidity
and mortality by targeting at risk populations for interventions and improving CRC screenings.
These goals are as follows: (1) Increase the proportion of adults who receive a colorectal cancer
screening based on the most recent guidelines, (2) Reduce the colorectal cancer death rate (3)
Reduce invasive colorectal cancer , and (4) Increase the proportion of adults who were counseled
by their providers about colorectal cancer screening (Healthy People 2020, 2014). Healthy
People 2020 initiatives and objectives support all aspects of this project’s design and processes.
Screening Guidelines
Grades of evidence and recommendations for CRC high-risk factors and screening were
reviewed. To assure consistency, CRC screening guidelines from multiple organizations were
compared and found to be congruent in recommendations (American Cancer Society [ACS],
2013; American College of Gastroenterology[ACG], 2008; American College of Radiology
[ACR], 2008), American Gastroenterology Association [AGA], 2008; American
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Gastroenterological Society [AGSE], 2009; U.S. Multi-society Task Force on Colorectal Cancer
[USMSTF], 2008; U.S. Preventive Services Task Force [USPSTF], 2008; National Cancer
Institute [NCI], 2014). These experts concurred that high-risk CRC screening recommendations
should be guided by individual and familial risk factors and that CRC screening tests and
recommendations were generally categorized by cancer prevention, cancer detection, or by level
of risk for developing CRC (ACS, 2013; Rex et al., 2008).
Individuals identified to be at increased CRC risk due to a pertinent family history were
defined as those with colorectal cancer or adenomatous polyps in any first-degree relative before
age 60, or in two or more first-degree relatives at any age if not a hereditary syndrome (ACS,
2013). For those identified as having an increased risk for CRC, colonoscopy is recommended
every five years beginning at age 40 or 10 years before the youngest case in the immediate
family, whichever is earlier (Grade 1B, ACS, 2013). CRC screening using flex sigmoidoscopy or
colonoscopy should begin at age 40 for patients at increased risk due to a pertinent family
history, defined as colorectal cancer or adenomatous polyps in any first-degree relative age 60 or
older, or in a second second-degree relatives at any age (Grade 1B, ACS, 2013).
Genetic counseling with our without testing and a detailed personal history are
recommended to screen those at highest CRC risk, which include individuals with familial
adenomatous polyposis (FAP), hereditary non-polyposis colon cancer (HNPCC), and
inflammatory bowel disease, chronic ulcerative colitis, or Crohn’s disease (ACS, 2013).
According to ACS (2013), high-risk guidelines for FAP screenings should begin at age 10 to 12
years. Genetic testing or suspected FAP without genetic testing confirms the diagnosis. ACS
recommends yearly flexible sigmoidoscopy to identify signs of FAP (ACS, 2013). If genetic test
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results are positive, removal of the colon (colectomy) is considered the secondary prevention
measure of choice (ACS, 2013; Grade 2B, AGS, 2008).
For individuals who have or who are at increased risk for HNPCC based on family
history without genetic testing, colonoscopy is recommended every one to two years beginning
at age 20 to 25 years, or 10 years before the youngest case in the immediate family, along with
genetic counseling and/or genetic testing (ACS, 2013). In addition, genetic testing should be
offered to first-degree relatives of those found to have HNPCC mutations or if one of the first
three of the modified Bethesda criteria is met (NCI, 2014).
Individuals with inflammatory bowel disease, including chronic ulcerative colitis or
Crohn's disease, have a high risk of developing CRC. ACS (2013) reports cancer risk is
significant eight years after the onset of pancolitis (involvement of entire large intestine), or 12 to
15 years after the onset of left-sided colitis (ACS, 2013). Colonoscopy is recommended every
one to two years with biopsies for dysplasia (ACS, 2013). The ACS recommends that patients
with these diseases and risk factors should be referred to a center with experience in the
surveillance and management of inflammatory bowel disease (ACS, 2013).
The AGS (2008) paradigm shift toward prevention measures as opposed to detection tests
was evident throughout the literature. The screening modality most often recommended for highrisk patients was colonoscopy or flexible sigmoidoscopy. Consideration of patient acceptance,
utility of tests, and expert recommendations were cited in multiple sources, including the
American Cancer Society (2013), Gellad & Provenzale (2010), and Levin et al. (2008).
Gellad & Provenzale (2010) reported that “adherence to a screening regimen FOBT
[fecal occult blood tests] or structural exams [colonoscopy or flexible sigmoidoscopy] appeared
to be more important in terms of life-years gained than the specific screening modality…patient
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willingness to undergo a particular screening test needs consideration because some patients
refuse invasive structural exams”(p.2182). Thus, the impetus to consider is that although one test
may be perceived as superior to another (e.g. FOBT, secondary prevention measure versus
screening colonoscopy), compliance with a particular screening test is better than the patient
having no screening at all. FOBT assays vary in degrees of accuracy and scope and “detect CRC
cancer that has already developed …(and) only as good as proper… utilization of such tests, and
are not useful in detecting precancerous polyps” (Levin et al, 2008, p.1573). Depending on risk
factors, patient selection, and consideration of benefits and limitations, FOBT tests (secondary
prevention only) are appropriate alternatives when colonoscopy is not available or if patient
refuses structural exam (Grade 1B) (AGS, 2009). Flexible sigmoidoscopy is a less invasive
screening option in some situations if a patient refuses colonoscopy. However, patients must be
informed that detection rate for advanced neoplasia was three times higher following screening
by sigmoidoscopy than by FOBT and participation rates were similar (Segnan et al., 2005).
Flexible sigmoidoscopy is less invasive than colonoscopy and is a viable screening option in
some high-risk patients (ACS, 2013).
Brenner et al. (2010), demonstrated the efficacy of screening colonoscopy in a statewide
cross-sectional cohort study (n=3287) in older adults over 55 years of age. Of those, 2701 had no
previous colonoscopy, and 586 had previous colonoscopy within past ten years before the
screening colonoscopy. Advanced neoplasia was found in 36 (6.1%) of the 586 participants who
had history of a previous colonoscopy in past ten years, compared with 308 (11.4%) of the 2701
participants with no previous colonoscopy (including 41 participants with colorectal cancer), a
crude prevalence ratio of 0.54 (95% confidence interval [CI] = 0.39 to 0.75). Previous
colonoscopy was strongly and inversely associated with prevalence of advanced neoplasia in the
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left-sided colon and rectum but not with prevalence of advanced neoplasia in the right-sided
colon (Brenner, et al., 2010). Brenner et al., (2010) stated
Adjusted prevalence ratios were 0.99 (95% CI = 0.50 to 1.97) for the cecum and
ascending colon, 1.21 (95% CI = 0.60 to 2.42) for the hepatic flexure and transverse
colon, 0.36 (95% CI = 0.16 to 0.82) for the splenic flexure and descending colon, 0.29
(95% CI = 0.16 to 0.53) for the sigmoid colon, and 0.07 (95% CI = 0.02 to 0.40) for the
rectum. Respective estimates of adjusted prevalence ratios for the right-sided colon
combined and the left-sided colon and rectum combined were 1.05 (95% CI = 0.63 to
1.76) and 0.33 (95% CI = 0.21 to 0.53), respectively. Prevalence ratios for advanced
neoplasms were similar for previous colonoscopies conducted 1–5 years ago and 6–10
years ago (0.89 and 1.23 for the right-sided colon, and 0.35 and 0.31 for the left colon
and rectum, respectively) (p. 92).
Based on these findings, the authors suggest that prevalence of left-sided advanced
colorectal neoplasms, but not right-sided advanced neoplasms, was reduced within a ten-year
period after colonoscopy, even in the community setting. Evidence from this study may be
extrapolated to younger patients at high risk for developing CRC with known prevalence of left
colon lesions.
Colonoscopy, when performed according to personal and familial risk factors, can
potentially “prevent” colorectal cancer in high-risk patients. In addition, colonoscopy is
efficacious in detecting precancerous adenomatous polyps and removal can prevent conversion
into colon cancer (Levin et al, 2008). This assertion mirrors recommendations for screenings in
the guidelines for high-risk individuals. However, researchers noted that benefits of colonoscopy
on long-term mortality rates were unproven in follow-up studies or randomized controlled trials
(RCTs, Levin et al, 2008).
Singh et al. (2010) performed a retrospective review on colonoscopies completed
between 1987 and 2007 on individuals between the age of 50 and 80 years without prior CRC
disease, inflammatory bowel disease, colorectal surgery or resection. Singh et al. (2010)
compared CRC mortality after the index colonoscopy with that of the general population by
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22
standardized mortality ratios (SMRs). The researchers found a 29% reduction in overall CRC
mortality (SMR, 0.71; 95% confidence interval [CI], 0.61–0.82), a 47% reduction in mortality
from distal CRC (SMR, 0.53; 95% CI, 0.42–0.67), and no reduction in mortality from proximal
CRC (SMR, 0.94; 95% CI, 0.77–1.17) (Singh et al., 2010, p.1132). The reduction in mortality
from distal CRC remained significant for follow-up beyond 10 years (SMR, 0.53; 95% CI, 0.31–
0.84) (Singh et al., 2010). Findings from this study provide further evidence supporting benefits
for routine colonoscopies for those at high risk for CRC in all except those found in the proximal
colon. Limitations for applicability included age of participants and lack of differentiation
between average and high-risk CRC individuals.
Screening Barriers
Searches for systematic reviews, summaries, clinical guidelines, synopses, meta-analyses,
research studies, and case studies were conducted to evaluate the evidence for “barriers to CRC
screening.” A discussion follows on a CRC screening intervention study by Leone et al. (2013),
White, Sahu, Poles, & Francois (2012) survey of physician high-risk CRC screening barriers,
Jilcott-Pitts et al. (2010) focus group study to identify barriers to CRC screening, and Spruce and
Sanford (2012) collaborative interventional scholarly project to improve CRC screening rates.
Leone et al. (2013) conducted an intervention study using a mailed screening reminder
letter and decision aid followed by telephone support from an offsite, Medicaid-based, patient
navigator of 12 clinical practices in the Cape Fear Region of North Carolina (Eastern). Eligible
patients were aged 50 years or older, insured by Medicaid, and not current with colorectal cancer
screening recommendations. The primary outcome measurement was to determine if CRC
screening rates would improve. The researchers review Medicaid claims data again at six months
to determine if screening rates improved with the intervention aid and reminder, and was
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23
controlled for socio-demographic characteristics. The retrospective claim review for 240
beneficiaries of intervention participants had a colorectal cancer screening at the six month
review, 9.2% (n = 22) were compared to 13 (7.5%) of 174 in the control group. The intervention
had limited reach and little effect after six months on the number of participants screened.
Screening was still not significantly higher in the intervention group (1.68; 95% CI, 0.80–3.56)
(Leone et al., 2013). The study concluded that higher intensity interventions, such as use of
practice-based navigators, might be needed to reach and improve screening rates in vulnerable
populations (Leone et. al., 2013). This author postulates that further research may be helpful in
this cohort to identify possible unique psychosocial, cultural and ethnic variables.
In a national survey of physicians on CRC screening of high-risk populations, physician
respondents (n=512) most often identified the primary barriers to CRC screenings as “patient
refusal and lack of insurance reimbursement” (White, Sahu, Poles, & Francois, 2012, p.1).
Rosenwasser et al. (2013) studied CRC screening barriers specific to rural Pennsylvania women
and identified barriers related to provider practices, gender specific barriers to screening, patientrelated barriers, community-related barriers, physician practice-related (office) barriers.
Physicians in the study identified patient education as necessary for improving CRC screening in
their rural communities, but believed education would have to come from a source outside the
rural primary care office due to lack of resources, personnel, and time (Rosenwasser et al, 2013).
This author found no quantitative studies evaluating CRC screening barriers from the patient’s
perspective.
Jilcott-Pitts et al. (2010), conducted a qualitative study of four focus groups in rural
eastern NC (n=45) to assess perceived barriers or facilitators of CRC screenings. The researchers
identified ”costs, fear of testing, fear of cancer or burdening of family, fear of violation (men),
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
24
and embarrassment (women) as barriers to seeking preventive CRC screening. The focus group
identified facilitators for screening which included a doctor’s recommendation, symptoms,
family, support, and desire to live long and healthy life” (Jilcott-Pitts et al., 2011, p.78).
Financial issues were a recurring theme as a barrier to screening. Of note, this focus group was a
small group of economically challenged, underinsured persons in Eastern NC.
In an interventional scholarly project, Doctor of Nursing Practice students promoted
improved colorectal cancer screening in primary care by disseminating to primary care practices
a “toolkit” created by the Nevada Colon Cancer Partnership and the ACS (Spruce & Sanford,
2012). The tools and interprofessional collaboration demonstrated a novel approach with
partnership at levels of the community, provider, state, and national stakeholders to improve
CRC screening rates. This collaboration project demonstrated interprofessional partnerships and
teamwork to decrease the morbidity and mortality of CRC. The toolkit was useful to facilitate
efforts of office-based clinicians to reduce disparities by applying screening guidelines on a
universal basis to the age-appropriate population (Spruce & Sanford, 2012).
Knowledge and Practice Patterns
Systematic reviews, summaries, clinical guidelines, synopses, meta-analysis, research
studies, and case studies were sought to evaluate evidence for the scholarly project concepts of
provider knowledge and practice pattern in high-risk CRC screening. No systematic reviews
were located on provider knowledge or provider practice patterns in high-risk CRC cancer
screening.
This author found only one US study evaluating provider knowledge of high-risk CRC
guidelines using web-based survey. This survey of a sample of the American Medical
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25
Association (AMA) internists, physicians, gastroenterologists membership (n= 25,000) with a
two percent (n=512) response rate (White, Sahu, Poles, & Francios, 2012, p. 2).
Results showed overall guideline knowledge (n= 189, 37% +18, p < 0.001). Only 61
(12%) of physicians correctly identified the screening initiation point and follow-up interval
(p < .0001) (White, Sahu, Poles, & Francios, 2012, p. 3). Physicians who reported no awareness
of the current high-risk CRC screening guidelines achieved significantly lower scores on the
knowledge questions compared to their counterparts who expressed knowledge( n=204, 40%
+18; n= 158, 31% + 12, p= 0.002) respectively (White, Sahu, Poles, & Francois, 2012). For a
high-risk patient whose grandmother had colorectal cancer at age 65, only 61(12%) of physicians
correctly identified correct screening and follow-up recommendations “(White, Sahu, Poles, &
Francois, 2012). Limitations included the small response rate, poor design, limited
generalizability, and inability to draw conclusions about general knowledge and practice patterns
for all physicians who provide care for those requiring CRC screening. There were no studies
located that addressed NP knowledge of high-risk CRC screening knowledge.
Methodology
Survey Design
The survey tool entitled “The survey of NP provider knowledge, barriers, and current
practice in referring high-risk patients for CRC screenings” was developed for this scholarly
project using the American Cancer Society (ACS) high-risk CRC screening guidelines to guide
project design, implementation and evaluation (ACS, 2014). The Checklist for Reporting Results
of Internet E-surveys (CHERRIES) tool guided tool development for this web based email
Qualtrics® survey and the Institutional review board (IRB) submission process (Appendix A,
Eysenbach, 2004). Survey questions were designed in case-based format to evaluate the four
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26
clinical questions formed in the scholarly project. Response choices included multiple choice and
free text response questions. One “skip logic” question limited respondents who met exclusion
criteria who were sent to the end of the survey. The remainder of survey questions provided
descriptive experiential data about NPs’ beliefs about high-risk CRC screening (Appendix B).
The scholarly project was submitted to the IRB for expedited review and approval and IRB
approval was obtained on April 22, 2014 (Appendix C).
Participant Protection
Participant protection involved informed consent: an e-page consent on first page of the
survey informed subjects of the voluntary nature of the survey, scholarly project purpose, and the
right to withdraw or not complete survey, and any anticipated precautions and/or discomforts
that can be experienced completing the survey. Participants would waiver out in the email prior
to entering the anonymous survey link. The survey did not involve patient contact or access to
protected health information (PHI). Participation was voluntary and refusal to participate
involved no penalty. Participants were free to withdraw and discontinue participation at any
time. The participants in the survey received no compensation. The principal investigator’s
email address was provided for any concerns about the survey. The survey was not advertised
and was sent via closed email invitations using an anonymous survey link. The principal
investigator had exclusive access to the survey responses and data, which was password
protected.
Population
A convenience sample of 5065 registered nurses listed as advanced practice nurses
(APNs) from the North Carolina Board of Nursing (NCBON) was obtained at a cost of $225.00.
The excel file contained email addresses, practice county, setting, APN titles, and certification.
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27
These data were sorted based on inclusion and exclusion criteria appropriate for the survey
sample. The final survey sample file consisted of 2155 potential NP respondents. These NPs’
email addresses were entered in the Qualtrics® panel using potential respondents’ email addresses
and “First Name” “Last Name” in place of actual names to maintain anonymity.
Inclusion Criteria
Certification. Primary care NPs identified as adult, gerontological, and family nurse
practitioners practicing in North Carolina were included in the survey sample.
Practice setting. For purpose of clarity, settings considered as primary care were
practices identified as family practice, internal medicine, general practice, geriatrics, or
gerontology.
Exclusion Criteria
Certification. Advanced practice nurses listed as a certified registered nurse anesthetist,
clinical nurse specialist, or clinical nurse administrators were deleted.
Practice setting. NPs who practiced in outpatient specialty practices (n = 1096),
anesthesia or pain management setting (n = 17), adult psychiatry settings (n = 201), trauma
center, inpatient hospitalist, surgical specialties or critical care settings (n = 265), and pediatric
clinic settings (n = 596) were excluded.
Email. NPs who had no email listed or no identified practice setting were excluded from
the sample (n = 503).
Reliability and validity
The 16-question survey was pilot-tested for functionality prior to implementation,
utilizing the project committee, a faculty member, an IRB faculty member, and a gastrointestinal
specialty adult nurse practitioner ANP-C to assess survey usability and functionality. The
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28
CHERRIES tool guidelines were followed during the process of survey validation and IRB
application. Validity of responses was protected via a closed survey accessed by email invitation
only. Duplicate emails were screened by Qualtrics® software. One attempt was permitted per
email address to complete the survey. The survey was available to potential respondents from
June 1, 2014 through June 30, 2014.
Data protection
Data protection was assured by locked storage in East Carolina College of Nursing
research department office for any hard copies and password protected in Qualtrics® software for
electronic information. The author was principal investigator and had sole access to data files.
First and last names were removed from the NCBON email list and replaced with “First Name”
and “Last Name” in the Excel file and Qualtrics panel. Anonymous email invitations and
anonymous survey links in Qualtrics®. Data were accessible only to the project author and was
password protected. The computer was password protected. No data were saved on external
devices.
Process and Outcome Objectives
Process and outcome objectives guided the scholarly project timeline. The timeline
required frequent adjustment during the project process (Appendix D). Feedback from committee
chair and members was incorporated. Final project budget and funding expenditures were listed
(Appendix E).
Process objective 1) concept development. Formulation of concepts of scholarly project
to guide literature review and project planning process with completion goal was established for
September 30, 2013.
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Outcome objective 1) Interest in project narrowed from CRC screening to focusing on
high-risk CRC screening provider perceived knowledge, perceived barriers to screening, and
current practice patterns was identified September 30, 2013 (met).
Process objective 2) literature review. High-risk CRC screening knowledge, barriers,
and provider practice pattern literature search with completion goal of October 31, 2013.
Outcome objective 2) Literature review completed by October 31, 2013, and guided the
project development. Additional literature was reviewed through September, 2013 was
performed to assess for any updates of the current evidence as well (met).
Process objective 3) committee selection. Selection of chair, expert content member,
and community member goal was established for November 1, 2013.
Outcome objective 3) Requested and obtained committee member support including Dr.
Candace Harrington, chair, Dr. Carol King (expert content member), and Dr. Christopher
Kornegay (community member) (met November 1, 2013).
Process objective 4) survey tool development. Utilize CHERRIES and ACS (2013)
high-risk CRC screening recommendations to guide survey tool development by January 31,
2014.
Outcome objective 4) Tool development completion with revisions was tested for
functionality by committee and content and research experts by January 31, 2014 (met).
Process objective 5) IRB approval. Goal date for IRB approval was March 31, 2014.
Outcome objective 5) Submitted project for IRB approval February 2014. The project
was returned to author with one question for clarification from the IRB committee then
resubmitted with requested clarification. Final expedited IRB approval obtained 4/22/2014 (met,
with delay).
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30
Process objective 6) implementation. Project initiation through emailed invitations with
goal of May 1, 2014 was established.
Outcome objective 6) There was a delay in obtaining IRB approval and list serve for
convenience sample, thus resulting in implementation delay. Survey implemented 6/1/2014 until
6/30/2014 (met, with delay).
Process objective 7) data analysis. Goal for data analysis of results in SPSS set for
August 31, 2014.
Outcome objective 7) Data analysis was completed October 15, 2014, with addition of
Spearman Rho November 4, 2014. Data required additional recoding to obtain dichotomous
values for Chi Square and correlation examination. (met,with delay).
Process objective 8) dissemination. Goal for dissemination of scholarly project results
set for December 1, 2014, with plans for ongoing future dissemination opportunities as available
and accepted.
Outcome Objective 8) Dissemination outcomes
1) Eastern North Carolina Cancer Coalition presentation May 6, 2014 (met)
2) Scholarly presentation at ECU College of Nursing November 5, 2014 (met)
3) Paper submission 12/ 01/2014 to ECU ScholarShip scholarly paper repository by
December 1, 2014.
4) Manuscript submission 11/30/2014 to Clinical Scholars Review by November 25, 2014.
5) Plan poster presentation at ECU Collaborative Research day February, 2015
6) Plan national poster or podium presentation opportunity in 2015.
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31
Implementation
Qualtrics® survey software was used to distribute the survey to the 2155 NP convenience
sample via a voluntary closed invitation email that provided an anonymous survey link. The
survey was implemented June 1, 2014 through June 30, 2014. A reminder and thank you email
was sent mid-point in the survey to thank those who had completed the survey, and to remind
those who had not completed it of an opportunity to still participate. Of the 2155 potential
respondents, 43 % (n= 864) viewed the invitation email, 9.6% (n =223) started the survey and
8.3 % (n =180) of the respondents completed the entire survey. Incomplete surveys were not
included in the data analysis.
Results
Data were analyzed using SPSS® statistical software. Descriptive data analysis was used
to describe the respondents’ NP certification type, years of clinical experience, and demographic
distribution and to answer the following scholarly project clinical questions: 1) “Are NPs
knowledgeable about high-risk CRC guidelines”, 2) “Are there any perceived or identified
barriers that exist in CRC screening referrals”, 3) “What are NP’s current high-risk CRC
screening practice patterns?” A Chi square test for independence and Spearman Rho was used to
analyze clinical question the fourth clinical question, “4) Is there a relationship between NPs
CRC screening practice patterns and NPs self-perceived knowledge of the guidelines”, was
completed. Details of each analysis, relationship to specific survey questions, and explanation of
supporting evidenced based guideline follows.
Respondent Characteristics
Descriptive data of the survey sample included years of NP clinical experience, NP
education/certification, and practice region in North Carolina (NC). Of the respondents, 82.2%
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32
(n =146) selected family nurse practitioner (FNP) and 17.8% (n =34) identified themselves as
adult nurse practitioners (ANP) as their primary NP practice certification. Mean and standard
deviation calculations were deferred due to lack of normal distribution. Six respondents listed
geriatric NP as a free text credential. Clinical practice years were variable with 48.3 % (n =87)
having more than ten years of NP experience. Thirty-six NPs (20%) had between five to ten
years of NP experience. Eleven percent (n =19) had two to five years of NP experience. The
second largest group of 21% (n =38) had two years or less of NP experience.
State regional survey response rates were obtained using with a free text question that
asked for the county or counties of primary NP clinical practice. In order to maintain anonymity,
county response rates were recoded and reported by state region. The responses (n=180) were
sorted in an excel file into three regions of North Carolina: western (mountains, n= 34, 19%),
piedmont (central, n= 95, 53%), and eastern (coastal plain, n=51, 28 %). Respondents
represented 60 of 100 counties from all three regions of the state.
NP Perceived High-risk CRC Screening Knowledge
Clinical question one. “Are NPs knowledgeable about high-risk CRC guidelines?”
Questions eight and ten in the survey tool assessed NP perceived knowledge of high-risk
guidelines and comfort discussing them with patients. Question eight asked, “I feel
knowledgeable in the current colorectal cancer high-risk factors and screening
recommendations” with three response choices. The data results were recoded for analysis
purposes into “agree” labeled as “one,” and all other response (disagreed, and neither agreed nor
disagreed) labeled as “two.” Descriptive frequencies were performed and results were 57.8 %
(n=104) of NPs had self-perceived knowledge of the high-risk CRC screening guidelines, and
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33
42.2% (n=76) did not have or were uncommitted on self-perceived knowledge of high-risk CRC
screening guidelines.
Question ten also addressed indirect perceived knowledge asking if the NP felt confident
and comfortable discussing CRC high-risk factors and screening recommendations with (his or
her) patients. Response options were either “agreed, disagreed, or neither agreed nor disagreed.”
The data results were recoded for analysis purposes into “agree” labeled as “one,” and all other
response (disagreed, and neither agreed nor disagreed) labeled as “two.” On hundred thirtyseven (76%) of NP respondents expressed comfort discussing colorectal cancer high risk factors
and screening recommendations with their patients, and 23.9% (n=43) of respondents were either
uncomfortable or were uncommitted on comfort level of discussing these guidelines with
patients.
Perceived Colorectal Cancer Screening Barriers
Clinical question two. “Are there any perceived or identified barriers that exist in CRC
screening referrals?” Respondents were allowed to choose as many responses as applied and
were permitted to “free-text” responses not listed if desired for this question. Identified barriers,
were due to uninsured status, patient refusal (did not want to do bowel prep); patient refusal (fear
of finding cancer), patient refusal (fear of exposure-modesty issues), lack of access of patient
transportation services, lack of access-no gastroenterology services in community, provider
indifference among NP peers or physicians, and lack of FOBT supplies as a barrier to CRC
screening (Table 1).
NP Screening Practice Patterns
Clinical question three. “What are NP’s current CRC screening practice patterns?”
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34
The third clinical question was evaluated from questions 3,4, 12, 13, 14, and 15 of patients
seeking screening advisement based on specific high-risk factors provided in the cases in each
question (Table 2). Each question was in a multiple-choice format with one correct and three
incorrect options from which to choose and data from these responses evaluated screening
recommendation practice patterns. For data analysis, these questions were recoded into
dichotomous variables with the one correct response for each to allow non-parametric categorical
analysis and Spearman rho correlation tests.
Question 3. This question pertained to JL, a 47-year-old male, who presented for his first
physical in 20 years with past family history of his father having benign polyps removed at the
age of 50 as a personal risk factor. He asked when he should have a colonoscopy. Thirty-three
(18.3%) respondents chose the correct response based on his risk factors to refer for colonoscopy
at the end of the office visit, in congruence with the ACS (2013) guidelines. According to the
ACS (2013) guidelines, this patient is already at “increased risk” based on his family history of
“adenomatous polyps in any first-degree relative before the age of 60, or in two or more first–
degree relatives at any age (if not a hereditary syndrome)… [then screening at] age 40, or 10
years before the youngest case in the immediate family, whichever is earlier)” (ACS, 2013).
This question received incorrect response of 81.7% and revealed a significant gap in knowledge
in this particular screening guideline knowledge with JL’s particular risk factors. This question
received the most incorrect responses in provider practice patterns in the survey.
Question 4. Question four asked for NP decision on when “Individuals identified as
“high-risk” for colon cancer should referred for colonoscopy screenings” with a correct response
of “age 40 years, or 10 years before the youngest case in the immediate family” (ACS, 2014).
One hundred eight (60%) of the NPs surveyed chose the correct response. This generic question
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35
of screening practice recommendation sought to identify the earlier age recommendation of 40
years or younger depending on risk factors for those at higher risk based on individual and
family risk factors.
Question 12. This question pertained to MN, a 35-year-old female with no symptoms, no
prior screenings, but a pertinent family history of a sibling with familial adenomatous polyposis
(FAP). One hundred thirty two (73.3 %) respondents chose the correct response to “refer to a
gastroenterologist to schedule a screening flexible sigmoidoscopy and recommend genetic
testing” (ACS, 2013), with the remainder choosing one of the other incorrect responses.
Interestingly, this question was the most often correctly answered question.
Question 13. This question referenced the recommended referral age for colonoscopy for
DK, age 41, who tells his NP provider “My uncle Ted and Aunt Jill both had colon cancer but
they were 60 years old.” The recommendation to this patient should have been “you should
really get one done now, as soon as we can get it scheduled. The ACS (2013) guideline that
supported this practice pattern decision for DK was “CRC or adenomatous polyps in ay firstdegree relative age 60 or older, or in at least two second degree relatives at any age” (ACS,
2013). Fifty seven of the respondents (37%) answered this question correctly.”
Question 14. This case-based question referred to TS, and 18-year-old with positive
sibling history of HNPCC (hereditary no polyposis colon cancer) asking his NP for CRC
screening advice. The correct response in the survey was “if you have not had a screening
colonoscopy or offered genetic testing, we should schedule this right away.” The ACS (2013)
guideline suggests screening should begin at “age 20 to 25 years, or 10 years before the youngest
case in the immediate family... colonoscopy every one to two years; counseling to consider
genetic testing if it hasn't been done” (ACS, 2013. Para 7, “HNPCC”). Results showed 51 %
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
36
(n=91) selected the correct response; 49 % (n=89) selected incorrect responses; and 10.5 %
(n=19), stated, “I am not sure.” Once again, half of the respondents chose the correct high-risk
screening practice pattern for TS.
Question 15. This case-based question intended to identify knowledge of appropriate
screening for JT, age 39, with a higher risk for CRC due to personal history of Crohn’s disease.
The correct response was “you should have a colonoscopy done every one to two years with
biopsies to monitor for dysplasia, and we should refer you to a surveillance program at a
gastrointestinal center that specializes in Crohn's disease.” This survey response was supported
by (ACS, 2013) high-risk CRC guidelines. One hundred fourteen (63.3%) selected the correct
practice pattern response for this question.
Categorical Analysis
Clinical question four. "Is there a relationship between high-risk CRC screening
practice patterns and self-perceived knowledge of the guidelines?”
Aggregate data from the case-based scenarios presented in questions three, four, 12, 13, 14, and
15 were recoded into dichotomous variables (“yes” for the correct response; “no” for all other
responses). A Chi square test for independence was calculated to evaluate a statistically
significant relationship between self-perceived knowledge of high-risk CRC guidelines (question
eight) and actual high-risk CRC screening practices. The results from the aggregate data
demonstrated a statistically significant relationship between the 180 NP respondents clinical
practice patterns and perceived knowledge (self-reported) of high-risk CRC screening practice
guidelines (X2= 4.191, df = 1, p = .04). Chi square tests were then calculated for each of the
case-based clinical practice questions individually to assess for relationships between specific
high risk factor practice patterns and NP self-perceived knowledge (Table 3). With the exception
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37
of question 12 that addressed FAP (p=.001), individual question Chi Square analyses did not
demonstrate a statistically significant relationship between perceived knowledge practice pattern
for that particular question.
A Spearman rho was performed on practice pattern questions 3, 4, 12, 13, 14, and 15 as
compared to perceived knowledge of high-risk CRC screening guidelines. Family history of
polyps showed a strong positive correlation (rs[180] = .979, p = .001), a weak positive
correlation was noted with initial screening age for high-risk CRC persons (rs[180] = .243, p =
.001), and a weak positive correlation was noted personal history of Crohn’s disease (rs [180]=
.190, p = .01). Otherwise, there was no statistically significant correlation between self-perceived
high-risk CRC screening knowledge and high-risk CRC screening practice patterns in the
remaining clinical question scenarios.
Discussion
Descriptive data included respondent characteristics, perceived knowledge, perceived
barriers, and current practice patterns. A response rate of 8.3 % (n=180) was obtained. The
majority were FNPs, with ANP representation. Means and standard deviations were not
calculated because of lack of normal distribution of sample. Clinical experiences ranged from
zero to more than 10 years of experience. Geographical distribution of respondents mirrored
population distribution tendencies in North Carolina.
Questions pertaining to self-perceived knowledge of high-risk CRC screening knowledge
were subjective to ascertain the NP respondent’s perception of high-risk CRC screening
guideline knowledge. The reason for this questioning style was to ascertain perceived
educational needs of NPs of high-risk CRC guidelines. Thus, respondents that reported lack of
perceived high-risk CRC screening knowledge identified a knowledge gap and opportunity for
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
38
improvement for educational interventions for 42.2 % (n=78) of respondents. With emphasis of
prevention as intervention and goals of transitioning high-risk CRC screening from tertiary to
primary and secondary prevention models of care, this is one identified gap should be addressed
with targeted interventions to educated NPs on these guidelines.
Aggregate data analysis of clinical practice patterns and perceived knowledge (selfreported) of high-risk CRC screening practice guidelines using Chi square test for independence
should a statistically significant result. However, the subsequent analysis of individual questions
failed to confirm these findings. One hypothesis for this is the necessity for further tool
development for improved reliability and sensitivity.
Barriers to high-risk CRC screening referrals were also identified that contribute to
suboptimal CRC screening in high-risk persons. The majority of respondents identified
uninsured status as a huge barrier. Patient refusal due to bowel prep, fear of cancer, and fear of
exposure were also reported. Access issues such as transportation or lack of gastroenterology
services was also cited. All these barriers contribute to less than optimal screening and
disparities in screening rates that are driven by economic, cultural, or social motivators.
Barriers in this survey reflect findings in the literature review with higher rates notes in
rural regions and a noted cluster of 14 counties in rural northeastern NC east of I-95 to coastal
regions southeast of Virginia. These rural communities may benefit from targeted interventions
to improve screening rates.
The opinion based question responses provided valuable philosophical information about
NP practice goals and support Healthy People 2020 goals for improving screening and reducing
morbidity and mortality in colorectal cancer through targeted interventions. Evidence from this
project supports this concept in high-risk person through screening and surveillance of those with
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
39
personal or family history of genetic mutation carriers with history of first-degree relatives with
colorectal cancer.
NP application of Neuman’s systems model primary and secondary prevention to highrisk CRC screening was evaluated through opinion based questions. Neuman’s “prevention as
intervention” concept was validated in NP theoretical practice in the survey from the 95% of
respondents reporting the belief that CRC screening saves lives or can prevent cancer in highrisk persons. Interest in collaboration with community cancer coalition partners was expressed
by 46.1 % of respondents and provided valuable philosophical information about NP practice
goals using the “prevention as intervention” model in high-risk CRC cancer patients as well as
self-identified learning needs among respondents.
The majority of respondents felt more education opportunities were needed in high-risk
CRC screening guidelines. This mirrors the necessity that NPs understand high-risk CRC
screening criteria and guidelines in order to translate these screening recommendations to highrisk patients. These opinions further validate the need for education of high-risk CRC screening
guidelines in order to maximize clinical outcomes through earlier identification of high-risk CRC
persons tailored to individual and familial risk factors to promote prevention as intervention
models of care, thus supporting the paradigm shift from tertiary to primary and secondary
prevention.
Project Strengths
Strengths of this scholarly project were 1) the survey was anonymous in approach, and
2) the use of the ACS (2013) evidenced based high-risk CRC guidelines, and 3) the CHERRIES
tool guided and validated the survey process, and 4) participants could freely identify and
validate knowledge or lack of understanding of high-risk CRC screening guidelines, screening
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
40
barriers, and share opinions and learning needs in a nonthreatening anonymous manner. The
information gained from this survey facilitates future interventions to targeted groups. The
questions addressed each high risk factor to validate if asserted perceived knowledge of high-risk
CRC guidelines matched consistently with an actual high-risk factor scenario. The final strength
observed is the identification of knowledge as well as the opportunity for additional educational
efforts of high-risk CRC screening guidelines.
Project Limitations
The anonymous link was also a limitation. Although it protected the participants’
anonymity and facilitated gathering data in a non-threatening manner, further follow-up on the
same pool of respondents with inability to replicate the findings presents an issue. The variety of
type of questions and analysis of all the high-risk guidelines made data analysis difficult. Lack of
reliability and sensitivity for a new tool was an additional limitation. The author cannot assure
respondents carefully read the questions before responding.
Significance to Advanced Nursing Practice
This scholarly project contributed to scientific knowledge by identifying NP knowledge
gaps of the high-risk CRC practice guidelines, issues of clinical application, as well as
recognizing ongoing barriers to high-risk CRC screening. There was interest expressed by
respondents (in the opinion questions) in networking with community stakeholders to improve
high-risk CRC screening rates to improve health care outcomes. The survey tool will require
further development and validation but will eventually contribute to NP practice through
dissemination and tool use donation to East Carolina University College of Nursing in the
interest of educating APN students and other interprofessional healthcare partners. This DNP
project will promote NP partnerships with community stakeholders in interventions to reduce
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
41
screening barrier disparities in high-risk persons and at risk communities. Application and
follow-up interventions and studies to re-evaluate trends in knowledge and practice patterns
should follow.
Recommendations
This year, the USPSTF (2014) has identified research priorities for CRC to address
disparities, particularly ethnic or issues to determine if screening at an earlier age in particular
subgroups would be more beneficial to improve health outcomes (USPSTF, 2014).
Recommendations from this project include offering additional education to NPs and
stakeholders on the high-risk CRC screening guidelines, as well as on the preventive benefits of
appropriate colonoscopy screenings. Additionally, NPs and other healthcare professionals need
to consider increasing networking opportunities with regional and national cancer coalition
networks in communities to improve high-risk screenings. Targeted interventions will address
identified public and clinician screening barriers to improve screening rates. Finally, health
policy needs to address these barriers to screening, particularly economic cited barriers, if this
disparity is to improve over time.
Conclusion
This scholarly project evaluated NP knowledge of high-risk CRC screening guidelines,
perceived barriers to CRC screening, and current NP screening practice patterns. Insight was
gained by this project into evidence based practice guidelines as well as validating identified
gaps in literature resulted in education, networking and intervention recommendations to
promote best practice.
The paradigm shift from tertiary prevention to primary and secondary preventive highrisk CRC screening practices was identified as a key Healthy People 2020 initiative NPs can
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
42
frame clinical improvement interventions using Neuman’s Systems “prevention as intervention
concepts.” Application of these concepts and knowledge of high-risk CRC screening guidelines,
in partnership with local, community, state, national, and international partners, the NP will
positively influence the incidence of high-risk CRC screening referrals, and will be key partners
in transforming high-risk CRC screenings from tertiary prevention, to primary and secondary
prevention to improve health outcomes.
Scholarly Project Dissemination Plan
The Institutes for Health Improvement Triple Aim Model frames the dissemination plan
of this scholarly project. The plan includes identifying dissemination partners, the methods of
communication, the evaluation process, and final work plan.
Triple Aim
Better care for high-risk CRC population: Education for patients, providers, and
public of high-risk factors and case identification to achieve timely screenings of those at highrisk for colorectal cancer.
Better care experience for patients. Earlier screenings will result in reduction of
morbidity and mortality of high-risk colorectal cancer (secondary prevention), and potential
prevention of colorectal cancer (primary prevention), resulting in better life quantity and quality.
Lower costs through improvement. Prevention costs less than treatment, increases
years of life quantity and productivity.
One-year plan. Triple aim one: Dissemination of results through local regional and
national presentation opportunities.
Five-year plan. All three of the triple aims can be met through the following long-term
goal: Research and write grant proposal for a mobile unit for high-risk CRC screenings in closed
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
43
communities to improve high-risk CRC screening rates, as well as provider education
opportunities within high-risk CRC regions of Eastern North Carolina. Perform prevention and
cost analysis of screening versus high-risk CRC treatment as part of proposal to support longterm funding.
Who are the dissemination partners?
Healthy People 2020. NP partnerships with community stakeholders have been and
continue to be an integral part of the dissemination plan. The national goals and objectives for
CRC, Healthy People 2020 (2014) objectives database identified initiatives to reduce CRC
morbidity and mortality by targeting at risk populations for interventions and improving CRC
screenings. These goals are as follows: (1) Increase the proportion of adults who receive a
colorectal cancer screening based on the most recent guidelines, (2) Reduce the colorectal cancer
death rate (3) Reduce invasive colorectal cancer , and (4) (Developmental) Increase the
proportion of adults who were counseled by their providers about colorectal cancer screening
(Healthy People 2020, 2014). These goals aligned well with scholarly project purpose and
guided design and process and outcome goals following ACS high-risk CRC screening
guidelines for those as higher risk.
Eastern Carolina Cancer Coalition. Local dissemination partners include the Eastern
NC Cancer Coalition (ENCCC), where the scholarly project concept and current high-risk CRC
screening guidelines were presented to professional colleagues and community members in May
2014, via a podium PowerPoint regional presentation in Pitt County. The author was the
presenter and was able to share scholarly project literature review and the Healthy People 2020
goals with community and professional members present. Part of the dissemination plan includes
ongoing partnership with this local network.
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
44
What methods of communication will be used?

Scholarly paper submission ECU repository the ScholarShip

Submit abstract for poster presentation for Collaborative Research Day February, 2015

Submit abstract for poster presentation for DNP National conference 2015

Manuscript submission -Clinical Scholars Review 11/30/2014

Eastern NC Cancer Coalition-Interprofessional conference planned and held 5/6/2014
How will the dissemination plan be evaluated?
The scholarly paper, university presentation, and manuscript student work will be
evaluated by scholarly project committee chair, members, ECU college of Nursing faculty. The
poster presentation is optional in the curriculum but author wished to do so for future
presentations.
What is the final dissemination work plan?
After the above presentations are completed, the final dissemination plan is scholarly
journal publication. Local, state, and national presentation opportunities to inform and share
knowledge attained in this scholarly project will support further study and research, as well as
initiatives to improve patient care outcomes in those with high risk for CRC to obtain preventive
CRC screenings.
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
45
References
American Cancer Society (2013). Colorectal cancer. American Cancer Society
recommendations for colorectal cancer early detection. Retrieved October 13, 2013,
from
http://www.cancer.org/cancer/colonandrectumcancer/moreinformation/colonandrectumca
ncerearlydetection/colorectal-cancer-early-detection-acs-recommendations
American Association of Nurse Practitioners (2014), NP fact sheet. Retrieved from
http://www.aanp.org/all-about-nps/np-fact-sheet
Brenner, H., Hoffmeister, M., Arndt, V., Stegmaier, C., Altenhofen, L., Haug, U., (2010)
Protection from right- and left-sided colorectal neoplasms after colonoscopy: Populationbased scholarly project. Journal of the National Cancer Institute, 102 (2): 89-95. DOI:
10.1093/jnci/djp436. Epub 2009 Dec 30. Retrieved from
http://jnci.oxfordjournals.org/content/102/2/89.full.pdf+html
Centers for Disease Control. (2013). Cancer statistics: Rates of getting colorectal cancer by
state. Retrieved August 28, 2014, from
http://www.cdc.gov/cancer/colorectal/statistics/state.htm
Eysenbach, G. (2004). Improving the quality of web surveys: the checklist for reporting results
of internet E-surveys (CHERRIES). Journal of Medical Internet Research, 6(3), e34.
DOI: 10.2196/jmir.6.3.e34 . Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1550605
Fawcett, J. (2000). Analysis and evaluation of contemporary nursing knowledge: Nursing models
and theories. F.A. Davis: Philadelphia.
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
46
Gellad, Z.F., & Provenzale, D., (2010). Colorectal cancer: National and international perspective
on the burden of disease and public health impact. Gastroenterology, 138 (6), 21772190. DOI: 10.1053/j.gastro.2010.01.056. Retrieved from
http://www.gastrojournal.org/article/S0016-5085%2810%2900173-3/fulltext
Healthy People 2020, (2014). Healthy People 2020 objectives: cancer.
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=5
Jilcott-Pitts S.B., Lea C.S., May C.L., Stowe C., Hamill D.J., Walker K.T., & Fitzgerald T.L.,
(2013). Fault-line of an earthquake: A qualitative examination of barriers and facilitators
to colorectal cancer screening in rural, eastern North Carolina. [Epub 2012 Aug 1]
Journal of Rural Health, 29(1), 78--87. DOI:10.1111/j.1748-0361.2012.00424.x
Leone L.A., Reuland D.S., Lewis C.L., Ingle M., Erman B., Summers T.J.,…Pignone M.P.
(2013). Reach, usage, and effectiveness of a Medicaid patient navigator
intervention to increase colorectal cancer screening, Cape Fear, North Carolina, 2011.
Prevention Chronic Disease, 10 (E82) doi:10.5888/pcd10.120221
Leiu, C., Renfro, L., Gramont, A., Meyers, J., Maughan, T., Seymour, M.,…Eng, C., (2014).
Gastrointestinal cancer: Association of age with survival in patients with metastatic
colorectal cancer: Analysis from the ARCAD clinical trials program. Journal of Clinical
Oncology. 32 (7). 2975-2982. Retrieved from
http://jco.ascopubs.org/content/32/27/2975.short?rss=1
Levin, B., Leiberman, D.A., McFarland, B., Andrews, K.S., Brooks, D., Bond, J.,…Winawaer,
S.J. (2008). Screening and surveillance for the early detection of colorectal cancer and
adenomatous polyps, 2008: A joint guideline from the American Cancer Society, the U.S.
Multi-Society Task Force on colorectal cancer, and the American College of Radiology
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
47
American Cancer Society Colorectal Cancer Advisory Group, the Multi-Society Task
Force, and the American College of Radiology Colon Cancer committee. CA: A Cancer
Journal for Clinicians, 58(p) Retrieved 11/01/2013 from
http://www.asge.org/assets/0/71542/71544/ae31385d-5115-4e7f-8e6b70758db0e4b1.pdf
Naishadam, D., Lansdorp-Vogelaar, I, Seigel, R., Cokkinides, V., & Ahmedin, J., (2011)
State disparities in colorectal cancer mortality patterns in the United States. Cancer,
Epidemiology, Biomarkers, and Prevention. .20 (7). Retrieved from
http://cebp.aacrjournals.org/content/20/7/1296.full.pdf+html
National Cancer Institute (2014). Colorectal cancer screening. National Institute of Health.
Retrieved from
http://www.cancer.gov/cancertopics/pdq/screening/colorectal/Patient/page3
National Cancer Institute. (2014). Genetic colorectal cancer syndromes.
Retrieved from
http://www.cancer.gov/cancertopics/pdq/genetics/colorectal/HealthProfessional/page3
National Cancer Institute (2014). SEER stat fact sheets: Colon and rectum cancer. National
Institute of Health. Retrieved from
http://seer.cancer.gov/statfacts/html/colorect.html
North Carolina Center for Vital Health Statistics, (2014). 2007-2011 Colorectal cancer incidence
rates for selected sites. Retrieved from http://www.schs.state.nc.us/
Rex, D., Johnson, D., Anderson, J., Schoenfeld, P.S., Burke, C., & Inadomi, J., (2009). American
College of Gastroenterology guidelines for colorectal cancer screening 2008. The
American Journal of gastroenterology. 104. 739-750. Retrieved from
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
48
http://www.guideline.gov/content.aspx?id=36848&search=colorectal+cancer+screening#
Section420
Rosenwasser, L. A., McCall-Hosenfeld, J. S., Weisman, C. S., Hillemeier, M. M., Perry, A. N.,
& Chuang, C. H., (2013). Barriers to colorectal cancer screening among women in rural
central Pennsylvania: Primary care physicians' perspective. Rural and Remote Health, 13
(4), 2504. Retrieved from
http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=2504
Segnan, N., Senore, C., Andreoni, B., Arrigoni, A., Bisanti, L., & Cardelli, L., (2005).
A randomized trial of different screening strategies for colorectal cancer: Patient response
and detection rates. Journal of the National Cancer Institute, 97(5). Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/15741571
Sehgal, R., Sheahan, K., O’Connell, P.R., Hanly, A.M., Martin, S.T., &, Winter, D.C., (2014).
Lynch Syndrome: An updated review. 5; 497-507. Genes. Doi: 10.3390/genes503049.
Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/24978665
Singh, H., Nugent, Z., Demers, A., Kliewer, E., Mahmud, S., & Bernstein, C., (2010). The
reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer.
Gastroenterology. 139(4), 1128-1137. Retrieved from
http://www.gastrojournal.org/article/S0016-5085%2810%2900961-3/abstract?cc=y
Spruce, L. R., & Sanford, J. T. (2012). An intervention to change the approach to colorectal
cancer screening in primary care. Journal of the American Academy of Nurse
Practitioners, 24 (4), 167--174. doi:doi:10.1111/j.1745-7599.2012.00714.x Retrieved
from http://onlinelibrary.wiley.com/doi/10.1111/j.1745-7599.2012.00714.x/full
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
49
U.S. Preventive Services Task Force (2008). U.S. Preventive Services Task Force screening for
colorectal cancer recommendation statement. Annals of Internal Medicine, 149 (9),
627—637. DOI:10.7326/0003-4819-149-9-200811040-00243
U.S. Preventive Services Task Force, (2014). Screening for colorectal cancer. Final
research plan. Retrieved from
http://www.uspreventiveservicestaskforce.org/uspstf14/coloncan/coloncanfinalresplan.ht
m
Win, A., Dowty, S., Cleary, H., Buchanan, D., Young, J., Clendenning, M.,& Jenkins, M.
(2014). Risk of colorectal cancer for carriers of mutations in MUTYH, with and without a
family history of cancer. Gastroenterology.146 (5), 1208-1211.
doi:10.1053/j.gastro.2014.01.022 Retrieved June 1, 2014 from
http://www.ncbi.nlm.nih.gov/pubmed/24444654
White, P.M., Sahu, M., Poles, M.A., & Francois, F., (2012). Colorectal cancer screening of
high-risk populations: A national survey of physicians. BMC Research Notes. 5(64).
(open access). Retrieved from http://www.biomedcentral.com/1756-0500/5/64
DOI:10.1186/1756-0500-5-64
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Tables
Table 1. Results of Barriers to high-risk CRC screening
Reported barriers (ranked) (all that applied)
Uninsured/ not covered
Patient refusal expressed due to not wanting to do the bowel prep
Patient refusal expressed -fear of finding cancer
Patient refusal expressed due to modesty issues
Lack of access – patient without transportation resources
Lack of access- No GI services in the community
Provider indifference among your peers or physicians
Lack of adequate supplies for FOBT
Rates
(n)
%
162
149
80
67
27
16
15
1
86
79
42
35
14
8
8
1
Table 2. Results of NP high-risk CRC screening practice pattern survey questions
Survey question # 3, "Jl" with positive family history polyps
father 50, screening recommendations
Correct
Response
(n)
33
Correct
Response
(%)
18.3
Survey question # 4, Those “high-risk” for colon cancer should be
referred for colonoscopy
Survey question #12, "MN"+FH sibling familial adenomatous
polyposis (FAP), screening recommendations
104
57.8
132
73.3
Survey question # 13, "DK" with +FH colorectal cancer in 2
relatives, screening recommendations
Survey question #14 "TS" +FH sibling HNPCC (hereditary
nonpolyposis) CRC screening recommendations
Survey question #15 “JT,” +PMH of Crohn’s /advice on
surveillance/preventive screenings
57
31.7
91
51
114
63.3
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
51
Table 3. Individual Clinical Question Chi Square Analysis
Practice Pattern Question # with Chi square NP selfperceived knowledge of high-risk CRC screening guidelines
Survey question # 3, "JL" with positive family history
polyps father 50, screening recommendations
Chi square
X2 = 59.401, df = 1, p >.05
Survey question # 4, Those “high-risk” for colon cancer should be
referred for colonoscopy
X2 = .183, df = 1, p >.05
Survey question #12, "MN"+FH sibling familial adenomatous
polyposis (FAP), screening recommendations
X2 = 24.821, df = 1, p >.05
Survey question # 13, "DK" with +FH colorectal cancer in 2
relatives, screening recommendations
X2 = 9.644, df = 1, p=.001
Survey question #14 "TS" +FH sibling HNPCC (hereditary
nonpolyposis) CRC screening recommendations
X2 = 1.890, df = 1, p > .05
Survey question #15 “JT,” +PMH of Crohn’s /advice on
surveillance/preventive screening
X2 = 1.16229, df = 1, p > .05
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
52
Appendix A
Checklist for Reporting Results of Internet E-Surveys (CHERRIES) tool
Item Category
Checklist
Item Provider
Explanation
Survey of Nurse
Practitioner
Knowledge, Barriers, and Current
Practice in
Design
®
DescribePatients
survey design
Qualtrics
internet
anonymous email web
Referring High-risk
for Colorectal
Cancer
Screenings
IRB (Institutional
Lecia Reardon DNP Student
Review Board)
approval and informed
consent process
September 12, 2014
IRB approval
Appendix C, letter from IRB approval
Informed consent
Informed consent was included in the survey
with agreement to participate prior to
advancing to questions.
Data protection
P.21, section “data protection” per ECU policy
see Paragraph details. Password protected
computer sign on and files. PI had sole access
to data files.
Excel file from NCBON was scrubbed of all
personal identifiers with all first and last names
replaced with “first name” and “last name” in
Qualtrics.
Development and testing
Pilot tested for functionality prior to
implementation
Development and pretesting
Convenience sample from the NC BON
Recruitment process
and description of the
sample having access to
the questionnaire
Survey administration
Open survey versus
closed survey
Closed survey, invitation only
Contact mode
Principal investigator student email address
Advertising the survey
None
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
53
Checklist for Reporting Results of Internet E-Surveys (CHERRIES) tool
Item Category
Checklist
Item Provider
Explanation
Survey of Nurse
Practitioner
Knowledge, Barriers, and Current
Web/E-mail
Email
Practice in
®
Referring High-risk
Cancer
Screenings
Context Patients for Colorectal
Qualtrics
Lecia ReardonMandatory/voluntary
DNP Student
September 12, 2014
Voluntary
Incentives
None
Time/Date
6/1/14- 6/30/14 (under implementation section)
Randomization of items or
questionnaires
P 18. Design yes
Adaptive questioning
DESIGN SECTION- Yes, 1 skip logic to meet
exclusion criteria and send respondent to the
end of the survey
Number of Items
16
Number of screens (pages)
One screen per question
Completeness check
yes
Review step
yes
Unique site visitor
yes
View rate (Ratio of unique
Survey visitors/unique site
visitors)
N/A
Response rates
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
54
Checklist for Reporting Results of Internet E-Surveys (CHERRIES) tool
Item Category
Checklist
Item Provider
Explanation
Survey of Nurse
Practitioner
Knowledge, Barriers, and Current
Participation rate (Ratio of
864 respondents opened email
Practice in
Referring
unique visitors who agreed
to participate/unique first
High-risk
Patients
survey page
visitors)for Colorectal
Lecia ReardonCompletion
DNP Student
rate (Ratio of
Cancer Screenings
180
users who finished the
who agreed to
September 12,survey/users
2014
participate)
Yes automatic feature within Qualtrics®
Preventing multiple
entries from the same
individual
Cookies used
Yes
IP check
Per Qualtrics®
Log file analysis
Per Qualtrics®
Registration
Per Qualtrics®
Handling of incomplete
questionnaires
Yes, omitted from data analysis
Questionnaires submitted
with an atypical timestamp
None seen
Statistical correction
Did not count incomplete questionnaires
Analysis
(Eysenbach, 2004) (Source: Journal of medical internet research, 2004)
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
55
Appendix B
Survey Tool: Survey of nurse practitioner provider knowledge, barriers, and current
practice in referring high-risk patients for colorectal cancer screenings
Lecia Reardon DNP Student
East Carolina University
IRB approved on April 22, 2014
(Skip Logic) (Choose all that apply) Please choose the title(s) that best describes your current
Advanced Practice Nurse (APN) role?
*(Demographic descriptive)
o
o
o
o
o
o
Adult Nurse Practitioner (1)
Family Nurse Practitioner (2)
Doctorate in Nursing Practice (DNP) (3)
PhD (4)
Certified Registered Nurse Anesthetist (5)
Other: (please comment) (6) ____________________
*(If CRNA was selected, will exit before questions in survey begins)
Start of Survey
1. How many years have you been in clinical practice in your current APN role? (Ranges)
*(Demographic descriptive)




0-2 years (1)
> 2 to 5 years (2)
> 5 years to 10 years (3)
>10 years or more (4)
2. Please indicate which North Carolina County location of your NP practice (Free text or
dropdown box).
*(Demographic descriptive) County (1) ____________________
3. JL a 47 year old male comes to your office for his first physical in 20 years.
You complete a thorough history and examination with normal exam findings. PMHnonsmoker, no ETOH or drugs, BMI 27, normal vital signs, and no symptomatic complaints.
His family history is significant for Diabetes (mother), and benign polyps (father) removed at
age of 50. No other risk factors are reported by J.L. He asks you when he should get a screening
colonoscopy performed. Your recommendation is
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
56
*(knowledge based – NP practice pattern,+ family history polyps x 2 higher risk factors)





To refer for a screening colonoscopy at end of office visit (1)
At age 50, sooner if problems or symptoms develop (2)
At age 60 just like his father (3)
See him back in 1-2 years and do FOBT (fecal occult blood testing) (4)
I am not sure (5)
4. Individuals identified as “high-risk” for colon cancer should referred for colonoscopy
screenings
*(general high-risk screening practice pattern based question, NP knowledge)






Earlier, at least 5 years than low risk age of referral (1)
To be clinically determined by provider and patient based on risk factors (2)
At Age 40 years, or 10 years before the youngest case in the immediate family (3)
If symptomatic bleeding has occurred (4)
If having abdominal pain (5)
I am not sure (6)
5. My general personal opinion of colorectal cancer screening guidelines for high-risk
patients is that
*(opinion of clarity of guidelines, NP knowledge)
 The guidelines based on low, average, and high-risk leave a lot of room for error in making
recommendations. (1)
 The guidelines are clear and easily understood and make screening recommendation
guidelines easy to follow (2)
 I am not sure what the CRC screening guidelines are for high-risk patients (3)
6. BARRIERS (Please choose top 3 answers that apply):
Less than half of people who should be screened for colorectal cancer are having these
screenings. What do you feel are the top 3 barriers for patients in obtaining CRC screenings?
* (Any NP perceived barriers to screening- clinical question 2)
o
o
o
o
o
o
o
o
Uninsured/ not covered (1)
Patient refusal expressed due to modesty issues (2)
Patient refusal expressed due to religious issues (3)
Patient refusal expressed due to expressed fear of finding cancer (4)
Patient refusal expressed due to not wanting to do the bowel prep (5)
Lack of access – No Gastroenterology services in the community (6)
Lack of access- patient without transportation resources (7)
provider indifference among your peers or physicians (8)
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
o
o
o
o
Lack of adequate supplies for FOBT (9)
Other------------- (text comment) (10) ____________________
No barriers experienced in colorectal cancer screenings referral in my practice setting (11)
I do not refer patients for these screenings (12)
7. More educational opportunities are needed regarding high-risk colorectal screening
referral guidelines
*(Opinion, comfort with guideline clarity, NP knowledge- based question)
 Agree (1)
 Neither agree nor disagree (2)
 Disagree (3)
8. I feel knowledgeable in the current colorectal cancer high-risk factors and screening
recommendations.
*(Opinion, comfort with guideline clarity, NP knowledge- based question)
 Agree (1)
 Neither agree nor disagree (2)
 Disagree (3)
9. I believe colorectal cancer screening in high-risk populations following high-risk
guidelines can reduce cancer morbidity and possibly prevent colorectal cancer.
*(Opinion of the outcomes evidence, NP knowledge)
 Agree (1)
 Neither Agree nor Disagree (2)
 Disagree (3)
10. I feel confident and comfortable discussing colorectal cancer high-risk factors and
screening recommendations with my patients.
*(NP perceived comfort/ knowledge of screening recommendations)
 Agree (1)
 Neither Agree nor Disagree (2)
 Disagree (3)
57
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
58
11. I would like the opportunity to network with my regional cancer coalition network to
stay informed about screening and educational opportunities, survivorship support groups,
and information to share with my patients and families.
*(networking, inquiry – opinion )
 Agree (1)
 Neither Agree nor Disagree (2)
 Disagree (3)
12. Mrs. MN, a 35 year old female, comes to your clinic for a complete physical
as a new patient. You complete a thorough history and physical examination with normal
findings. She informs you that a sibling was diagnosed with familial adenomatous polyposis
(FAP). She asks when she should consider getting a screening colonoscopy (no prior screenings)
and your recommendation is
* (knowledge base- NP practice patterns of FAP high-risk guidelines)
 Tell patient you recommend “Annual FOBT (Fecal occult blood testing) in the office and
monitor for FOBT changes (4)
 Explain to patient “Since you are feeling well, just continue annual physical and obtain
routine colonoscopy at age of 50 years or sooner if you have symptoms” (5)
 Refer to gastroenterologist to schedule a screening flexible sigmoidoscopy and recommend
genetic testing (7)
 Recommend Genetic testing only (8)
13. DK, age 41, tells his NP provider “My uncle Ted and Aunt Jill both had colon cancer
but they were 60 years old when they got it. They did chemotherapy and treatments but didn’t
survive the cancer. I feel great and have no health problems. Do you think I need to get a
colonoscopy when I turn 50 years old like I hear on TV?” Your recommendation to this patient
is:
*(knowledge based- NP practice patterns of + FH 2 relatives higher risk for CRC)




“That sounds like a good idea. Will schedule one when you turn 50 years old” (9)
“You should really get one done now, as soon as we can get it scheduled.” (10)
“We can just watch you with FOBT stool testing” (11)
“You should get screened when you turn 45 years old” (12)
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14. TS, an 18 year old college freshman informs the NP that he has a family history of
sibling having HNPCC (hereditary nonpolyposis colon cancer) and wants to know when he
should be screened. Your recommendation is
* (knowledge based- NP practice patterns of HNPCC genetic history high-risk factors)





I am not sure (10)
FOBT (fecal occult blood testing) is appropriate to screen you at this age (13)
You should be screened with colonoscopy at age 26 (14)
You are at no greater risk than anyone else because this is so rare (16)
If you have not had a screening colonoscopy or offered genetic testing, we should schedule
this right away. (17)
15. JT, age 39, has history of Pancolitis and Crohn’s disease for 12 years and asks about
what type of screenings he needs to monitor for progression of disease and any preventive
screenings. Your response to this patient is
*(knowledge based- NP practice patterns of Crohn’s high-risk CRC guidelines)
 I am not sure (10)
 You should obtain a screening colonoscopy at age 50 or if any bleeding develops, sooner
(19)
 We can monitor FOBT annually, and schedule a screening colonoscopy every 5- 10 years
starting this year (20)
 You should have a colonoscopy done every 1-2 years with biopsies to monitor for dysplasia,
and we should refer you to a surveillance program at a gastrointestinal center that specializes
in Cohn’s disease (21)
16. JL, 45 year old homemaker has an annual physical in your office. She has no lifestyle
or family risk factors for colorectal cancer and normal exam findings. She asks about what
age she should get her first colonoscopy screening. She had heard these were important to get
done. Your advice is
* (knowledge base, NP practice patterns of average risk guideline question, control)
 50 (2)
 55 (3)
 45 (4)
 I am not sure (5)
{Key: 1: demographic, 2: free text, 3 (1), 4 (3), 5 opinion, 6 all that apply, 7-11 opinion, 12 (7),
13 (10), 14 (17), 15 (21), 16 (2)}
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
Appendix
CBB
60
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
Appendix D
Project Timeline: Scholarly Project
61
SURVEY OF NURSE PRACTITIONER KNOWLEDGE
62
Appendix E
Scholarly project funding and budget

2013 - 2014 NPHF/Procter & Gamble Gastroenterology Endowed Scholarship recipient
$1000.00 to cover educational and any project additional expenses

Sigma Theta Tau Beta Nu research and creativity award $1000
Initial Project funding was estimated to cost approximately $1000.00 to implement
and cover supplies and basic implementation of the scholarly project. Sigma Theta Tau*
Beta Nu (Chapter) scholarship provided funding in a research and creativity award received
in March, 2014. To achieve this funding, I applied for the scholarship, sought committee
feedback and input on the application, and was fortunate to be awarded this scholarship. The
funds thus far have been used for Eastern North Carolina Cancer Coalition Council meetings,
supplies, payment for the North Carolina Board of Nursing (NCBON) NP list, paper, and
voluntary drawing for two fifty dollar donations to the American Cancer Society in honor of
participants (paid directly to the American Cancer Society). It is noted that there may be
unforeseen additional costs and this will be closely monitored throughout the project
progression. Unrestricted scholarship funds or personal funds will cover any remaining
expenses. Proctor & Gamble* awarded 2013-2014 Nurse Practitioner Healthcare foundation
Gastroenterology endowed unrestricted scholarship to fund the studies and project needs.
The following expenses have been realized to date in this scholarly project:
1.
2.
3.
4.
5.
Eastern North Cancer Coalition Meeting $350
Survivorship Summit (Greensboro NC) $200
NCNA List serve for survey $225.00
American Cancer society $150- 3 $50 dollar donations drawings 10/28/2014
Travel for meetings for hotel / gas/ food (committee, chair, library resources)
$800.00
6. Remainder for any further poster presentations- $40.00
*Funding from these sponsors is greatly appreciated and does not bias scholarly project
results or reports.