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BREAST CANCER SCREENING GUIDELINES
Breast Cancer Screening Guidelines: Does Education to Healthcare Providers in an
Outpatient Office Setting Increase Number of Screenings?
By
Maggie Dempsey
Pennsylvania Western University
250 University Ave.
California, PA 15419
A DNP Project Submitted to Pennsylvania Western University
In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree
November 2024
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Table of Contents
Chapter 1: Overview of the Project……………………………………………………………….4
Chapter 2: Review of Literature…………………………………………………………………10
Chapter 3: Methodology…………………………………………………………………………14
Chapter 4: Results and Findings…………………………………………………………………18
Chapter 5: Discussion of Findings…………………………………………………………….…23
References……………………………………………………………………………………….26
Appendix A. Pretest and Posttest 10-Question Assessment………………………………..……30
Appendix B. Breast Cancer Screening Guidelines Google Slides Presentation……………...….36
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Abstract
Breast cancer affects people all ages, genders, and races. The ways in which providers prevent
and detect breast cancer have change significantly over the years. Healthcare providers have a
number of resources to utilize to screen patients for breast cancer appropriately. However,
providers do not always follow the guidelines that are recommended likely due to lack of
knowledge. The purpose of this evidence-based quality improvement project was to increase
healthcare provider knowledge about current breast cancer screening guidelines and
recommendations. In August of 2024 over a two-week period, healthcare providers at a federally
qualified health center look-alike were asked to participate in an evidence-based quality
improvement project concerning breast cancer screening guidelines. Participants completed a
pretest and posttest questionnaire to measure if there was an increase in knowledge after
completing the presentation. Fifteen participants completed both the pretest and posttest. A
paired-samples t-test was utilized to analyze data which resulted in a statistically significant
finding. These results conclude that a breast cancer screening guidelines presentation helps to
increase provider knowledge.
Keywords: breast cancer screenings, guidelines, education, federally qualified health
center, provider knowledge
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Chapter 1: Overview of the Project
Guidelines are tools that healthcare providers use frequently to help treat patients
appropriately. Healthcare providers are fortunate to have guidelines at their disposal to help
screen patients for multiple diseases. Breast cancer screening guidelines are being researched and
updated often. A mammogram is a screening tool providers can use and educating healthcare
providers about the current guidelines is an important way to help identify breast cancer early.
Not all healthcare providers are aware of the most current guidelines available. Some
newer providers are not educated on the topic, and some of the more experienced providers are
using outdated guidelines. The American College of Obstetrics and Gynecology (ACOG), the
United States Preventive Service Task Force (USPSTF), and the American Cancer Society
(ACS) are common guidelines that healthcare providers use when treating patients. This Doctor
of Nursing Practice (DNP) evidence-based practice project aimed to increase knowledge of staff
and improve patient outcomes.
About one in eight women will develop breast cancer in their lifetime, and it is the
second leading cause of cancer death in women (ACS, 2023a). Since 1989 there has been a
steady decline in the breast cancer death rate (ACS, 2023a). This decrease is believed to be
related to increased awareness and screening methods (ACS, 2023a). One screening method that
is sometimes underutilized is the mammogram. A mammogram takes an x-ray picture of the
breast, and it is a tool that helps to identify breast cancer sometimes up to three years before it
can be felt (Centers for Disease Control and Prevention, 2022).
An educational Google Slides presentation summarized current breast cancer screening
guidelines to help increase healthcare provider knowledge at a primary care office. Increase in
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knowledge was measured by a pretest and posttest survey. Number of screenings documented at
the primary care office before and after the presentation were documented and discussed.
This project helped to extend prior research Rehman et al. (2022) conducted regarding
healthcare professionals lacking knowledge about screening tools and breast cancer risk factors.
Why has there been a decline in mammogram screening in women? Tsapatsaris et al. (2022)
discussed barriers to breast cancer screening for women. This project helped to close the gap in
literature by helping to increase adherence to current guidelines through an educational
presentation.
Background Context and Theoretical Framework
Guidelines and recommendations regarding breast cancer change constantly. It is difficult
for primary care providers to keep up with the changes. The people that suffer from missed
screenings are the patients. There are a multitude of findings that support screening for breast
cancer and encouraging patients to get yearly mammograms. However, more can be done to help
educate providers and screen more women to ultimately prevent women from dying from breast
cancer.
The Donabedian Model of Quality Care framework was the theoretical framework the
project followed. The three parts of the framework are: structure, process, and outcome
(Donabedian, 1988). The structure stands for the place the project took place along with the
providers and technology. The process stands for the intervention aimed at increasing provider
knowledge of breast cancer screening guidelines. The outcome is measurement of effectiveness
of the presentation and adhering to the recommendations summarized.
The nursing theory used for this project was Jean Watson’s theory of Transpersonal
Caring. The theory discusses how nursing involves promoting health and preventing illness
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(Watson, 2012). If a person does become ill, then nurses care for the sick and try to restore health
(Watson, 2012). Following guidelines regarding breast cancer screenings, is a way of promoting
health and preventing illness.
Problem Statement
About one in every thirty-nine women diagnosed with breast cancer will die from breast
cancer (ACS, 2023a). Without screening tools and treatment, that number would be much higher.
If providers use breast cancer screening guidelines, this will help to identify disease and get
treatment for patients sooner rather than later. It is not known why healthcare providers do not
screen using the recommended breast cancer screening guidelines.
Duffy et al. (2023) discussed the benefits of annual screenings and how missing one
screening appointment increases the risk of dying from breast cancer. There are multiple reasons
why women do not go for their annual breast cancer screening. First and foremost, they do not
know their risk. Patients need their healthcare provider to encourage and advise them to proceed
with a mammogram screening if they could benefit from it. In addition, do the healthcare
providers know who is at risk or when to start screening?
There have been multiple changes to breast cancer screening over the years. Certain
guidelines recommend screening women with average risk for breast cancer starting at age 40
with mammograms every year (ACS, 2023b). Other guidelines recommend to screen women
starting at age 40 and recommend mammograms every other year (USPSTF, 2024).
At the proposed site, there are multiple missed opportunities when it comes to screening
patients for breast cancer. Many providers only screen during preventative yearly exams.
However, in reality providers can and should be screening for breast cancer during every patient
encounter. Women are dying from breast cancer and there are ways in which this number can be
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lowered. Barriers result in less women that are screened for breast cancer and result in poorer
outcomes for patients and their families.
Purpose of the Study
The purpose of this evidence-based quality improvement project was to increase provider
knowledge of current breast cancer screening recommendations at a federally qualified health
center look-alike through an informational presentation. The proposed project used a pretest
posttest design to measure the degree of change based on the informational presentation
summarizing breast cancer screening recommendations. The goal of this project was to help to
educate providers and increase recommended screening practices.
The project took place at a federally qualified health center (FQHC) look-alike in
Northeastern Pennsylvania. The target population was the group of health care providers at the
FQHC look-alike. The informational presentation was distributed to the healthcare providers via
work email and participation was optional and anonymous. Information obtained will help to
contribute to the numerous other studies regarding breast cancer screening.
Research Question
The quality improvement project attempted to answer the following question: Does an
informational presentation summarizing current breast cancer screening recommendations help
to improve provider knowledge at a federally qualified health center look-alike? This project
relates to the current problem of women not being screened for breast cancer. Healthcare
providers are not aware of new guidelines and are not screening eligible women.
Rationale for the Study
Using a pretest posttest design was the best approach to achieve the goal of answering the
research question. Stratton (2019) discussed how a pretest posttest design gives directionality.
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This method is beneficial with quality improvement projects because one is able to test the
dependent variable of knowledge before and after the intervention (Stratton, 2019). The pretest
gave a baseline for what the participants knowledge level was prior to the informational
presentation. The posttest was given after the presentation to see if there was an improvement in
scores.
Significance of the Study
Why are women not being screened for breast cancer? Even with today's technology and
treatment advances, about 43,000 women died from breast cancer in 2023 (ACS, 2023a). Jean et
al. (2023) discusses the importance of evaluating barriers preventing women from obtaining
mammograms. Barriers that prevent women from being screened for breast cancer include:
language barriers, race, gender identity, religion, sexual orientation, and socioeconomic status
(Jean et al., 2023). Utilizing a presentation to help clarify guidelines and teach providers, can be
a way to evaluate one of the barriers. Whether or not a provider recommends a mammogram, is
a barrier that needs to be overcome.
Definitions of Terms
Definition of terms used for this project can be found below.
Breast Cancer Screenings: According to the American Cancer Society (2023b),
screening for breast cancer includes using tests and exams to find disease in people who
do not display symptoms.
This project defines breast cancer screenings, as imaging, genetic tests, or physical exams
to help detect breast cancer in asymptomatic patients.
Provider: Merriam-Webster Dictionary (n.d.-a) defines provider as one that provides.
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This project defines a provider as medical doctors, doctors of osteopathic medicine, nurse
practitioners, physician assistants, licensed practical nurses, or registered nurses in a
primary care setting that provide care to patients.
Knowledge: Merriam-Webster (n.d.-b) states knowledge is gained through experience
and is the condition of knowing something with familiarity.
This project defines knowledge as the information that is obtained and utilized after an
educational presentation about breast cancer screening.
Federally Qualified Health Center: Rural Health Information Hub (n.d.) defines
Federally Qualified Health Center (FQHC) as outpatient clinics. Under Medicare and
Medicaid, a FQHC qualifies for certain reimbursement systems.
For the purpose of this project, FQHC is defined as the outpatient primary care office
where the project will take place.
Breast cancer screening guidelines are frequently updated and adjusted. Healthcare providers
should be aware of changes and educate patients accordingly. Educating providers about the
current guidelines will ultimately help with early detection of breast cancer. Also, provider
education will help to prevent over-screening. A Google Slides presentation discussing current
guidelines, helped to educate providers. In order to determine if the presentation increased
education regarding screening guidelines, a pretest and posttest were utilized. Breast cancer is a
devastating disease that affects countless people every day. Increasing screening will help to
decrease the number of people devastated by this disease.
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Chapter 2: Review of Literature
The Doctor of Nursing Practice (DNP) project focuses on using previous research and
building upon that research to help bridge the gap. Breast cancer screenings and methods of
improving adherence to current literature was the main focus of this DNP project. The purpose of
this chapter is to review the existing literature regarding preventative screening guidelines and
methods of educating healthcare providers. This quality improvement project aimed at
implementing best practices as indicated in the research identified.
The literature review was conducted using PubMed. Initial search consisted of keywords
breast cancer and 516,628 results were found. The search was then filtered to only include
articles within the last 5 years (2019-2024). This filter resulted in 134,077 articles. Next,
screening guidelines were added to breast cancer and this resulted in 2,377 results. Finally,
adding adherence to the above keywords resulted in 252 articles. Free full text filter and peer
reviewed filters were used which resulted in 164 research articles to investigate for this literature
review This chapter will be separated into barriers and review of the literature.
The main problem regarding breast cancer screening relates to adherence to guidelines.
The gap in research relates to the barriers that prevent healthcare providers from adhering to the
guidelines. This DNP project helped to see if provider knowledge and awareness are one of the
barriers.
Rehman et al. (2022) performed an interventional study with 260 medical professionals.
An educational session was utilized to educate the health professionals about breast cancer risks
and guidelines (Rehman et al., 2022). A questionnaire was utilized for before and after to
determine effectiveness of the educational session (Rehman et al., 2022). Results showed an
increase in knowledge after the intervention (Rehman et al., 2022).
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Friedman-Eldar et al. (2020) conducted a retrospective observational study between the
years 2012 and 2015. Researchers examined women diagnosed with breast cancer for the first
time at Kaplan Medical Center, Rehovot, Israel (Friedman-Eldar et al., 2020). Women were
separated into two groups which included early-stage breast cancer and advanced breast cancer
(ABC; Friedman-Eldar et al., 2020).
The primary outcome included whether or not patients adhered to the guidelines in Israel
during that time (Friedman-Eldar et al., 2020). Results showed that screening mammography
reduced the likelihood of diagnosis at an advanced stage. However, there was a significant
portion of women who presented with advanced disease even with following current
recommended guidelines. Friedman-Eldar et al. (2020) discussed how extending the guidelines
to include women younger than 50 would help with diagnosing at an earlier stage.
Wehbe et al. (2023) performed a study to determine predictors of nonadherence to breast
cancer screening guidelines among women. Researchers reviewed charts of women who received
more than one screening mammogram in order to see if guidelines were followed related to
breast cancer risk and breast density (Wehbe et al., 2023). Wehbe et al. (2023) utilize the
American Cancer Society recommendations regarding yearly mammography and breast
magnetic resonance imaging (MRI) for women considered high risk starting at age 30.
Results showed that providers underutilized supplemental screening tools like a breast
magnetic radiation imaging (MRI) for women who were at increased risk for breast cancer
(Wehbe et al., 2023). Barriers to supplemental screening include lack of knowledge by the
healthcare provider (Wehbe et al., 2023). Wehbe et al. (2023) suggested that the lack of
standardized screening guidelines for women with dense breasts, may influence healthcare
providers to order supplemental imaging.
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A cross-sectional web-based survey was conducted in Minnesota to determine breast
cancer screening practices among primary care providers (Blaes et al., 2020). The questionnaire
focused on screening practices among women at increased risk for breast cancer (Blaes et al.,
2020). Less than half of the providers recommended a breast MRI in addition to the screening
mammography (Blaes et al., 2020). Researchers concluded that there is a need for increased
education among healthcare providers (Blaes et al., 2020). To summarize, providers were not
following current guidelines.
A qualitative research project was conducted in Indonesia to determine the barriers to
early detection of breast cancer (Icanervilia et al., 2023). Subjects included breast cancer
patients, healthcare professionals, and healthy womens with no history of breast cancer
(Icanervilia et al., 2023). Through in-depth interviews, researchers collected data to investigate
barriers to the delay in breast cancer detection (Icanervilia et al., 2023). Barriers include public
awareness, access to health services, enhancing the referral system, and strengthening the health
facilities (Icanervilia et al., 2023).
Nachtigal et al. (2020) surveyed healthcare providers in Wisconsin in 2018. Researchers
used a 46-question survey about breast cancer screening among women of average risk
(Nachtigal et al., 2020). Survey was sent to 1031 providers and 295 people responded. The
majority of respondents chose U. S. Preventive Services Task Force (USPSTF) as very
influential in regards to their decision making (Nachtigal et al., 2020). However, it was
discovered that most of those providers were not following the USPSTF recommendations
(Nachtigal et al., 2020). In addition, Nachtigal et al. (2020) concluded that healthcare providers
in Wisconsin overestimate the usefulness of clinical and self-breast exams despite
recommendations against them.
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Chandra et al. (2023) investigated the effectiveness of an employer-based health program
on increasing mammography adherence. The study included 318 women from a Texas-based
company (Chandra et al., 2023). Researchers concluded that an employer-based health
promotion program alone was insufficient in improving breast cancer screening.
Determinants of mammogram adherence included access to healthcare coverage, those
who disagree with belief that everything causes cancer, and those who perceive cancer screening
as important (Chandra et al., 2023). The lack of association between increase in adherence to
breast screening guidelines and an employer-based health promotion program, may indicate the
absence of enough information or support (Chandra et al.,2023). Therefore, one can conclude
more education needs to take place to help promote adherence to guidelines.
Overall, the above research highlights the needs and the barriers regarding breast cancer
screening and adhering to guidelines. The research discusses the importance of education.
Educating the public about their risk for cancer is important to promote adherence. Educating
healthcare providers about current and recommended guidelines will help to improve care given
to patients. To overcome the barriers, it is important to continue to learn and grow as providers.
Contradicting guidelines can cause confusion among providers. Therefore, knowing the research
that supports the guidelines is important to share with patients.
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Chapter 3: Methodology
The focus of this quality improvement project was to increase healthcare provider
knowledge about current breast cancer screening recommendations at a federally qualified health
center look-alike in Northeastern PA. The project took place in August of 2024, and gained
internal review board approval from both the Wright Center for Community Health and
Pennsylvania Western University. This chapter is composed of how the project was carried out
and the methodology used.
Research Question
The group of healthcare providers treat patients in the primary care setting. The pretest
posttest design helped to see if the breast cancer screening guidelines presentation was effective
at increasing knowledge of the participants. Knowledge refers to an increased understanding of
breast cancer screening guidelines. The participants were recruited via work email. Google
Slides was utilized for the breast cancer screening guidelines presentation. Google Forms was
utilized for the pretest and posttest. Participation in the project was optional and the pretest and
posttest responses were anonymous and kept secure. The initial email gave the purpose of the
project and link to the pretest. Three days after sending the initial email, a follow-up email was
sent with a link to the Google Slides presentation and posttest.
Research Design and Methodology
The pretest posttest design helped to answer the research question. This methodology was
used as opposed to other designs because pretest and posttest design gives directionality and the
student was able to test the dependent variable before and after the intervention (Stratton, 2019).
The quantitative research design allowed the student to measure knowledge quantitatively by
comparing the pretest and posttest scores.
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The quasi-experimental design was chosen in order to evaluate the effectiveness of the
educational presentation. Ledford and Gast (2014) discuss how the main advantage of the onegroup pretest-posttest is the opportunity to compare scores of participants before and after the
treatment in the same group of participants. The educational Google Slides presentation was
utilized as the intervention. The pretest and posttest scores were used to determine the
effectiveness of the presentation.
Population and Sample Selection
The target population for this project were healthcare providers who worked in nine
outpatient offices located throughout Northeastern PA. For the purpose of this study, healthcare
providers included: 24 internal and family medicine attendings, 18 advanced practice providers,
and 27 nurses. In order to increase the sample size, the project was also emailed to the internal
medicine residents that participate within Graduate Medical Education program.
Emails were addressed to the healthcare. Healthcare providers included the family and
internal medicine attendings and residents, nurse practitioners, physician assistants, and nurses.
Convenience sampling was used to enroll participants. Emails were sent to participants’ work
email.
The facility has an internal review board (IRB). IRB approval was obtained before the
quality improvement project took place. The student completed necessary training courses and
submit forms to IRBNet before the IRB scheduled meeting in order to obtain approval. All
materials used for the project needed to gain approval as well.
When the participant filled out the pretest, they were asked to create their own unique
identifier. The unique identifier consisted of one letter and two numbers. The participants were
asked to remember this and use their unique identifier for the posttest. This information was kept
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secure in an Google Sheet. Three days after the pretest was emailed, the participant was then
asked to complete the self-guided Google Slides presentation and posttest. The posttest results
were documented in a secure Google Sheet. A third Google Sheet was utilized to complete the
analysis of data after two weeks of data collection. A paired-samples t-test was performed to see
if scores improved, decreased, or stayed the same after the educational presentation.
Instrumentation or Sources of Data
Validity and Reliability
The pretest questionnaire (Appendix 1) was developed by the student, and had face
validity only. Questions were reviewed and revised by the project mentor. Next, the
questionnaire was submitted to the IRB. The pretest consisted of a series of questions measuring
the healthcare provider's knowledge prior to the educational presentation. The posttest consisted
of the same series of questions.
Data Collection and Management
Data collection included Google Forms and Google Sheets. The pretest and posttest were
out of 10 total possible points. In addition, demographic information collected included: job title,
gender, age, and education background. The participants' pretest score was compared to their
posttest score. Statistical analysis was run on the data using a paired t-test. Alpha was set at 0.05.
If the p value was less than 0.05, then this student could reject the null hypothesis and results
could be considered statistically significant. Information is kept secure and anonymous. Results
were analyzed while on a secure password protected network.
Limitations
Limitations include distributing the presentation through email. Some participants may
not check email or only fill out the pretest. Participant completion of both the pretest and posttest
BREAST CANCER SCREENING GUIDELINES
is necessary to accurately compare results. The participants must also remember their unique
identifier. Participants may forget the unique identifier they created which will make results
difficult to analyze accurately. Timeframe is also a limitation. Two weeks is a short amount of
time to complete the project. Also, the test being used to measure knowledge does not have
established reliability.
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Chapter 4: Results and Findings
The purpose of this evidence-based quality improvement project was to increase
knowledge of healthcare providers about current breast cancer screening guidelines. Guidelines
were summarized and placed into an informational Google Slides presentation. Healthcare
providers were given the opportunity to participate in the quality improvement project from
Monday August 12th, 2024 until Monday August 26th, 2024.
One hundred fifty-two emails were sent to healthcare providers with information about
the project and link to a pretest. Three days later, the same employees were emailed a link to the
presentation and posttest. Thirty-two employees completed the pretest and 21 employees
completed the posttest. Return rate for the pretest was 21% and 14% for the posttest. Fifteen
respondents were used for final analysis. Fifty-two percent of the posttest responses were not
utilized due to different unique identifier used between pretest and posttest. Data and results
were analyzed using Google Sheets and XL Miner Application. XL Miner Application is free
add-in software available to Google Sheets users.
Sample Characteristics
Table 1 shows the participant demographics. Fourteen females and one male completed
both the pretest and posttest. Ages ranged from 28 to 56 and two respondents chose not to
answer. Six of the participants were nurses. Five of the participants were nurse practitioners or
physician assistants. Two of the participants were family medicine doctors and two were internal
medicine doctors. Five of the participants had a high school diploma or a general educational
development (GED) diploma. One of the participants had a bachelor’s degree. Three of the
participants had a master’s degree, and six of the participants had a doctoral degree.
Table 1
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Participant Demographics
Characteristic
n
%
Age
20-29
30-39
40-49
50+
Prefer not to answer
2
7
2
2
2
13.3
46.6
13.3
13.3
13.3
Gender
Male
Female
1
14
6.6
93.3
Profession
Nurse
Nurse Practitioner/
Physician Assistant
Physician
6
5
40
33.3
4
26.6
Highschool / GED
Bachelor’s
Masters
Doctorate
5
1
3
6
33.3
6.67
20
40
Education
Results
Figure 1 shows the individual’s pretest and posttest score. XL Miner Analysis application
through Google Sheets was used to perform data analysis and descriptive statistics. A pairedsamples t-test was conducted in order to determine if the participants pretest score was
significantly different from the posttest score. Table 2 shows the results of the paired-samples ttest. Average score of the pretest was 5.13, and average score of the posttest was 8.86. The
standard deviation of the pretest was 2.53, and the standard deviation of the posttest was 1.80.
Range of the pretest was 9, and range of the posttest was 7. Variance of the pretest was 6.40, and
variance of the posttest was 3.26. Alpha was set a 0.05. P value was found to be 0.0001.
Figure 1
Pretest Posttest Results
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Pretest Posttest Results
Questionaire Score
12
9
10
7
8
10
10
8
10
7
1010
8
10
8
6
6
9
8
5
2
2
1
2
10
9
5
3
4
10
5
6
9
7
33
0
A11 L56 X12 JB1 M12 C13 S56 T90 L22 D07 A10 A93 K17 A20 E14
Unique Identifer
Pretest Score
Posttest Score
Note. The pretest results of participants are shown in pink and the posttest results of participants
are shown in purple. The x-axis is the unique identifier and the y-axis is the questionnaire score.
Table 2
Paired Sample t-test
Pretest
Posttest
N
Mean
SD
Range
Variance
15
15
5.13
8.86
2.53
1.80
9
7
6.40
3.26
Significance
p = 0.0001057
Electronic Health Record Data
Upon completion of the quality improvement project, data was obtained with the help of
the Clinical Quality Compliance and Reporting Manager at the facility. Table 3 shows data that
was complied. Four weeks prior the quality improvement project (July 14th, 2024 – August 10th,
2024) 2,831 female patients between the ages of 40-74 were seen for appointments. Of those
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2,831 patients, 1,598 women did not have a mammogram screening on file in the last 18 months.
Of the 1,598 women, 578 women had a mammogram ordered during their visit. This resulted in
1,020 missed screenings.
Data was also analyzed four weeks after the completion of the project between August
27th, 2024 and September 24th, 2024. During that time span, 3,139 women were seen for
appointments. Of the 3,139 women, 1,829 patients did not have a mammogram on file for the
last 18 months. Of the 1,829 women that were seen for an appointment, 548 women had a
mammogram ordered. This resulted in 1,281 screenings that were missed.
Table 3
Electronic Health Record Data
Pre-Intervention Electronic Health Record
Data
Women Aged 40-74 Seen for
Appointment
2831
No Mammogram on File
1598
Women who had mammogram
ordered
578
Screenings missed
1020
Percentage of screenings completed 36.17%
Percentage of screenings missed
63.80%
Post-Intervention Electronic Health Record
Data
Women Aged 40-74 Seen for
Appointment
3139
No Mammogram on File
1829
Women who had mammogram
ordered
548
Screenings missed
1281
Percentage of screenings completed 30%
Percentage of screenings missed
70%
Data Limitations
In order to keep results anonymous, emails were not collected. Participants were able to
submit more than one pretest and posttest. In addition, for the majority of the project the pretest,
presentation, and posttest could be accessed at the same time. Participants could have taken the
pretest after the presentation which could have also affected the results. This could have been
prevented by ending the pretest date when the posttest started. Small sample size is an additional
limitation of this project and data analysis. Results may have been different with a larger sample
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size. Sample size was likely influenced by staff on vacation and limited timeline to complete
project.
In regards to the electronic health records that were analyzed, limitations include
mammograms not documented. Meaning, patients may have actually completed the
mammogram, but it was not properly pulled into the system and documented appropriately. Also,
many women have their mammograms ordered by their women’s health provider.
Summary
Overall, data analyzed comparing pretest and posttest scores were statistically significant
using a paired-samples t-test. Average score of the 10-question pretest improved after
participants completed the self-guided Google Slides presentation regarding breast cancer
screening guidelines. We can infer that the participants gained a better understanding and
increased knowledge of current guidelines and recommendations after completing the
presentation. This data can be helpful to future projects that aim to increase knowledge of breast
cancer screening guidelines and increase number of screenings.
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Chapter 5: Discussion of Findings
The purpose of this evidence-based quality improvement project was to increase provider
knowledge through an educational presentation regarding breast cancer screening guidelines at a
federally qualified health center look-alike. The project took place in August of 2024 over a twoweek period. This chapter will discuss findings of this project and how it relates to future
practice regarding breast cancer screenings and recommendation. This chapter will cover
summary of findings, implications, and recommendations for future practice.
Summary of Findings
Overall, the majority of the healthcare providers that participated in the project had
improved scores after completing the presentation. Scores of the 10-question assessment
improved significantly after completion of the Google Slides presentation regarding breast
cancer screening guidelines. Fifteen participant responses were utilized for data analysis. Data
analysis was completed using Google Sheets and XL Miner Application. The paired-samples ttest resulted in a p-value of less than 0.05.
Data collected from the electronic health record showed there were multiple missed
opportunities for mammograms. Yearly mammograms ordered prior to the quality improvement
project were compared to the number of yearly mammograms ordered after the quality
improvement project was completed. There was an increase in missed mammograms after the
quality improvement project was completed.
Implications
Breast cancer is a disease that continues to devastate patients and their families.
Screening patients on time and routinely could help to lessen this devastation. Education and
knowledge are the keys to screening more patients. Results from this project have implications
BREAST CANCER SCREENING GUIDELINES
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for nursing practice. Providers demonstrated increased understanding of current breast cancer
screening guidelines after completing the presentation. Thus, implementing a self-guided
presentation into a yearly educational module required by providers can help to increase
awareness of current guidelines and ultimately improve screening numbers.
Limitations for this quality improvement include timeline for the project and small
sample size. It took place over a two-week period which is a short amount of time. The project
took place in August in which many providers were out of office on vacations. Due to time
constraints and provider availability, an in-person presentation was not a realistic option. Future
projects should include a larger cohort from multiple outpatient offices including women’s health
facilities.
Recommendations
It is recommended that providers continue to utilize current guidelines and screening
tools with every patient encounter. Healthcare providers should be aware which guideline they
are using the research that supports the recommendations. Patients place an immense amount of
trust in their clinician, and in return healthcare providers should make sure they are following
evidence-based practice.
The goal of clinicians is to provide quality care to all patients. Researchers need to further
investigate why and how more patients can be screened. This quality improvement project
helped to understand that knowledge and awareness of current guidelines are likely barriers that
prevent more women from getting screened for breast cancer.
Conclusion
Overall, patients deserve to be treated by healthcare providers that utilize evidence-based
guidelines and recommendations. Breast cancer screening tools and recommendations have
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changed significantly over time. Education and knowledge are barriers that can prevent
screenings. A presentation that summarizes these recommendations for providers can help to
increase their knowledge and ensure they are up to date on current research. Learning more ways
to help increase knowledge and awareness can ultimately help to increase screenings and help to
detect breast cancer sooner rather than later.
BREAST CANCER SCREENING GUIDELINES
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References
American Cancer Society. (2023a). Key statistics for breast cancer.
https://www.cancer.org/cancer/types/breast-cancer/about/how-common-is-breastcancer.html
American Cancer Society. (2023b). American Cancer Society recommendations for the early
detection of breast cancer. https://www.cancer.org/cancer/types/breast-cancer/screeningtests-and-early-detection/american-cancer-society-recommendations-for-the-earlydetection-of-breast-cancer.html
Blaes, A., Vogel, R. I., Nagler, R. H., Allen, A., Mason, S., Teoh, D., Talley, K., Raymond, N.
C., & Wyman, J. F. (2020). Breast cancer screening practices for high-risk women: A
cross-sectional survey of primary care providers. Journal of Women's Health, 29(5), 686–
692. https://doi.org/10.1089/jwh.2018.7463
Centers for Disease Control and Prevention. (2022). What is a mammogram?.
https://www.cdc.gov/cancer/breast/basic_info/mammograms.htm
Chandra, M., Yu, R., & Shete, S. (2023). Association between employer-based health promotion
programs and adherence to breast cancer screening in Texas. Preventive Medicine
Reports, 32, 102128. https://doi.org/10.1016/j.pmedr.2023.102128
Donabedian, A. (2005). Evaluating the quality of medical care. The Milbank Quarterly, 83(4),
691–729. https://doi.org/10.1111/j.1468-0009.2005.00397.x
Donabedian, A. (1988). The quality of care. How can it be assessed?. The Journal of the
American Medical Association, 260(12), 1743–1748.
https://doi.org/10.1001/jama.260.12.1743
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Duffy, S. W., Yen, A. M., Tabar, L., Lin, A. T., Chen, S. L., Hsu, C. Y., Dean, P. B., Smith, R.
A., & Chen, T. H. (2023). Beneficial effect of repeated participation in breast cancer
screening upon survival. Journal of Medical Screening, 31(1), 3–7.
https://doi.org/10.1177/09691413231186686
Friedman-Eldar, O., Zippel, D., Guy-Chen, H., Eitan Gur, S., Ben-Baruch, N., Sharon, E., &
Allweis, T. M. (2020). Advanced breast cancer at diagnosis: Over one third adherent to
screening recommendations. Women's Health Reports, 1(1), 301–307.
https://doi.org/10.1089/whr.2020.0044
Icanervilia, A. V., Choridah, L., Van Asselt, A. D. I., Vervoort, J. P. M., Postma, M. J.,
Rengganis, A. A., & Kardinah, K. (2023). Early detection of breast cancer in Indonesia:
Barriers identified in a qualitative study. Asian Pacific Journal of Cancer Prevention:
APJCP, 24(8), 2749–2755. https://doi.org/10.31557/APJCP.2023.24.8.2749
Jean, S., Vishwanath, V., Chung, H. L., & Moseley, T. W. (2023). Identifying and reducing
barriers to breast imaging. Current Breast Cancer Reports, 15(2), 114–118.
https://doi.org/10.1007/s12609-023-00480-8
Ledford, J. R., & Gast, D. L. (Eds.). (2014). Single case research methodology: Applications in
special education and behavioral sciences. Routledge.
https://www.taylorfrancis.com/books/edit/10.4324/9780203521892/single-case-researchmethodology-david-gast-jennifer-ledford
Merriam-Webster. (n.d.-a). Provider. In Merriam-Webster.com dictionary. Retrieved June 15,
2023, from https://www.merriam-webster.com/dictionary/provider
Merriam-Webster (n.d.-b). Knowledge: In Merriam-Webster.com dictionary. Retrieved June 15,
2023, from https://www.merriam-webster.com/dictionary/knowledge#:~:text=a(1),b(1)
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Nachtigal, E., LoConte, N. K., Kerch, S., Zhang, X., & Parkes, A. (2020). Variation in breast
cancer screening recommendations by primary care providers surveyed in Wisconsin.
Journal of General Internal Medicine, 35(9), 2553–2559. https://doi.org/10.1007/s11606020-05922-y
Rehman, H. T., Jawaid, H., Tahir, A., Imtiaz, M., Zulfiqar, T., & Aziz, T. (2022). Breast cancer
knowledge among health professionals: A pre-post-knowledge-based intervention study.
Journal of Family Medicine and Primary Care, 11(9), 5649–5655.
https://doi.org/10.4103/jfmpc.jfmpc_1226_22
Rural Health Information Hub. (2021). Federally qualified health centers (FQHCs) and the
health center program. https://www.ruralhealthinfo.org/topics/federally-qualified-healthcenters
Stratton S. J. (2019). Quasi-experimental design (pre-test and post-test studies) in prehospital and
disaster research. Prehospital and Disaster Medicine, 34(6), 573–574.
https://doi.org/10.1017/S1049023X19005053
Tsapatsaris, A., Babagbemi, K., & Reichman, M. B. (2022). Barriers to breast cancer screening
are worsened amidst COVID-19 pandemic: A review. Clinical Imaging, 82, 224–227.
https://doi.org/10.1016/j.clinimag.2021.11.025
United States Preventive Services Task Force. (2024). Breast cancer: Screening.
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancerscreening#:~:text=The%20Task%20Force%20recommends%20that,This%20is%20a%20
B%20grade.
Watson J. (2012). Human caring science: A theory of nursing (2nd ed.). Jones and Bartlett
Learning
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Wehbe, A., Gonte, M. R., O'Neill, S. C., Amit-Yousif, A., Purrington, K., Manning, M., &
Simon, M. S. (2023). Predictors of nonadherence to breast cancer screening guidelines in
a United States urban comprehensive cancer center. Cancer Medicine, 12(14), 15482–
15491. https://doi.org/10.1002/cam4.6182
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Appendix A
Pretest and Posttest 10-Question Assessment
30
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Appendix B
Breast Cancer Screening Guidelines Google Slides Presentation
36
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Breast Cancer Screening Guidelines: Does Education to Healthcare Providers in an
Outpatient Office Setting Increase Number of Screenings?
By
Maggie Dempsey
Pennsylvania Western University
250 University Ave.
California, PA 15419
A DNP Project Submitted to Pennsylvania Western University
In Partial Fulfillment of the Requirements for the Doctor of Nursing Practice Degree
November 2024
1
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Table of Contents
Chapter 1: Overview of the Project……………………………………………………………….4
Chapter 2: Review of Literature…………………………………………………………………10
Chapter 3: Methodology…………………………………………………………………………14
Chapter 4: Results and Findings…………………………………………………………………18
Chapter 5: Discussion of Findings…………………………………………………………….…23
References……………………………………………………………………………………….26
Appendix A. Pretest and Posttest 10-Question Assessment………………………………..……30
Appendix B. Breast Cancer Screening Guidelines Google Slides Presentation……………...….36
BREAST CANCER SCREENING GUIDELINES
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Abstract
Breast cancer affects people all ages, genders, and races. The ways in which providers prevent
and detect breast cancer have change significantly over the years. Healthcare providers have a
number of resources to utilize to screen patients for breast cancer appropriately. However,
providers do not always follow the guidelines that are recommended likely due to lack of
knowledge. The purpose of this evidence-based quality improvement project was to increase
healthcare provider knowledge about current breast cancer screening guidelines and
recommendations. In August of 2024 over a two-week period, healthcare providers at a federally
qualified health center look-alike were asked to participate in an evidence-based quality
improvement project concerning breast cancer screening guidelines. Participants completed a
pretest and posttest questionnaire to measure if there was an increase in knowledge after
completing the presentation. Fifteen participants completed both the pretest and posttest. A
paired-samples t-test was utilized to analyze data which resulted in a statistically significant
finding. These results conclude that a breast cancer screening guidelines presentation helps to
increase provider knowledge.
Keywords: breast cancer screenings, guidelines, education, federally qualified health
center, provider knowledge
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Chapter 1: Overview of the Project
Guidelines are tools that healthcare providers use frequently to help treat patients
appropriately. Healthcare providers are fortunate to have guidelines at their disposal to help
screen patients for multiple diseases. Breast cancer screening guidelines are being researched and
updated often. A mammogram is a screening tool providers can use and educating healthcare
providers about the current guidelines is an important way to help identify breast cancer early.
Not all healthcare providers are aware of the most current guidelines available. Some
newer providers are not educated on the topic, and some of the more experienced providers are
using outdated guidelines. The American College of Obstetrics and Gynecology (ACOG), the
United States Preventive Service Task Force (USPSTF), and the American Cancer Society
(ACS) are common guidelines that healthcare providers use when treating patients. This Doctor
of Nursing Practice (DNP) evidence-based practice project aimed to increase knowledge of staff
and improve patient outcomes.
About one in eight women will develop breast cancer in their lifetime, and it is the
second leading cause of cancer death in women (ACS, 2023a). Since 1989 there has been a
steady decline in the breast cancer death rate (ACS, 2023a). This decrease is believed to be
related to increased awareness and screening methods (ACS, 2023a). One screening method that
is sometimes underutilized is the mammogram. A mammogram takes an x-ray picture of the
breast, and it is a tool that helps to identify breast cancer sometimes up to three years before it
can be felt (Centers for Disease Control and Prevention, 2022).
An educational Google Slides presentation summarized current breast cancer screening
guidelines to help increase healthcare provider knowledge at a primary care office. Increase in
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knowledge was measured by a pretest and posttest survey. Number of screenings documented at
the primary care office before and after the presentation were documented and discussed.
This project helped to extend prior research Rehman et al. (2022) conducted regarding
healthcare professionals lacking knowledge about screening tools and breast cancer risk factors.
Why has there been a decline in mammogram screening in women? Tsapatsaris et al. (2022)
discussed barriers to breast cancer screening for women. This project helped to close the gap in
literature by helping to increase adherence to current guidelines through an educational
presentation.
Background Context and Theoretical Framework
Guidelines and recommendations regarding breast cancer change constantly. It is difficult
for primary care providers to keep up with the changes. The people that suffer from missed
screenings are the patients. There are a multitude of findings that support screening for breast
cancer and encouraging patients to get yearly mammograms. However, more can be done to help
educate providers and screen more women to ultimately prevent women from dying from breast
cancer.
The Donabedian Model of Quality Care framework was the theoretical framework the
project followed. The three parts of the framework are: structure, process, and outcome
(Donabedian, 1988). The structure stands for the place the project took place along with the
providers and technology. The process stands for the intervention aimed at increasing provider
knowledge of breast cancer screening guidelines. The outcome is measurement of effectiveness
of the presentation and adhering to the recommendations summarized.
The nursing theory used for this project was Jean Watson’s theory of Transpersonal
Caring. The theory discusses how nursing involves promoting health and preventing illness
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(Watson, 2012). If a person does become ill, then nurses care for the sick and try to restore health
(Watson, 2012). Following guidelines regarding breast cancer screenings, is a way of promoting
health and preventing illness.
Problem Statement
About one in every thirty-nine women diagnosed with breast cancer will die from breast
cancer (ACS, 2023a). Without screening tools and treatment, that number would be much higher.
If providers use breast cancer screening guidelines, this will help to identify disease and get
treatment for patients sooner rather than later. It is not known why healthcare providers do not
screen using the recommended breast cancer screening guidelines.
Duffy et al. (2023) discussed the benefits of annual screenings and how missing one
screening appointment increases the risk of dying from breast cancer. There are multiple reasons
why women do not go for their annual breast cancer screening. First and foremost, they do not
know their risk. Patients need their healthcare provider to encourage and advise them to proceed
with a mammogram screening if they could benefit from it. In addition, do the healthcare
providers know who is at risk or when to start screening?
There have been multiple changes to breast cancer screening over the years. Certain
guidelines recommend screening women with average risk for breast cancer starting at age 40
with mammograms every year (ACS, 2023b). Other guidelines recommend to screen women
starting at age 40 and recommend mammograms every other year (USPSTF, 2024).
At the proposed site, there are multiple missed opportunities when it comes to screening
patients for breast cancer. Many providers only screen during preventative yearly exams.
However, in reality providers can and should be screening for breast cancer during every patient
encounter. Women are dying from breast cancer and there are ways in which this number can be
BREAST CANCER SCREENING GUIDELINES
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lowered. Barriers result in less women that are screened for breast cancer and result in poorer
outcomes for patients and their families.
Purpose of the Study
The purpose of this evidence-based quality improvement project was to increase provider
knowledge of current breast cancer screening recommendations at a federally qualified health
center look-alike through an informational presentation. The proposed project used a pretest
posttest design to measure the degree of change based on the informational presentation
summarizing breast cancer screening recommendations. The goal of this project was to help to
educate providers and increase recommended screening practices.
The project took place at a federally qualified health center (FQHC) look-alike in
Northeastern Pennsylvania. The target population was the group of health care providers at the
FQHC look-alike. The informational presentation was distributed to the healthcare providers via
work email and participation was optional and anonymous. Information obtained will help to
contribute to the numerous other studies regarding breast cancer screening.
Research Question
The quality improvement project attempted to answer the following question: Does an
informational presentation summarizing current breast cancer screening recommendations help
to improve provider knowledge at a federally qualified health center look-alike? This project
relates to the current problem of women not being screened for breast cancer. Healthcare
providers are not aware of new guidelines and are not screening eligible women.
Rationale for the Study
Using a pretest posttest design was the best approach to achieve the goal of answering the
research question. Stratton (2019) discussed how a pretest posttest design gives directionality.
BREAST CANCER SCREENING GUIDELINES
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This method is beneficial with quality improvement projects because one is able to test the
dependent variable of knowledge before and after the intervention (Stratton, 2019). The pretest
gave a baseline for what the participants knowledge level was prior to the informational
presentation. The posttest was given after the presentation to see if there was an improvement in
scores.
Significance of the Study
Why are women not being screened for breast cancer? Even with today's technology and
treatment advances, about 43,000 women died from breast cancer in 2023 (ACS, 2023a). Jean et
al. (2023) discusses the importance of evaluating barriers preventing women from obtaining
mammograms. Barriers that prevent women from being screened for breast cancer include:
language barriers, race, gender identity, religion, sexual orientation, and socioeconomic status
(Jean et al., 2023). Utilizing a presentation to help clarify guidelines and teach providers, can be
a way to evaluate one of the barriers. Whether or not a provider recommends a mammogram, is
a barrier that needs to be overcome.
Definitions of Terms
Definition of terms used for this project can be found below.
Breast Cancer Screenings: According to the American Cancer Society (2023b),
screening for breast cancer includes using tests and exams to find disease in people who
do not display symptoms.
This project defines breast cancer screenings, as imaging, genetic tests, or physical exams
to help detect breast cancer in asymptomatic patients.
Provider: Merriam-Webster Dictionary (n.d.-a) defines provider as one that provides.
BREAST CANCER SCREENING GUIDELINES
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This project defines a provider as medical doctors, doctors of osteopathic medicine, nurse
practitioners, physician assistants, licensed practical nurses, or registered nurses in a
primary care setting that provide care to patients.
Knowledge: Merriam-Webster (n.d.-b) states knowledge is gained through experience
and is the condition of knowing something with familiarity.
This project defines knowledge as the information that is obtained and utilized after an
educational presentation about breast cancer screening.
Federally Qualified Health Center: Rural Health Information Hub (n.d.) defines
Federally Qualified Health Center (FQHC) as outpatient clinics. Under Medicare and
Medicaid, a FQHC qualifies for certain reimbursement systems.
For the purpose of this project, FQHC is defined as the outpatient primary care office
where the project will take place.
Breast cancer screening guidelines are frequently updated and adjusted. Healthcare providers
should be aware of changes and educate patients accordingly. Educating providers about the
current guidelines will ultimately help with early detection of breast cancer. Also, provider
education will help to prevent over-screening. A Google Slides presentation discussing current
guidelines, helped to educate providers. In order to determine if the presentation increased
education regarding screening guidelines, a pretest and posttest were utilized. Breast cancer is a
devastating disease that affects countless people every day. Increasing screening will help to
decrease the number of people devastated by this disease.
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Chapter 2: Review of Literature
The Doctor of Nursing Practice (DNP) project focuses on using previous research and
building upon that research to help bridge the gap. Breast cancer screenings and methods of
improving adherence to current literature was the main focus of this DNP project. The purpose of
this chapter is to review the existing literature regarding preventative screening guidelines and
methods of educating healthcare providers. This quality improvement project aimed at
implementing best practices as indicated in the research identified.
The literature review was conducted using PubMed. Initial search consisted of keywords
breast cancer and 516,628 results were found. The search was then filtered to only include
articles within the last 5 years (2019-2024). This filter resulted in 134,077 articles. Next,
screening guidelines were added to breast cancer and this resulted in 2,377 results. Finally,
adding adherence to the above keywords resulted in 252 articles. Free full text filter and peer
reviewed filters were used which resulted in 164 research articles to investigate for this literature
review This chapter will be separated into barriers and review of the literature.
The main problem regarding breast cancer screening relates to adherence to guidelines.
The gap in research relates to the barriers that prevent healthcare providers from adhering to the
guidelines. This DNP project helped to see if provider knowledge and awareness are one of the
barriers.
Rehman et al. (2022) performed an interventional study with 260 medical professionals.
An educational session was utilized to educate the health professionals about breast cancer risks
and guidelines (Rehman et al., 2022). A questionnaire was utilized for before and after to
determine effectiveness of the educational session (Rehman et al., 2022). Results showed an
increase in knowledge after the intervention (Rehman et al., 2022).
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Friedman-Eldar et al. (2020) conducted a retrospective observational study between the
years 2012 and 2015. Researchers examined women diagnosed with breast cancer for the first
time at Kaplan Medical Center, Rehovot, Israel (Friedman-Eldar et al., 2020). Women were
separated into two groups which included early-stage breast cancer and advanced breast cancer
(ABC; Friedman-Eldar et al., 2020).
The primary outcome included whether or not patients adhered to the guidelines in Israel
during that time (Friedman-Eldar et al., 2020). Results showed that screening mammography
reduced the likelihood of diagnosis at an advanced stage. However, there was a significant
portion of women who presented with advanced disease even with following current
recommended guidelines. Friedman-Eldar et al. (2020) discussed how extending the guidelines
to include women younger than 50 would help with diagnosing at an earlier stage.
Wehbe et al. (2023) performed a study to determine predictors of nonadherence to breast
cancer screening guidelines among women. Researchers reviewed charts of women who received
more than one screening mammogram in order to see if guidelines were followed related to
breast cancer risk and breast density (Wehbe et al., 2023). Wehbe et al. (2023) utilize the
American Cancer Society recommendations regarding yearly mammography and breast
magnetic resonance imaging (MRI) for women considered high risk starting at age 30.
Results showed that providers underutilized supplemental screening tools like a breast
magnetic radiation imaging (MRI) for women who were at increased risk for breast cancer
(Wehbe et al., 2023). Barriers to supplemental screening include lack of knowledge by the
healthcare provider (Wehbe et al., 2023). Wehbe et al. (2023) suggested that the lack of
standardized screening guidelines for women with dense breasts, may influence healthcare
providers to order supplemental imaging.
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A cross-sectional web-based survey was conducted in Minnesota to determine breast
cancer screening practices among primary care providers (Blaes et al., 2020). The questionnaire
focused on screening practices among women at increased risk for breast cancer (Blaes et al.,
2020). Less than half of the providers recommended a breast MRI in addition to the screening
mammography (Blaes et al., 2020). Researchers concluded that there is a need for increased
education among healthcare providers (Blaes et al., 2020). To summarize, providers were not
following current guidelines.
A qualitative research project was conducted in Indonesia to determine the barriers to
early detection of breast cancer (Icanervilia et al., 2023). Subjects included breast cancer
patients, healthcare professionals, and healthy womens with no history of breast cancer
(Icanervilia et al., 2023). Through in-depth interviews, researchers collected data to investigate
barriers to the delay in breast cancer detection (Icanervilia et al., 2023). Barriers include public
awareness, access to health services, enhancing the referral system, and strengthening the health
facilities (Icanervilia et al., 2023).
Nachtigal et al. (2020) surveyed healthcare providers in Wisconsin in 2018. Researchers
used a 46-question survey about breast cancer screening among women of average risk
(Nachtigal et al., 2020). Survey was sent to 1031 providers and 295 people responded. The
majority of respondents chose U. S. Preventive Services Task Force (USPSTF) as very
influential in regards to their decision making (Nachtigal et al., 2020). However, it was
discovered that most of those providers were not following the USPSTF recommendations
(Nachtigal et al., 2020). In addition, Nachtigal et al. (2020) concluded that healthcare providers
in Wisconsin overestimate the usefulness of clinical and self-breast exams despite
recommendations against them.
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Chandra et al. (2023) investigated the effectiveness of an employer-based health program
on increasing mammography adherence. The study included 318 women from a Texas-based
company (Chandra et al., 2023). Researchers concluded that an employer-based health
promotion program alone was insufficient in improving breast cancer screening.
Determinants of mammogram adherence included access to healthcare coverage, those
who disagree with belief that everything causes cancer, and those who perceive cancer screening
as important (Chandra et al., 2023). The lack of association between increase in adherence to
breast screening guidelines and an employer-based health promotion program, may indicate the
absence of enough information or support (Chandra et al.,2023). Therefore, one can conclude
more education needs to take place to help promote adherence to guidelines.
Overall, the above research highlights the needs and the barriers regarding breast cancer
screening and adhering to guidelines. The research discusses the importance of education.
Educating the public about their risk for cancer is important to promote adherence. Educating
healthcare providers about current and recommended guidelines will help to improve care given
to patients. To overcome the barriers, it is important to continue to learn and grow as providers.
Contradicting guidelines can cause confusion among providers. Therefore, knowing the research
that supports the guidelines is important to share with patients.
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Chapter 3: Methodology
The focus of this quality improvement project was to increase healthcare provider
knowledge about current breast cancer screening recommendations at a federally qualified health
center look-alike in Northeastern PA. The project took place in August of 2024, and gained
internal review board approval from both the Wright Center for Community Health and
Pennsylvania Western University. This chapter is composed of how the project was carried out
and the methodology used.
Research Question
The group of healthcare providers treat patients in the primary care setting. The pretest
posttest design helped to see if the breast cancer screening guidelines presentation was effective
at increasing knowledge of the participants. Knowledge refers to an increased understanding of
breast cancer screening guidelines. The participants were recruited via work email. Google
Slides was utilized for the breast cancer screening guidelines presentation. Google Forms was
utilized for the pretest and posttest. Participation in the project was optional and the pretest and
posttest responses were anonymous and kept secure. The initial email gave the purpose of the
project and link to the pretest. Three days after sending the initial email, a follow-up email was
sent with a link to the Google Slides presentation and posttest.
Research Design and Methodology
The pretest posttest design helped to answer the research question. This methodology was
used as opposed to other designs because pretest and posttest design gives directionality and the
student was able to test the dependent variable before and after the intervention (Stratton, 2019).
The quantitative research design allowed the student to measure knowledge quantitatively by
comparing the pretest and posttest scores.
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The quasi-experimental design was chosen in order to evaluate the effectiveness of the
educational presentation. Ledford and Gast (2014) discuss how the main advantage of the onegroup pretest-posttest is the opportunity to compare scores of participants before and after the
treatment in the same group of participants. The educational Google Slides presentation was
utilized as the intervention. The pretest and posttest scores were used to determine the
effectiveness of the presentation.
Population and Sample Selection
The target population for this project were healthcare providers who worked in nine
outpatient offices located throughout Northeastern PA. For the purpose of this study, healthcare
providers included: 24 internal and family medicine attendings, 18 advanced practice providers,
and 27 nurses. In order to increase the sample size, the project was also emailed to the internal
medicine residents that participate within Graduate Medical Education program.
Emails were addressed to the healthcare. Healthcare providers included the family and
internal medicine attendings and residents, nurse practitioners, physician assistants, and nurses.
Convenience sampling was used to enroll participants. Emails were sent to participants’ work
email.
The facility has an internal review board (IRB). IRB approval was obtained before the
quality improvement project took place. The student completed necessary training courses and
submit forms to IRBNet before the IRB scheduled meeting in order to obtain approval. All
materials used for the project needed to gain approval as well.
When the participant filled out the pretest, they were asked to create their own unique
identifier. The unique identifier consisted of one letter and two numbers. The participants were
asked to remember this and use their unique identifier for the posttest. This information was kept
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secure in an Google Sheet. Three days after the pretest was emailed, the participant was then
asked to complete the self-guided Google Slides presentation and posttest. The posttest results
were documented in a secure Google Sheet. A third Google Sheet was utilized to complete the
analysis of data after two weeks of data collection. A paired-samples t-test was performed to see
if scores improved, decreased, or stayed the same after the educational presentation.
Instrumentation or Sources of Data
Validity and Reliability
The pretest questionnaire (Appendix 1) was developed by the student, and had face
validity only. Questions were reviewed and revised by the project mentor. Next, the
questionnaire was submitted to the IRB. The pretest consisted of a series of questions measuring
the healthcare provider's knowledge prior to the educational presentation. The posttest consisted
of the same series of questions.
Data Collection and Management
Data collection included Google Forms and Google Sheets. The pretest and posttest were
out of 10 total possible points. In addition, demographic information collected included: job title,
gender, age, and education background. The participants' pretest score was compared to their
posttest score. Statistical analysis was run on the data using a paired t-test. Alpha was set at 0.05.
If the p value was less than 0.05, then this student could reject the null hypothesis and results
could be considered statistically significant. Information is kept secure and anonymous. Results
were analyzed while on a secure password protected network.
Limitations
Limitations include distributing the presentation through email. Some participants may
not check email or only fill out the pretest. Participant completion of both the pretest and posttest
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is necessary to accurately compare results. The participants must also remember their unique
identifier. Participants may forget the unique identifier they created which will make results
difficult to analyze accurately. Timeframe is also a limitation. Two weeks is a short amount of
time to complete the project. Also, the test being used to measure knowledge does not have
established reliability.
17
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Chapter 4: Results and Findings
The purpose of this evidence-based quality improvement project was to increase
knowledge of healthcare providers about current breast cancer screening guidelines. Guidelines
were summarized and placed into an informational Google Slides presentation. Healthcare
providers were given the opportunity to participate in the quality improvement project from
Monday August 12th, 2024 until Monday August 26th, 2024.
One hundred fifty-two emails were sent to healthcare providers with information about
the project and link to a pretest. Three days later, the same employees were emailed a link to the
presentation and posttest. Thirty-two employees completed the pretest and 21 employees
completed the posttest. Return rate for the pretest was 21% and 14% for the posttest. Fifteen
respondents were used for final analysis. Fifty-two percent of the posttest responses were not
utilized due to different unique identifier used between pretest and posttest. Data and results
were analyzed using Google Sheets and XL Miner Application. XL Miner Application is free
add-in software available to Google Sheets users.
Sample Characteristics
Table 1 shows the participant demographics. Fourteen females and one male completed
both the pretest and posttest. Ages ranged from 28 to 56 and two respondents chose not to
answer. Six of the participants were nurses. Five of the participants were nurse practitioners or
physician assistants. Two of the participants were family medicine doctors and two were internal
medicine doctors. Five of the participants had a high school diploma or a general educational
development (GED) diploma. One of the participants had a bachelor’s degree. Three of the
participants had a master’s degree, and six of the participants had a doctoral degree.
Table 1
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Participant Demographics
Characteristic
n
%
Age
20-29
30-39
40-49
50+
Prefer not to answer
2
7
2
2
2
13.3
46.6
13.3
13.3
13.3
Gender
Male
Female
1
14
6.6
93.3
Profession
Nurse
Nurse Practitioner/
Physician Assistant
Physician
6
5
40
33.3
4
26.6
Highschool / GED
Bachelor’s
Masters
Doctorate
5
1
3
6
33.3
6.67
20
40
Education
Results
Figure 1 shows the individual’s pretest and posttest score. XL Miner Analysis application
through Google Sheets was used to perform data analysis and descriptive statistics. A pairedsamples t-test was conducted in order to determine if the participants pretest score was
significantly different from the posttest score. Table 2 shows the results of the paired-samples ttest. Average score of the pretest was 5.13, and average score of the posttest was 8.86. The
standard deviation of the pretest was 2.53, and the standard deviation of the posttest was 1.80.
Range of the pretest was 9, and range of the posttest was 7. Variance of the pretest was 6.40, and
variance of the posttest was 3.26. Alpha was set a 0.05. P value was found to be 0.0001.
Figure 1
Pretest Posttest Results
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20
Pretest Posttest Results
Questionaire Score
12
9
10
7
8
10
10
8
10
7
1010
8
10
8
6
6
9
8
5
2
2
1
2
10
9
5
3
4
10
5
6
9
7
33
0
A11 L56 X12 JB1 M12 C13 S56 T90 L22 D07 A10 A93 K17 A20 E14
Unique Identifer
Pretest Score
Posttest Score
Note. The pretest results of participants are shown in pink and the posttest results of participants
are shown in purple. The x-axis is the unique identifier and the y-axis is the questionnaire score.
Table 2
Paired Sample t-test
Pretest
Posttest
N
Mean
SD
Range
Variance
15
15
5.13
8.86
2.53
1.80
9
7
6.40
3.26
Significance
p = 0.0001057
Electronic Health Record Data
Upon completion of the quality improvement project, data was obtained with the help of
the Clinical Quality Compliance and Reporting Manager at the facility. Table 3 shows data that
was complied. Four weeks prior the quality improvement project (July 14th, 2024 – August 10th,
2024) 2,831 female patients between the ages of 40-74 were seen for appointments. Of those
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2,831 patients, 1,598 women did not have a mammogram screening on file in the last 18 months.
Of the 1,598 women, 578 women had a mammogram ordered during their visit. This resulted in
1,020 missed screenings.
Data was also analyzed four weeks after the completion of the project between August
27th, 2024 and September 24th, 2024. During that time span, 3,139 women were seen for
appointments. Of the 3,139 women, 1,829 patients did not have a mammogram on file for the
last 18 months. Of the 1,829 women that were seen for an appointment, 548 women had a
mammogram ordered. This resulted in 1,281 screenings that were missed.
Table 3
Electronic Health Record Data
Pre-Intervention Electronic Health Record
Data
Women Aged 40-74 Seen for
Appointment
2831
No Mammogram on File
1598
Women who had mammogram
ordered
578
Screenings missed
1020
Percentage of screenings completed 36.17%
Percentage of screenings missed
63.80%
Post-Intervention Electronic Health Record
Data
Women Aged 40-74 Seen for
Appointment
3139
No Mammogram on File
1829
Women who had mammogram
ordered
548
Screenings missed
1281
Percentage of screenings completed 30%
Percentage of screenings missed
70%
Data Limitations
In order to keep results anonymous, emails were not collected. Participants were able to
submit more than one pretest and posttest. In addition, for the majority of the project the pretest,
presentation, and posttest could be accessed at the same time. Participants could have taken the
pretest after the presentation which could have also affected the results. This could have been
prevented by ending the pretest date when the posttest started. Small sample size is an additional
limitation of this project and data analysis. Results may have been different with a larger sample
BREAST CANCER SCREENING GUIDELINES
22
size. Sample size was likely influenced by staff on vacation and limited timeline to complete
project.
In regards to the electronic health records that were analyzed, limitations include
mammograms not documented. Meaning, patients may have actually completed the
mammogram, but it was not properly pulled into the system and documented appropriately. Also,
many women have their mammograms ordered by their women’s health provider.
Summary
Overall, data analyzed comparing pretest and posttest scores were statistically significant
using a paired-samples t-test. Average score of the 10-question pretest improved after
participants completed the self-guided Google Slides presentation regarding breast cancer
screening guidelines. We can infer that the participants gained a better understanding and
increased knowledge of current guidelines and recommendations after completing the
presentation. This data can be helpful to future projects that aim to increase knowledge of breast
cancer screening guidelines and increase number of screenings.
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Chapter 5: Discussion of Findings
The purpose of this evidence-based quality improvement project was to increase provider
knowledge through an educational presentation regarding breast cancer screening guidelines at a
federally qualified health center look-alike. The project took place in August of 2024 over a twoweek period. This chapter will discuss findings of this project and how it relates to future
practice regarding breast cancer screenings and recommendation. This chapter will cover
summary of findings, implications, and recommendations for future practice.
Summary of Findings
Overall, the majority of the healthcare providers that participated in the project had
improved scores after completing the presentation. Scores of the 10-question assessment
improved significantly after completion of the Google Slides presentation regarding breast
cancer screening guidelines. Fifteen participant responses were utilized for data analysis. Data
analysis was completed using Google Sheets and XL Miner Application. The paired-samples ttest resulted in a p-value of less than 0.05.
Data collected from the electronic health record showed there were multiple missed
opportunities for mammograms. Yearly mammograms ordered prior to the quality improvement
project were compared to the number of yearly mammograms ordered after the quality
improvement project was completed. There was an increase in missed mammograms after the
quality improvement project was completed.
Implications
Breast cancer is a disease that continues to devastate patients and their families.
Screening patients on time and routinely could help to lessen this devastation. Education and
knowledge are the keys to screening more patients. Results from this project have implications
BREAST CANCER SCREENING GUIDELINES
24
for nursing practice. Providers demonstrated increased understanding of current breast cancer
screening guidelines after completing the presentation. Thus, implementing a self-guided
presentation into a yearly educational module required by providers can help to increase
awareness of current guidelines and ultimately improve screening numbers.
Limitations for this quality improvement include timeline for the project and small
sample size. It took place over a two-week period which is a short amount of time. The project
took place in August in which many providers were out of office on vacations. Due to time
constraints and provider availability, an in-person presentation was not a realistic option. Future
projects should include a larger cohort from multiple outpatient offices including women’s health
facilities.
Recommendations
It is recommended that providers continue to utilize current guidelines and screening
tools with every patient encounter. Healthcare providers should be aware which guideline they
are using the research that supports the recommendations. Patients place an immense amount of
trust in their clinician, and in return healthcare providers should make sure they are following
evidence-based practice.
The goal of clinicians is to provide quality care to all patients. Researchers need to further
investigate why and how more patients can be screened. This quality improvement project
helped to understand that knowledge and awareness of current guidelines are likely barriers that
prevent more women from getting screened for breast cancer.
Conclusion
Overall, patients deserve to be treated by healthcare providers that utilize evidence-based
guidelines and recommendations. Breast cancer screening tools and recommendations have
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changed significantly over time. Education and knowledge are barriers that can prevent
screenings. A presentation that summarizes these recommendations for providers can help to
increase their knowledge and ensure they are up to date on current research. Learning more ways
to help increase knowledge and awareness can ultimately help to increase screenings and help to
detect breast cancer sooner rather than later.
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Appendix A
Pretest and Posttest 10-Question Assessment
30
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Appendix B
Breast Cancer Screening Guidelines Google Slides Presentation
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Media of