Hereditary
Beverly Mangerich, RN, MSN • Jaynelle F. Stichler, DNSc, RN, FACHE, FAAN
A New Model For Educating WomenA New Model For Educating Women
Ovarian Cancer
A New Model For Educating Women
Cancer
Hereditary
Imagine that a patient of yours, a 32-year-old woman named Susan, has just
been diagnosed with breast cancer. She shares with you that her mother died
of breast cancer when Susan was a teenager, and she wants to know if she’s also
going to die of breast cancer. She states she always “knew” she would get breast
cancer, because everyone in her mother’s family seemed to die of the disease.
Susan married young and had her family right away, with the haunting fear that
she would never live long enough to see her children grown. Susan isn’t alone
in her worries; many women with a family history of hereditary breast and/or
ovarian cancer (HBOC) worry about what a diagnosis could mean for them
and their families. They need supportive and comprehensive education on the
topic. This paper discusses one breast cancer center’s approach toward chang-
ing its model of education on HBOC.
&and
Breast
Rates of HBOCWhile breast cancer is the most prevalent form of cancer in
women (National Comprehensive Cancer Network [NCCN],
2007), approximately 5 percent to 10 percent or 18,000 cases
per year are associated with an identifi ed hereditary autosom-
al-dominate gene mutation or HBOC (Garber & Offi t, 2005).
Today, women with family histories of early onset breast can-
cers and/or ovarian cancers at any age have options to test for
a mutation in chromosome 17, referred to as BRCA1, and in
chromosome 13, referred to as BRCA2. Once tested and identi-
fi ed with a mutated gene, these women can be offered timely
and lifesaving medical options. Women diagnosed with HBOC
need education to help them make critical decisions, such as
whether to undergo prophylactic mastectomies. But what’s the
most effi cient way to deliver that education? This paper dis-
cusses a management change project that was initiated to de-
crease the amount of time spent on education for women with
a family history of early onset breast cancer without compro-
mising the quality of patients’ experiences.
Changing the Education ModelThis paper describes the development and implementation of
a quality HBOC management project at the Scripps Polster
Breast Care Center (SPBCC) in La Jolla, CA. The SPBCC is in
a separate building on the medical campus of Scripps Memo-
rial Hospital—La Jolla. The SPBCC is one of the leading breast
screening and diagnostic centers in the San Diego region. Be-
fore the project, all education for HBOC was done individu-
ally for each patient. While identifying, educating and testing
for HBOC is now considered the standard of care by several
organizations, including the American Society of Clinical On-
cology (ASCO) (Khatcheressian et al., 2006), U.S. Preventive
Services Task Force (2005), National Society of Genetic Coun-
selors (Trepanier et al., 2004) and the National Comprehensive
Cancer Network (NCCN, 2007), it’s important to consider the
cost-effectiveness of delivering these services. A preliminary
time analysis on individual patient appointments was com-
pleted and showed the need for a more effi cient delivery model
for the components associated with patient education and risk
assessment. A new program was designed using a conceptual
framework and a review of evidence-based literature to guide
the program design and educational content.
Conceptual FrameworkThe conceptual framework entitled “Nursing Administration
for Researchers and Administrators,” which was created by Bi-
ron, Richer, and Ezer (2007), was used to develop the HBOC
education class. The framework “links patient health care needs,
nursing resources and the nursing care process to the context
of the health care system, and the social, political and cultural
environments of care” (Biron et al., p. 188). This framework
links three important nursing administration concerns: (1)
providing evidence-based patient care, (2) maximizing nursing
resources and (3) using the nursing care process when making
decisions. At the core of the framework are patient- and nurse-
sensitive outcomes. Contributors to these outcomes are patient
health care needs, nursing care processes and nursing resources.
Nursing administration research must take into account the
dynamic needs of both the patient and nurse in the current
political, social, cultural and economic environment, as all of
these factors infl uence administration decision-making for the
HBOC management project. The HBOC management project
considered the need for patient education and risk assessment
before genetic testing, along with the limited nursing resources.
Also considered in the planning was the effectiveness of
various patient education models. Calzone et al. (2005) studied
breast cancer and compared an individual-based genetic edu-
cation program with group-based education, and reported that
there were no signifi cant differences in knowledge scores be-
tween the individual or group methods of education (P=0.21).
Satisfaction scores also remained constant between the two
methods of genetic education. The study revealed that group
education allows for greater access to genetic information, risk
assessment and genetic testing and is more cost-effective than
individual education.
SPBCC elected to use a nurse educator to deliver education,
risk assessment and testing, working under the direction of the
medical director, because a genetic counselor was not available
nor was there enough volume to justify the cost of adding a ge-
netic counselor to the service. Traditionally, genetic counselors
deliver genetic counseling; however, the International Society
of Nurses in Genetics (2005) outlines the responsibilities and
competencies of nurses who may be involved in genetic coun-
492 © 2008, AWHONN http://nwh.awhonn.org
Beverly Mangerich, RN, MSN, is a liaison nurse for the Scripps Polster Breast Care Center in La Jolla, CA. Jaynelle F. Stichler, DNSc, RN, FACHE, FAAN, is an associate professor at San Diego State University in San Diego, CA. Address correspondence to: [email protected].
DOI: 10.1111/j.1751-486X.2008.00383.x
• Being diagnosed with or having a family history of hereditary breast or ovarian cancer can be emotionally draining for women.
• Women and their family members need support-ive, comprehensive education on the issue.
• Group classes can provide effective education that meets patients’ expectations while being more cost-effi cient than individual education.
Bottom Line
December 2008 January 2009 Nursing for Women’s Health 493
seling, including patient assessment, identifi cation, education,
care and support for genetics in health care. Nurses with exper-
tise in the clinical genetics aspect of health and illness can also
provide delivery of genetic information (Vogel, 2003), so the
SPBCC adopted an educational and informational program led
by a nurse educator. The SPBCC nurse educator has attended
local and national seminars on HBOC. The SPBCC also hosts a
quarterly meeting with other breast cancer genetic educators to
review cases. A genetic counselor leads these group discussions.
As professional nursing practice encompasses roles in patient
education, specifi c screening practices, patient advocacy and
counseling for health care choices, this seemed to be the most
appropriate and cost-effective model.
The Need to Save TimeAlthough genetic education and risk assessment are tradition-
ally conducted on an individual basis, the process is time-con-
suming. With the increasing need for HBOC patient education,
it was determined that a more time-effi cient education method
was needed in order to continue offering HBOC education.
Before the new program, patients made appointments free
of charge to meet with the nurse educator at SPBCC for an in-
dividual education session and risk assessment evaluation. The
hospital made a decision to offer the program without cost to
the patient because the education and counseling met the rec-
ommended standard of care for patients with a family history
of early breast cancer or ovarian cancer. After the individual pa-
tient session, a summary letter was written to the physician who
evaluated the patient for testing based on the risk assessment.
Physicians who wished their patient to continue with genetic
testing would write a prescription for genetic testing. The nurse
educator would then assist the patient with the genetic testing
process. Another patient appointment was made with the nurse
educator to give test results and to review the implication of
test results on medical options that were to be discussed with
their physician. Family members at risk for a positive BRCA
gene mutation were identifi ed and the patient’s responsibility
to inform identifi ed family members was discussed. The indi-
vidual education was time intensive and illustrated the need for
a more effi cient education.
Not only was the process for education and testing time-in-
tensive, but during 2007 the company with the patent on testing
for the BRCA1 and 2 mutations initiated a marketing cam-
paign to obstetricians and gynecologists in San Diego, which
signifi cantly increased the number of referrals for HBOC risk
assessment and testing. Referrals from physicians for HBOC
education and assessment grew from 11 percent in 2006 to 20
percent in 2007. Currently, physicians utilize the HBOC indi-
vidual patient education services due to the number of patient
concerns that resulted from the expanded marketing of the
BRCA test. The patients had many questions, emotional reac-
tions and concerns, which were presented to physicians, but
with competing priorities in the offi ce to see patients in an ex-
pedient manner, physicians had less time to spend in address-
ing individual patient concerns (Tai-Seale, McGuire, & Zhang,
2007). Individual genetic education and testing takes anywhere
from 1 to 2.5 hours (Calzone et al., 2005). Physicians were un-
able to devote the needed time during an offi ce visit, and the
increase in referrals to SPBCC made it costly and ineffi cient for
the nurse educator to spend time addressing individual con-
cerns and education instruction one patient at a time. At the
same time, the information and education was critical for pa-
tients to use as a basis for crucial medical care decisions.
What Are Women’s Concerns?The content for the new HBOC education class was based on
a review of evidence-based literature on fi ve factors of concern
for patients regarding their potential risk and possible treat-
ment alternatives: (1) risk factors, (2) interpretation of test
results, (3) medical intervention for HBOC, (4) psychosocial
concerns and (5) health insurance issues.
Risk FactorsOne of the most important features in HBOC is the increased
incidence of breast cancer at an early age. A personal or family
history of premenopausal breast cancer indicates the possibil-
ity of a genetic mutation (Frank et al., 2002). Other indicators
of an inherited mutated gene are male breast cancer, multiple
primary breast cancer, epithelial ovarian cancer at any age and
specifi c ethnicities associated with increase mutations in the
BRCA genes, such as Ashkenazi Jewish and Icelandic.
The majority of women with a BRCA gene mutation will
develop breast and/or ovarian cancer. Although genetic infor-
mation is not deterministic, mutation in the BRCA genes are
Group education allows for greater access to genetic information, risk assessment and genetic testing and
is more cost-effective than individual education
494 Nursing for Women’s Health Volume 12 Issue 6
associated with a lifetime risk of 45 percent to 78 percent for
breast cancer (Antoniou et al., 2003). The lifetime cumulative
risks in BRCA1-mutation carriers are 65 percent for breast
cancer and 39 percent for ovarian cancer (Antoniou et al.).
BRCA2-mutation carriers had a 45 percent risk of breast cancer
and 11 percent risk of ovarian cancer.
Women diagnosed with breast cancer with an inherited
BRCA1 and 2 gene also have an increased risk of developing
a second primary breast cancer. Risk of a contralateral breast
cancer, within 5 years of the initial diagnosis, ranges from 23
percent to 27 percent, according to Metcalfe et al. (2004). Risk
of a contralateral breast cancer increases between 50 percent
and 64 percent by the time a women reaches age 70.
Interpreting Test ResultsThere are categories for test results regarding BRCA1 and 2.
The fi rst category is positive for a deleterious mutation. A
deleterious mutation in either the BRCA1 or 2 gene prevents
translation of the full-sized protein (Peshkin, DeMarco, Bro-
gan, Lerman, & Isaacs, 2001). When proteins fail to decrease
cell replication, the increased percentages of accruing breast/
ovarian cancer apply to the individual testing positive.
The second category is negative results or results in which
no mutation is detected. They have two different interpreta-
tions. The fi rst interpretation is considered a true negative
when a mutation has been found previously in a family mem-
ber. A negative result in a subsequent family member reverts
the family members’ breast and ovarian cancer risk back to the
general population (Ponder, 1997). The second negative inter-
pretation is considered “indeterminate” and takes place when
there are no known mutations in the family. Women with in-
determinate test results may still be considered high-risk and
should choose treatment based on their family history (Lan-
caster et al., 2007).
The last category of test results is a genetic variant of un-
certain signifi cance labeled as inconclusive, according to the
NCCN (2007). Sequence analysis may identify changes in the
gene that have not been identifi ed previously. The signifi cance
of these variants for breast and ovarian cancer is unknown
(Peshkin et al., 2001). Other family members can be tested for
the variant to acquire more information on which to base deci-
sion-making. Management of patients with uncertain variance
should be based on personal and family history (NCCN).
Medical InterventionsThe NCCN has recommended that women identifi ed with a
mutated BRCA1 and 2 gene receive a semiannual clinical breast
exam, annual mammography and magnetic resonance imag-
ing starting at age 25 or individualized based on the earliest
age of onset of breast cancer in their families (Hartman et al.,
2004). The most invasive but effective management is prophy-
lactic mastectomies, which have been shown to reduce the risk
of breast cancer by more than 91 percent (van Sprundel et al.,
2005).
Unlike breast cancer screening, surveillance for ovarian
cancer is often ineffective, according to the NCCN. Although
less than an ideal surveillance, the NCCN (2007) recommends
the combination of the CA-125 blood test, ultrasound of the
ovaries and bimanual pelvic exam as the most effective way to
screen for ovarian cancer. More effective than surveillance for
ovarian cancer is prophylactic salpingo-oophorectomy. Reb-
beck et al. (2002) and Kauff et al. (2002) both found a signifi -
cant reduction in both ovarian and breast cancer following a
prophylactic salpingo-oophorectomy and recommended the
procedure in patients who screen positive for the BRCA mu-
tation. Recommendations from these studies included a pro-
phylactic salpingo-oophorectomy as soon as possible after
childbearing is complete or by age 35 (McEwen et al., 2004).
It’s important to explore a patient’s past experiences and perception regarding the subject of cancer, her family history of cancer and her family’s perceptions regarding genetic testing
December 2008 January 2009 Nursing for Women’s Health 495
The New Education ModelBased on the conceptual framework and the evidence-based
literature review of the fi ve educational areas, a new method of
providing patient education was explored for its effectiveness
and cost benefi ts.
Planning for the program included the need for develop-
ing a HBOC education class process and for garnering support
from physicians for the class. It was determined that new edu-
cation slides and handouts needed to be developed in addition
to assessment tools to measure participants’ acquired knowl-
edge and satisfaction with the new class format. A demographic
questionnaire describing the characteristics of the group was
Psychosocial ConcernsThe NCCN Guidelines (2007) recommend psychological as-
sessment and support for individuals seeking genetic testing.
Education on HBOC includes considerations of the worry of
cancer, potential diffi culty communicating within families, at-
titudes toward prevention and surveillance options, and the
need for support (Hamilton, Bowers, & Williams, 2005). Im-
plications of testing affect not only the individual but also her
family members. Effective family communication is stressed,
as it’s the individual’s responsibility to communicate positive
genetic testing results to family members who may or may not
choose to be tested.
It’s important to explore a patient’s past ex-
periences and perception regarding the subject
of cancer, her family history of cancer and her
family’s perceptions regarding genetic testing.
Patients having diffi culty coping with the risk
of breast or ovarian cancer may need profes-
sional intervention with a psychologist or other
mental health professional.
Health Insurance ConcernsWomen may not only fear positive results and
how they will affect their relationships, but they
may also be concerned with how test results will
affect their ability to obtain health insurance.
So while genetic testing has the great potential
to enhance patient care, this testing also carries
the concern of potential discrimination in em-
ployment and health care benefi ts. The Health
Insurance Portability and Accountability Act
(HIPAA) of 1996 is one federal policy that ad-
dresses genetic discrimination. HIPAA affords
some protection to group markets by prohibit-
ing insurers from charging different premiums
within a group plan. HIPAA also mandates
that genetic information cannot be used to de-
termine insurance eligibility or be viewed as a
preexisting condition when a diagnosis is not
present. The Genetic Information Nondiscrim-
ination Act, which provides protection against
discrimination based on an individual’s genetic
information for health insurance coverage and
employment, was signed into law by President
Bush on May 21, 2008. Many states also have
laws that prohibit the use of genetic informa-
tion for insurance coverage and employment
(Hall & Rick, 2000), and, therefore, genetic and
nurse counselors should familiarize themselves
with their state regulations.
BOX 1 Questionnaire Used at SPBCC
Please indicate whether you think each item is True or False or if you don’t know. This is not a test. This information will help us evaluate our educa-tion program.
True False Don’t Know
A father can pass down an altered BRCA gene to his daughter.
All people who have an altered BRCA gene will get breast cancer.
A person who does not have an altered BRCA gene can still get breast cancer.
A woman who has an altered BRCA gene has a 100% chance of passing it to her daughter.
Most breast cancer is inherited.
My doctor will tell my family if they need to test for the BRCA gene mutation.
A woman who has a sister with an altered BRCA gene has a 50% chance of also hav-ing an altered BRCA gene.
If there are 4 siblings in a family and 2 already have breast cancer, then the other 2 don’t have the gene mutation.
A bilateral mastectomy eliminates the risk of breast cancer.
A woman whose gene mutation test is negative does not need to have regular mammograms.
California laws prohibit health insurance to discriminate based on genetic results.
496 Nursing for Women’s Health Volume 12 Issue 6
would be required to make an individual appointment with the
nurse. During the appointment a three-generation pedigree is
obtained and the patient’s risk assessed using the BRCAPRO
tool (the computer program that determines risk for the BRCA
1 and 2 gene) (Parmigianni et al., 2007). Although the IES isn’t
administered formally as in Calzone (2005) research, patients
are assessed verbally by the nurse educator using the IES as a
guide. A letter summarizing the patients’ risk is sent to the phy-
sician, and the physician decides if the patient is to be tested for
the BRCA gene mutation. If the physician decided to proceed
with patient testing, a prescription is forwarded to the SPBCC
nurse educator, who assists the patient with the testing process.
Educational ContentEducation material covered in the class was developed from
the review of the literature on selected core content for patient
education and approved by the medical director of the SPBCC.
The class includes information on the following: (1) identifying
factors of HBOC, (2) possible test results, (3) elevated risks of
breast and ovarian cancer, (4) available medical interventions,
(5) psychosocial concerns and (6) insurance discrimination.
The learning objectives of the class are shown in Box 2.
The education class begins with breast cancer facts and iden-
tifying factors in a family history that alert the physician, nurse
and participants of possible HBOC. Pedigrees are reviewed
with the mutated gene inherited from the paternal side and the
maternal side of the family. When HBOC factors are identi-
fi ed, testing is performed with a possibility of various results.
When test results are indeterminate or inconclusive, patients
created. Knowledge of HBOC would be assessed using an 11-
item, true/false scale modifi ed from the work of Calzone et al.
(2005). The Calzone questionnaire, modifi ed from a tool devel-
oped by the National Human Genome Research Institute Can-
cer Genetics Studies Consortium, has reported psychometric
properties (Cronbach’s alpha of ≥0.75). The instrument was
modifi ed because during the pilot testing some items were un-
clear to participants, and, therefore, they were either eliminated
or revised to be appropriate for the setting and were reviewed
by a panel of experts at the SPBCC. Reliability testing of the
modifi ed Calzone instrument will be conducted once there is
a suffi cient number for statistical analysis. See Box 1 for the
modifi ed Calzone instrument used at SPBCC. All other re-
sources needed for the new education delivery method were
already available at the center, including handout materials,
laptop computer, projector and conference room.
Participants, who were either self-referred or referred by
their physicians, would register ahead of time for the class. Fam-
ily members were encouraged to attend. Classes were offered
twice a month during the day and scheduled for approximately
1 to 1.5 hours of educational content, including questions and
answers. The class length varied depending on the size of the
class. More participants would generate more questions and
increase the length of the class.
The class began with participants fi lling out a demograph-
ic questionnaire and the 11-item pretest. Introductions were
made by the nurse educator, including a disclaimer that the in-
structor is not a genetic counselor but that she holds a master’s
degree in nursing and has years of experience in the breast and
ovarian cancer fi eld. Participants were invited to share as much
personal history as they were comfortable sharing. The edu-
cation component was presented via a lecture method using
slides and handouts. The nurse educator would address ques-
tions from the participants during the presentation for imme-
diate clarifi cation. Following the presentation, the participants’
satisfaction of the class would be assessed by a questionnaire
using a 5-point Likert scale. The 11-item post-test using a true/
false scale was repeated at the conclusion of the class to assess
knowledge gained from the educational content. Although
Calzone’s (2005) research included the Impact of Events Scale
(IES), this wasn’t included in the educational session since it
wasn’t the focus for this program.
Patients wishing to proceed with a personal risk assessment
BOX 2 Learning Objectives for the HBOC Group Class
At the conclusion of the presentation participants will be able to identify the following:
• Risk factors associated with hereditary breast and ovarian cancer
• Breast and ovarian cancer risks associated with BRCA mutations
• Medical intervention options for women test-ing positive for BRCA mutation
• Implications of positive and negative BRCA test results for family members
• Potential psychosocial implications with ge-netic testing
• Relevant health insurance issues
Testing is done in the context of the patient’s psychological well-being and her individual family dynamics
December 2008 January 2009 Nursing for Women’s Health 497
tient sessions versus group education. The total time expendi-
ture for individual education is approximately 125 minutes per
patient. By expanding the number of participants to two partic-
ipants per class, the total time expenditure was reduced to 114
minutes per patient. There is further incremental reduction in
time spent with each additional class participant. Further gains
resulted when after the class participants realized their family
history of breast cancer did not put them in a high-risk cat-
egory for HBOC and they didn’t need to test for the BRCA gene
mutation. The HBOC class has resulted in the ability to use less
of the nurse educator’s time with a natural “self screening” for
patients away from unnecessary testing.
Box 4 shows the conversion of time expended into salary
expenses for individual education compared with group edu-
cation. Cost per individual patient education using $40/hour
salary cost was approximately $80 per patient. By providing edu-
cation in a class setting, even with as few as two participants, the
cost per patient was reduced to $73 per patient. Six participants
in a class reduced the cost per patient to $46.66. Because SPBCC
already had the other educational materials and the equipment,
no other expenses were incurred in the change from individual
to group education. Marketing of the program was an existing
role expectation of the nurse educator, so no incremental costs
were incurred as a result of the program change and marketing
to physicians who were already referring patients.
Class ParticipationThe fi rst three group classes enrolled a total of 15 participants.
The age range of the participants was 30 to 66 with a mean
of 50 years and a median of 49 years. All of the participants
reported having some college education, with fi ve participants
completing a baccalaureate degree, four a master’s degree and
are counseled to base their medical decisions on their personal
and family history. Positive results, however, give the patient
additional options of surgical medical management. A positive
result, indicating a mutated gene, signifi cantly increases the
risk of breast (86 percent) and ovarian cancer (44 percent) and
increases the risk of a second primary breast cancer in the con-
tralateral breast (64 percent).
Testing is done in the context of the patient’s psychological
well-being and her individual family dynamics. Patients are of-
ten concerned about their family members’ cancer risks as well
as their own. Along with family risk concerns, patients are also
concerned about health insurance eligibility following positive
test results. Federal and California nondiscriminatory laws are
included in the content of the class as well as the challenges of
obtaining health insurance after a cancer diagnosis.
Marketing the ProgramThe program was marketed to ensure its success. The free class
was marketed to Scripps physicians and to the public. Fliers
were also developed for the class by the marketing department
and distributed by marketing personnel and the SPBCC nurse
educator during visits to physicians’ offi ces. Pamphlets were
also distributed to patients at the SPBCC and community edu-
cation events. News articles and marketing in the community
will be planned as the program develops.
ResultsTime AnalysisAn analysis was completed to evaluate the time and cost dif-
ference between individual appointments and the HBOC class.
Box 3 demonstrates the expenditure of time for individual pa-
BOX 3 Comparison of Time Spent on Individual Versus Group Education
Number of participants per class 1 2 3 4 5 6
Class registration 5 6 9 12 15 18
Class set up 1x expenditure 0 15 15 15 15 15
Class time 1x expenditure 70 90 90 90 90 90
Data analysis 1x expenditure 0 15 15 15 15 15
Individual risk assessment 30 minutes/pt 30 60 90 120 150 180
Explanation of results 20 minutes/pt 20 40 60 80 100 120
Total minutes 125 226 294 352 405 468
Time per patient 125 113 93 83 77 73
Cost per patient at $40/hour employee $80 $73 $60 $53.33 $49.33 $46.66
498 Nursing for Women’s Health Volume 12 Issue 6
Pre- and Post-Test ResultsParticipants’ baseline knowledge of breast cancer genetics was
assessed using an 11-item pretest. Results from the pretest
showed an average of 63 percent of the questions answered cor-
rectly with 37 percent answered incorrectly or with a response
of “I don’t know.” The mean score was 6.92 with a standard
deviation of 2.67. The same 11-item questionnaire was used
for the post-test. The post-test showed an increase in correct
responses when compared with the baseline scores. The post-
test showed 95 percent of the questions answered correctly by
the participants. The mean score of the post-test was 10.3 with
a standard deviation of 0.89, demonstrating an improvement
in participants’ content knowledge.
Patient SatisfactionA satisfaction survey was also given to the participants to deter-
mine their level of satisfaction with the new HBOC education
program. All participants “strongly agreed” or “agreed” that the
education method provided suffi cient information to increase
their knowledge of HBOC. The majority of the participants felt
the class helped them make a decision whether or not to test
for the BRCA gene mutation. Most participants were “strongly
satisfi ed” or “satisfi ed” with the class setting, handouts and time
to ask questions.
ConclusionAlthough women with HBOC comprise a small proportion of
breast cancer cases, HBOC education and risk assessment is the
standard of care according to numerous medical organizations
and is an important component in patient medical decision-
making. Although this education is important to patients, when
done on an individual basis it’s a labor-intensive process. A cost-
effective process was needed that considered patient outcomes,
nursing resources and nursing process. The change project
developed an education process in which education would be
delivered in a classroom setting without compromising the
quality of patients’ education. Test scores revealed a signifi cant
improvement between pretest and post-test education. Partici-
pants in the classes were engaged and asked questions that the
whole group benefi ted from. Class participants were supportive
of each of the individual situations that participants shared.
Patient education and health risk assessment conducted on
an individual basis remains a labor intensive process during a
time when administration directives are to provide cost-effec-
tive care. Analysis of the class versus individual appointments
has shown a marked decrease in the nurse educator’s time. A
decrease in the nurse’s time allows a cost benefi t to the center.
One limitation to the twice-monthly class offerings has been
that newly diagnosed patients need to have the testing as soon as
possible in order to make decisions regarding surgery for their
breast cancer and this time between classes is diffi cult for some
one a doctorate degree. This fi nding was refl ective of the type
of patients seen at SPBCC and the surrounding community,
which includes two universities, high-tech industries and re-
search centers and a population of upper-class, highly educated
individuals. The majority of participants were women (n=11)
with four men attending to support their partners. Eight par-
ticipants came to the class because their physician had recom-
mended the class. Six participants had been diagnosed with
breast cancer and three were diagnosed in the last year.
Motivation for attending the class varied among the group.
Seven attendees were concerned about the potential genetic
mutation that they may have passed on to their children. Six
participants had a family member newly diagnosed with breast
or ovarian cancer and another six were concerned about their
family history of breast/ovarian cancer being inherited. Eight
participants had a family member diagnosed with breast cancer
under the age of 50 years. Only three participants had a family
member diagnosed with ovarian cancer.
BOX 4 Patient Cost for HBOC Education
Sala
ry C
ost
Number of patients educated
Cost per patient with classCost if individual appointmentsTotal cost of class
December 2008 January 2009 Nursing for Women’s Health 499
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Lancaster, J., Powell, C., Kauff, N., Cass, I., Chen, M., Lu, K., et al. (2007). Society of Gynecologic Oncologists Education Commit-tee statement on risk assessment for inherited gynecologic can-cer predispositions. Gynecologic Oncology, 107(2), 159–162.
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patients. Therefore, in order to accommodate the patient’s need,
these patients are seen individually for education and testing.
This project considered patient outcomes, nursing resourc-
es and the nursing process in developing and implementing a
group education class that was effective in its goals of decreas-
ing the amount of the nurse educator’s time spent on educa-
tion, while still providing an effective class to patients. NWH
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