An urge for Quality and Quality Assurance of basic nurse education, Pakistan: The Leadership perspective

Gupta Sanjay Kumar1*, Khare Neeraj2, Khare Sonali3, Gaur Neeraj4, Nandeshwar Sunil5
  1. MD; Associate Professor, Community Medicine Peoples College of Medical Sciences and Research Center, Bhopal-India
  2. PG Student; Department of Community Medicine, Peoples College of Medical Sciences and Research Center, Bhopal-India
  3. M.Pharma; Assistant Professor; Department of Pharmacy, Peoples College of Pharmacy, Bhopal -India
  4. MD; Assistant Professor, Community Medicine Peoples College of Medical Sciences and Research Center, Bhopal-India
  5. MD; Associate Professor, Community Medicine GMC Bhopal- India
Corresponding Author: Dr. Sanjay K. Gupta MD, Associate. Professor, Department of Community Medicine, Peoples College of Medical Sciences and Research, Bhanpur Bhopal MP-462037, India Email: [email protected] Ph. 0755-4005118 fax-0755-4005112 Mob.: 08989003934
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Background: Quality assurance has become absolutely crucial in nurse education to ensure its quality for the delivery of safe and high quality nursing care. The need further propelled by market forces which demand competent nurses for dynamic complex health care delivery systems, policies, regulations and professionalisms. However, until now, there is a little evidence to support the existence of a comprehensive, agreed by all stakeholders and regularly applied quality assurance (QA) system to ensure quality of basic nurse education (BNE) in Pakistan.

Aim: This paper describes the experience and beliefs of a group of nurse leaders in relation to the quality and quality assurance in the BNE and their desire to establish an appropriate system to ensure quality of nurse education.

Method: The data drawn from a qualitative case study conducted in 2004. Among a sample of 71 nurses from various level of nursing, a group of eleven nurse- leaders from all over the country were interviewed on one-to-one basis. A semi-structured, open-ended questionnaire concerning concepts of quality of education, on-going QA system, its effectiveness along with suggestions for improvement was used. Hermeneutic approach to do thematic analysis of verbatim transcripts of interviews was applied.

Findings: First time this study initiated discussion and studied the experiences and beliefs of nurse leaders on quality and quality assurance in the BNE. The findings reveal a unanimous desire of the nurse leaders to gauge quality of nurse education through efficient and effective quality assurance system.

Conclusion: The findings provide initial insights into the existence situation and discern the need for an appropriate system in place to ensure quality of education. A continuous quality improvement (CQI) framework based on Plan-Do-Check-Act (PDCA) cycle or certain aspects of it can be used to determine `what to establish` and `how to implement` a desired QA system.

Key words

Breast self Examination, ICDS, Breast lump (disease)

Short title

Educational intervention for breast cancer


Breast cancer is the second most common malignancy affecting female worldwide. Breast cancer causes 3,76000 deaths a year worldwide; about 90, 0000 females are diagnosed every year with the disease mortality rate from breast cancer have increased during past 60 years in every country.1,2 Early diagnosis and treatment of the disease in precancerous stage can reduce the incidence of this widely prevalent malignancy among women. A strong family history, early puberty and late menopause are major risk factors for breast cancer in females.7 Breast self examination (BSE) 3, clinical examination, mammography and biopsy are few of the techniques used to diagnose breast cancer. But in the developing countries like India where resources are scare, early diagnoses and treatment is the best option for reducing the incidence and complication of this disease and so BSE is the most appropriate technique by which we can make females aware, so that they can detect the lump or any change in the breast, such as dimpling of the breast, pain and redness in the breast etc., by their own. Breast cancer is most frequently found by themselves by self examination than by a physician in a routine examination. Standard treatment options include local therapy like surgery or radiation therapy and systemic therapy like chemotherapy, biological therapy and hormone therapy. The causes of breast cancer is not known their fore there is not known way to prevent the disease. The best alternative is to discover the disease as early as possible through regular breast examination.


1) To educate female for detection of benign/malignant breast disease by BSE
2) To detect new cases of benign/malignant breast disease and to promote them to teach other females in their contact about BSE


The present cross sectional study was carried out among females attending ICDS units of the Bhopal city (Ambedkar nagar, Sudama nagar, Rahul nagar, Om nagar), total 110 subjects participated. Selected females were divided in five groups (Around 25 in each), lectures and demonstration were taken regarding breast self examination techniques, self reading materials also provided to each participant, like pamphlets, booklets etc., in local language. All participants were motivated to teach these techniques to other females in their family and contact. Information about each participant were collected in predesigned and pretested proformas after obtaining informed consents, data was collected regarding their age, socioeconomic status, age of menarche and menopause, parity and duration of breast feeding etc. Assessment of socio-economic status done by using Gupta and Mahajan classification 11, clinical examination was done of all participants for detection of any change/lump in breast.

Action Plane

First step: Female volunteers and doctors taught about breast self examination technique to integral child development scheme (ICDS) workers and females attending ICDS unit, and encourage them to tell about breast self examination (BSE) technique to others female friends/relatives.
Second step: By this method we detected lump cases in community.
Third step: All those who had lump referred to medical college hospital

Steps of Breast Self Examination (BSE)

Breast Self examination (BSE): BSE done monthly, 7-10 days from the first day of your period, same day every month if you are not menstruating. (Shown in the Graph at Appendix)
Criteria used for diagnosis of benign or malignant breast disease. 8, 9


Results are displayed in the Figures and Tables which are shown at the end of the manuscript.


Breast cancer is the second most common malignancy affecting women worldwide. Mammography has long been used as a screening tool in developed country it involves sophisticated imagine technology, complex quality control procedures with enormous cost in terms of manpower and material resources. This method is therefore unsuitable for developing countries.
Breast self examination (BSE) on the other hand is an inexpensive method. BSE is the visual and manual examination of your normal breast structure so that you can easily identify any unusual spontaneous changes. The majority of breast lump are found by the women herself. Early medical attention to these changes can greatly impact the treatment and prognosis if you are diagnosed with breast cancer. It is also important to have an annual clinical breast examination by a physician or health care professional.
Other diagnostic techniques are USG, Computed tomography, 3D ultrasound guided biopsy, MRI, laser mammography. In India 50% of women with breast cancer and 70% of cervical cancer present themselves in a late stages 3rd and 4th, so the intervention feasible are physical examination of the breast by the trained female health worker along with the teaching of BSE techniques.10
According to our observation there is no increased risk of breast cancer in women using OCPs, which has already been proved in several other studies, with the increase in the age of menarche risk of getting benign / malignant breast disease have found to be increase. Breast cancer can be controlled by significant awareness and adequate steps taken at right time.


All the participants were unaware of breast self examination techniques initially and now they are aware of it and participating regularly, around 25% females were detected lump in the breast during study. All 28 females were referred to medical college hospital and 2 (7.14%) were confirmed malignant in biopsy report and operated. According to our observation females who have late menarche (at 17-18 year of age) late marriage (after 25 years) and who don’t breast feed or feed less than 3 months are prone to develop benign or malignant breast diseases. According to our observation OCPs consumption is not significant risk factor for breast diseases.


We are very thankful to the Aganwadi worker for helping in conducting the study.


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7. Morrison AS. Review of evidence on the early detection and treatment of Breast cancer. Cancer. 1989;64:2651-6.

8. Fletcher SW, Black W, Harris R, Rimer BK, Shapiro S. Report of the International Workshop on Screening for Breast Cancer. J Natl Cancer Inst. 1993; 85:1644-56.

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10. The textbook of Preventive and Social Medicine by Mahajan and Gupta. 2003, 3:117-8.
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