Strengthening nurse-led clinical breast examination (CBE) screening through quality improvement: A prospective implementation study from a tertiary hospital in eastern India.

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Background: India, representing nearly one-fifth of the global female population, faces a rapidly increasing breast cancer burden. The age-adjusted incidence rate has risen from 25 per 100,000 in the 1990s to nearly 40 per 100,000 in 2022. Alarmingly, over 60% of Indian women are diagnosed in locally advanced or metastatic stages. While the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) provides a policy framework for screening, its operationalization remains limited by workforce and infrastructure constraints. Nurse-led CBE models, integrated into existing hospital workflows, have the potential to address these gaps efficiently. At our institution, women attending the General Surgery OPD were not routinely offered CBE unless they presented with breast complaints. Nurses, though integral to patient flow, were minimally involved in cancer screening and rarely engaged in Quality Improvement (QI) efforts. This presented an opportunity to transform existing human resources into active participants in cancer prevention. Methods: A prospective Quality Improvement study was conducted at a tertiary care teaching hospital in eastern India. The project adopted the Model for Improvement, focusing on iterative PDSA cycles. A multidisciplinary QI team did a Gemba walk of the General Surgery OPD to observe the workflow and identify barriers to screening. The fishbone diagram and Pareto chart identified major obstacles. Four sequential PDSA cycles were implemented, each lasting approximately one month namely hands-on nurse training, developing Institutional policies, empowering nurses to conduct CBE independently and institutionalizing recurrent training to address nurse rotation and attrition. Results: The baseline CBE rate in August 2024 was 0%. After the first intervention cycle, the screening rate rose to 36%. Following further workflow optimization and patient engagement, the rate stabilized above 60%, reaching 63.6% at six months. Among those screened, the ones showing abnormalities such as palpable lumps, skin dimpling, or nipple discharge were referred to surgical oncologists for further diagnostic evaluation. Nurses reported enhanced confidence and professional ownership. The administrative leadership noted improved patient satisfaction and expressed willingness to scale the model across departments. Conclusions: Nurse-led CBE screening implemented through structured QI methodology significantly improved screening uptake and awareness among women in a tertiary care hospital in eastern India. This initiative demonstrated that task-shifting to trained nurses is feasible, scalable, and sustainable within LMIC health systems.