ORIGINAL RESEARCH
Oncology & Screening
Knowledge, Attitude and Practice of Breast Self-Examination Among Nurses in Tertiary Hospitals in Malaysia
Key Findings
- While a majority of nurses demonstrated good theoretical knowledge of breast self-examination (BSE), a significant proportion did not regularly perform BSE themselves, revealing a notable knowledge-practice gap.
- Positive attitudes toward BSE were widespread, with most respondents agreeing that BSE is an important tool for early breast cancer detection and that healthcare professionals have a responsibility to practise and promote it.
- Barriers to regular BSE practice among nurses included forgetfulness, lack of confidence in examination technique, fear of discovering an abnormality, and competing time demands from professional and domestic responsibilities.
- Nurses who had received formal training in BSE technique were significantly more likely to practise it regularly compared to those who had not received such training.
Background and Context
Breast cancer is the most common cancer affecting women in Malaysia. According to the Malaysian National Cancer Registry, breast cancer accounts for approximately one-third of all female cancer cases, with an age-standardised incidence rate that places Malaysia among the countries with moderate-to-high breast cancer burden in the Asia-Pacific region. The five-year survival rate for breast cancer in Malaysia is notably lower than in high-income countries, a difference largely attributed to later-stage presentation at diagnosis.
Breast self-examination (BSE) is a simple, non-invasive screening behaviour that enables women to become familiar with the normal appearance and feel of their breasts, thereby facilitating the early detection of changes that may warrant clinical investigation. While the evidence base for BSE as a standalone population-level screening strategy has been debated — with some international guidelines emphasising mammography as the primary screening modality — BSE remains an important component of breast awareness promotion, particularly in resource-limited settings where access to mammographic screening is constrained.
In Malaysia, where mammographic screening coverage remains incomplete, especially among younger women and those in rural areas, BSE serves as a practical and accessible complement to clinical breast examination and mammography. Healthcare professionals, particularly nurses, play a dual role in breast cancer screening: they are both practitioners responsible for educating patients about BSE and women who should themselves be practising regular breast self-examination.
Study Design and Methods
This cross-sectional study was conducted among female nurses working in tertiary hospitals in Malaysia. The study assessed three domains — knowledge, attitude, and practice — related to breast self-examination. A structured, self-administered questionnaire was developed and validated for the study, incorporating items drawn from established instruments in the BSE literature and adapted for the Malaysian healthcare context.
Knowledge was assessed through items testing understanding of BSE technique (timing, positioning, palpation patterns), awareness of breast cancer risk factors, and recognition of signs and symptoms warranting clinical referral. Attitude items explored beliefs about the effectiveness and importance of BSE, perceived vulnerability to breast cancer, and perceptions of professional responsibility regarding breast health promotion. Practice items assessed the frequency, regularity, and technique of BSE performance, as well as barriers encountered.
Key Results
| Domain | Finding |
|---|---|
| Knowledge — BSE technique | Majority of nurses demonstrated good overall knowledge of correct BSE methods and timing |
| Knowledge — Risk factors | Awareness of breast cancer risk factors (family history, age, hormonal factors) was generally adequate |
| Attitude — Importance of BSE | Overwhelmingly positive attitudes; most nurses endorsed BSE as valuable for early detection |
| Attitude — Professional role | Strong agreement that nurses should serve as role models for patients regarding BSE |
| Practice — Regular BSE | Significant proportion of nurses did not practise BSE regularly despite positive knowledge and attitudes |
| Practice — Formal training | Nurses with prior formal BSE training demonstrated significantly higher practice rates |
The central finding of this study was the conspicuous gap between knowledge and attitude on one hand and actual practice on the other. Despite knowing how to perform BSE and believing in its importance, a substantial number of nurses did not perform BSE regularly. This knowledge-practice gap is a recurring theme in health behaviour research and suggests that awareness and positive attitudes, while necessary, are not sufficient conditions for sustained health behaviour adoption.
Barriers to BSE Practice Among Nurses
Qualitative and quantitative exploration of barriers revealed several factors hindering regular BSE practice. Forgetfulness was the most commonly cited reason — despite understanding the importance of monthly BSE, nurses reported difficulty maintaining the routine amid busy work schedules and personal responsibilities. Lack of confidence in self-examination technique was also prevalent, suggesting that even healthcare professionals may feel uncertain about their ability to detect abnormalities through self-palpation.
Fear of finding a lump or abnormality emerged as a psychologically significant barrier. Some nurses described anxiety about the possibility of discovering a breast abnormality in themselves, preferring avoidance to the distress of confronting a potential cancer diagnosis. This finding has important implications for health education design: programmes that address the emotional and psychological dimensions of screening behaviour may be more effective than those focused solely on knowledge transmission.
Implications for Nursing Education and Practice
The finding that formal BSE training was significantly associated with higher practice rates provides a clear and actionable recommendation: nursing education curricula and continuing professional development programmes should incorporate hands-on BSE training as a standard component. This training should include not only technique instruction but also strategies for integrating BSE into personal routine and approaches for teaching BSE to patients during clinical encounters.
At the institutional level, tertiary hospitals could implement workplace breast health promotion programmes for their nursing staff, including annual breast cancer awareness campaigns, access to clinical breast examination, and facilitated mammography referrals. Such programmes would serve the dual purpose of protecting nurses’ own health and strengthening their capacity as credible and practising advocates for breast cancer screening among their patients.
From a broader public health perspective, if nurses — who represent the largest healthcare workforce in Malaysia — do not consistently practise BSE themselves, the credibility of their patient education messages may be undermined. Addressing the knowledge-practice gap among healthcare professionals is therefore not only a workforce health issue but also a strategy for improving population-level screening behaviour.
Limitations
The study was conducted in tertiary hospitals, where nurses may have greater access to health education resources and clinical expertise than their counterparts in primary care, community, or rural settings. The findings may therefore underestimate the knowledge-practice gap among nurses in less resourced settings. Self-reported practice measures are subject to social desirability bias, and cross-sectional design prevents assessment of temporal relationships between training exposure and behaviour change. The study also did not assess clinical breast examination or mammography utilisation among the study participants.
Citation
Raja Gopal R, Md Isa Z, Daud W, Nurumal M, Syed Zakaria S. Knowledge, attitude and practice of breast self-examination among nurses in tertiary hospitals in Malaysia. Malaysian Journal of Public Health Medicine. 2014; 14(3): 54–62.
© 2014 The Authors. Licensed under CC BY-NC 4.0.