The benefits of setting up a nurse hysteroscopy service

The Government supports and encourages nurses to undertake advanced practice, an issue that is an important aspect of The NHS Plan (Department of Health, 2000). A multidisciplinary team from Bradford Hospital's NHS Trust and the University of Bradford has developed what is thought to be the world's first advanced practice hysteroscopy module. It aims to educate and train nurses to the advanced level required to practise diagnostic hysteroscopy independently. This is a role traditionally undertaken by doctors. Two nurses, previously nurse facilitators in Bradford's hysteroscopy service, were students on the first intake of the course.

Background to the service
Outpatient hysteroscopy is now the method of choice for the investigation of abnormal uterine bleeding (Lumsden et al, 1997). Approximately 900 women attend Bradford's outpatient hysteroscopy service for the investigation of this condition every year.

The service was launched in 1994 - the first clinic in the country to provide direct access for GPs. Before their training, the nurse facilitators' role in the clinic was to counsel women before the procedure and give provisional results and information regarding treatment options.

In 2001 the two consultant gynaecologists involved in the hysteroscopy clinic proposed an extension of the service from being purely diagnostic to offering simple operative treatments. It was agreed by all team members that the natural progression would be for the two nurse facilitators to take over the diagnostic work. This would also provide other benefits to the women, including:

- The provision of an all-female team. This is particularly important in Bradford, which has a large ethnic-minority population. For many Asian women, it is a cultural requirement that they are not examined by a male

- Continuity of care. The women appreciate receiving their pre- and post-test hysteroscopy counselling from the person who performs the procedure, thus combining the nurses' previous role with their new one

- Having a permanent nurse hysteroscopist. Due to duty rotation individual doctors' experiences in hysteroscopy and the treatments offered may be limited

- Patients find it easier to talk to nurses. Research, anecdotal evidence and patient's comments have shown that patients believe nurses are approachable (Otte, 1996; Easton and Burns, 2001; De Zeew and Carroll, 2001)

- Reduced waiting times with the introduction of additional nurse-led clinics

- Better treatment options for women - new outpatient treatments were planned, such as removal of endometrial polyps, outpatient endometrial ablation and hysteroscopic sterilisation.

Training
A questionnaire asking about nurses' interest in performing hysteroscopy was distributed to all gynaecologists throughout the country, by one of Bradford's gynaecologists.

The results showed that, although there was much interest in nurse hysteroscopy, no nurses were undergoing formal training. A multidisciplinary steering group was then formed in Bradford, consisting of the consultant, the nurse facilitators, the nurse manager, the trust's head of professional development and a representative from the University of Bradford.

Along with guidance from the trust's advanced practice steering group the module was developed over the space of a year. The British Society for Gynaecological Endoscopy (BSGE) agreed to accredit the training module. In addition, the validation process was undertaken by the University of Bradford, which resulted in the module being awarded 20 credits at level 3.

The theoretical components of the module are delivered at Bradford Royal Infirmary over 10 days by a consultant gynaecologist at Bradford Royal Infirmary and the women's health lecturer at the University of Bradford. Other lecturers are also invited to speak on various topics including accountability and professional issues, protocols and the management of complications. A practical session is also held in order that each student gains hands-on experience of pelvic examination, using a speculum and handling the equipment and instruments using models. Each student also has the opportunity to perform their first hysteroscopy under supervision in the outpatient hysteroscopy clinic, with the woman's permission.

The practical training is undertaken in the student's own hospital under the supervision of their local trainer, who would be their consultant. It is a very important role combining supervision, teaching and support. The students undertake at least 25 cases observing, 50-100 cases under direct supervision and 50-100 cases under indirect supervision (or until both student and trainer are confident of competency). Logbooks are also completed, documenting theoretical and practical competences and 10 case studies of 500 words each are submitted. If the logbooks and case studies meet the required standard, the students may then sit the final assessment - an observed structured clinical examination (OSCE). This will be offered every six months, enabling a flexible time scale for training.

The first intake of eight students took their final exam in June 2002. All passed and in Bradford the two nurses began their new role as nurse hysteroscopists. During training, there were other issues to consider, for example:

- Developing patient group directions approved by the pharmacy and professional development department for the administration of listed medication to patients (Spyropoulos, 2002)

- Gaining approval from the heads of departments for the nurse hysteroscopists to request investigations, such as histology, haematology and radiology

- Writing hysteroscopy protocols and amendments to existing documentation.

Some concern has been expressed about the effect of nurses taking on extended roles on junior doctors' training, in that junior doctors may not be able to get the experience they need if nurses are taking up training sessions (Newland and Burns, 2001). While in training, the nurses shared clinic sessions with the junior doctors. On completion of the training, the nurse hysteroscopists supervise them where necessary.

Patients' views
Bradford's nurses were trained in two clinics, enabling them to see a variety of conditions - from elderly women with post-menopausal bleeding (PMB) to younger women with various menstrual disorders.

Each woman was asked to give permission for a nurse in training to perform their hysteroscopy and video the findings for feedback purposes. Written consent was obtained by the nurses, and during the whole training period no woman refused permission.

Audit
During the training period, three audits were performed. First the module itself was evaluated throughout by the consultant and, as a result, minor adjustments were made to the course timetable. For example, it was found that having a more interactive practical session on the first morning allowed the learners to get to know each other and become more confident.

Second, patients' comments on the service, taken from a patient satisfaction audit performed during the nurse's training, showed that satisfaction with the service has remained the same as with previous audits (Box 1).

The third audit was carried out over the last six months of the nurses' training in Bradford. The aim was to look at the clinic failure rates now that the nurses were performing some of the hysteroscopies. Failure was defined as the hysteroscopist being unable to perform the hysteroscopy, usually due to cervical stenosis. Articles have been published commenting on nurses taking over doctors' roles. For example, White (2002) reports on doctors' mixed views, and Horrocks et al (2002) found that patients were as satisfied with nurses as they were with doctors but commented that more research was needed.

Women who had undergone an outpatient hysteroscopy during the six-month period were included in the audit. There were 435 women in total - 318 (73%) hysteroscopies were performed by medical staff (doctors of all grades) and 117 (27%) were performed by the nurses. The data were collected from clinic records for all the cases performed between January and June 2001. The only women not included in this audit were those who had been inappropriately referred to the clinic and for whom no hysteroscopy had therefore been performed. Issues considered are shown in Box 2.

Discussion
In this audit, the nurses had a lower failure rate than the doctors. The results indicated the value of the structured training plan undertaken by the nurses. At present, there is no formal training plan for doctors in outpatient hysteroscopy. In Bradford, training is varied and doctors attend a clinic where rotation and on-call allows.

The nurse hysteroscopists wish to use these findings to form the basis of future research, focusing on the advantages of the training programme.

It has been suggested to the Royal College of Gynaecologists (RCOG) that a similar training plan would be beneficial for doctors, in line with nurses and doctors undergoing colposcopy training (British Society for Colposcopy and Cervical Pathology, 2002).

The fourth nurse hysteroscopy module is now well under way. Bradford's two nurse hysteroscopists are still involved with the students and are able to support them during their training. There has also been interest from local GPs in undertaking the training and two GPs were trainees on the third module and completed their training in June 2003.

The future
This type of training could be used as a model for other advanced practice modules. Within Bradford's trust, the two nurse hysteroscopists have been giving advice to the steering group who are setting up a module for advanced practice nurse sigmoidoscopy.

It is the intention that the nurse hysteroscopists will not only cover the doctors' absences but will run their own nurse-led clinics. They feel they will be able to combine the doctor's role with the skills of the nurse, talking to patients, offering reassurance and giving them information to allow them to make decisions. The extra clinics will reduce waiting times and enable consultants to concentrate on developing outpatient operative treatments.

Bradford's nurse hysteroscopists are at present undergoing training to enable them to fit an inter-uterine progestogen-only system, licensed for contraception and menorrhagia. It is thought that, in the future, they may learn to perform other outpatient operative techniques - for example, endometrial ablation.

Conclusion
The nurse hysteroscopists are proud to be part of such a pioneering project. They feel that their work contributes to a modern NHS in that it combines advanced practice techniques with nursing by not losing the nurse/patient relationship. Doctors in training rotate regularly and are therefore not a constant presence in the hysteroscopy clinic. The nurse hysteroscopists, however, are permanent, available to the women by telephone before and after their procedure and are their named nurse throughout their episode of care.

To undertake any training of this kind, nurses need the support of their consultant trainer, nurse manager and trust, as working independently can be isolating. Grading and pay can also be an issue. Among trainees to date, grades have ranged from E to H.

Nurses are now taking on many new roles - for example, working as first assistants in theatre and advanced practitioners in accident and emergency departments in addition to colposcopy, cystoscopy and now hysteroscopy. Mullally (2000) states that the future for nurses promises to be exciting and challenging. A strong sense of professionalism can be enhanced by developing new ways of working, offering better learning opportunities and ensuring improved team work. Developments such as the hysteroscopy module result in a higher quality of care for patients.

Acknowledgement
The authors wish to acknowledge the assistance of Dawn Jankowicz (audit midwife).

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