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Advancing practice in endoscopy

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Scotland currently has 20 practising nurse endoscopists, all of whom have undergone a training programme in upper or lower gastrointestinal endoscopy.

Anne Macdonald, BSc, MA, RN, SCM.

Clinical Nurse Specialist in Gastroenterology, Endoscopy Unit, Victoria Hospital, Fife

 

 

For the past decade - since publication of the Calman Report (Department of Health, 1993) and the government report on junior doctors’ hours (DoH, 1991) - nurses have had the opportunity to train in many procedures traditionally undertaken by doctors.

Around the same time, the British Society of Gastroenterology issued guidelines (Box 1) suggesting it would be acceptable for nurses to carry out uncomplicated upper and lower gastrointestinal endoscopy following appropriate training.

The UKCC (1992), now the Nursing and Midwifery Council, also supported nurses wanting to develop their professional practice.

Autonomy

The nurse endoscopist has a wider role in the care of patients with gastrointestinal cancers and chronic illnesses such as Crohn’s disease and ulcerative colitis. Many manage nurse-led clinics and are responsible for their own caseload. They also provide support and advice to patients.

As clinical nurse specialists and nurse practitioners, they could be regarded as the equivalent of the advanced practice nurse in the US, where nurses have been performing cancer-screening flexible sigmoidoscopy for the past 20 years.

The American Nurses’ Association defines advanced clinical practice as follows (Snyder and Mirr, 1995): ‘Nurses in advanced clinical nursing practice have a graduate degree in nursing. They conduct comprehensive health assessments, demonstrate a high level of autonomy and possess expert skills in the diagnosis and treatment of complex responses of individuals, families and communities to actual or potential health problems. They formulate clinical decisions to manage acute and chronic illness and promote wellness.’

It adds that clinical nurse specialists integrate education, research, management, leadership and consultation into their clinical role in collaboration with their nursing and medical colleagues.

Training

Scottish nurse endoscopists have undergone training in gastroscopy, examination of the upper gastrointestinal tract, and/or flexible sigmoidoscopy, examination of part of the colon. All have completed an ENB-accredited course at the University of Hull.

The clinical part of training for a nurse endoscopist is the same as for a medical endoscopist. Before nurses can practice independently they must observe and carry out a minimum of 150 procedures. These are done under the close supervision of a consultant surgeon or physician, who acts as clinical supervisor.

Theoretical training is based on a log and video record of clinical practice and the submission of four written assignments. When the clinical supervisor has assessed competency, the nurse can begin to practise independently.

Faster diagnosis

The establishment of three nurse endoscopists in one NHS trust in Scotland has led to a fall in waiting times from 16 to four weeks (Figure 1). Patients are referred by the GP via an open-access endoscopy service.

This one-stop diagnostic service has benefited patients in two ways. First, the time from seeing the GP and the investigation is shorter. Second, treatment can be started sooner.

In the same NHS trust the average time from diagnosis to treatment of upper GI cancer in 2001 was 15 days, which is also partly attributable to the work of nurse endoscopists.

Shared practice

Ten years ago there were no nurse endoscopists in Scotland. Now, there are 20 fully trained and practising endoscopists from as far north as Elgin to Dumfries in the south. The majority are based in the central belt, in Scotland’s large teaching and general district hospitals.

The widespread geographical distribution makes it difficult to meet regularly, yet it is important that we do so to share practice and discuss future developments for nurses who want to train as endoscopists. The Association of Nurse Endoscopists in Scotland has been set up and holds meetings four times a year.

Training plans

To attend any of the training courses in endoscopy, which at the moment are available in England only, nurses from Scotland have to travel long distances. This increases the cost for the hospital trusts that pay for travel and accommodation, as well as the course fee.

The increasing demand for endoscopic procedures will require more nurses to have training, which has led to recognition of the need to set up a local centre in Scotland.

Glasgow Caledonian University has been chosen to run a degree-level course for nurses wanting to work as nurse endoscopists. Another course, which started last April at City University, London, is also offering a degree-level course for nurse endoscopists, with the option of proceeding to a master’s degree.

Collecting evidence

There has, as yet, been no study to assess the effectiveness of nurse endoscopists.

A UK-wide study launched this year will look at the cost-effectiveness and acceptability to patients of nurse endoscopy.

Eight hospitals in Scotland are participating and patients will be followed up for one-year post-endoscopy. Patients will be asked to complete questionnaires about their general health, symptoms pre- and post-endoscopy, and a satisfaction questionnaire.

The evidence so far demonstrates that this is a positive development for nurses and patients.The significant impact on waiting times has been recognised and this can only benefit patients. In future it is likely that nurses who wish to develop their professional practice and extend their role will continue to be trained in endoscopic procedures.

 

 

British Society of Gastroenterology Working Party Report (1994)The Nurse Endoscopist. London: BSG.

Department of Health (1993)Hospital Doctors: Training for the Future. Report of the Working Group on Specialist Medical Training (The Calman report). London: DoH.

Department of Health (1991)New Deal on Junior Doctors’ Hours. London: HMSO.

Snyder, M., Mirr, M. (1995)Advanced Nursing Practice: A Guide to Professional Development. New York, NY: Springer Publishing Company Inc.

UKCC. (1992)The Scope of Professional Practice. London: UKCC.

 

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