VOL: 97, ISSUE: 44, PAGE NO: 56
Pauline Matthews, RGN, DipSM, is sister/nurse endoscopist, Endoscopy Unit, Dorset County Hospital, Dorchester
The role of the nurse is constantly changing to meet the developing needs of the health service. The Scope of Professional Practice (UKCC, 1992) sets out conditions for post-registration expansion of nurses’ skills and aims to encourage nurses to take on more specialised roles than they previously had access to in order to improve patient care. It suggests that nurses are able to undertake certain practices, if they are deemed competent, after relevant and adequate training. The adjustment to practice must not compromise or fragment existing aspects of professional care.
I recognised five years ago that developing a specialised role would make a difference to the quality of the service patients receive when needing an upper gastrointestinal (GI) endoscopy. At the time the role was developed, no formal training was available. Today any nurse wishing to undertake this role can take up accredited training that has since been developed.
In 1994 the British Society of Gastroenterology (BSG, 1994) issued guidelines and recommendations suggesting that it would be appropriate for a suitably trained endoscopy nurse, with the full support of the gastroenterologist, to carry out uncomplicated upper and lower gastrointestinal (GI) endoscopy. Initially this would be carried out on unsedated patients.
Many common complaints of the digestive system can now be easily investigated via the endoscope, enabling correct diagnosis before treatment. This has resulted in a dramatic increase in the demand for GI endoscopy over the past 10 years.
West Dorset has provided an open access upper GI service to GPs for the past 25 years. The demand for a quick and accurate endoscopy has been fueled by the need to establish whether patients found to be infected with H Pylori have significant gastric or duodenal pathology, to avoid unnecessary or inappropriate treatment with proton pump inhibitors (PPIs) and H2RAs and to rule out underlying malignancy.
As the demand for upper GI endoscopy grew, the service west Dorset could provide was no longer adequate. Furthermore, many endoscopy lists were part of training for doctors in their first year as a registrar. This meant reduced activity and sometimes prolonged and uncomfortable procedures for patients. By the time trainees became competent in the technique they were ready to move on and another arrived. While training was an important part of the service, it offered little stability for the patient or referring GP.
Development of the nurse endoscopist
In January 1996 the consultant gastroenterologist and senior nurse recognised the possible benefits of training an experienced endoscopy nurse to become an upper GI nurse endoscopist. It was thought that this role would provide the following:
- A holistic package of care to patients attending for upper GI endoscopy, encompassing the psychological, physiological and sociological needs of the patient;
- Freedom for the skilled medical endoscopist to concentrate on high-risk and therapeutic procedures, with more time to support trainees;
- A predictable open-access service for GP referral;
- Reduction of waiting lists;
- Cover for annual leave and study leave;
- Few patients attending the clinic for endoscopy are calm and confident. They are hungry, thirsty (nil by mouth beforehand), frightened of the procedure and most of all afraid that the diagnosis may be bad news;
- Having a nurse who is able to carry out the diagnostic endoscopy provides comprehensive seamless care for all patients accessing the service. Also, the endoscopy nurse already has the skills and knowledge to assess the needs of each individual attending for endoscopy from first contact to discharge. She provides appropriate care before, during and after the procedure, gives advice on admission and discharge, ensures safe delivery of endoscopic equipmentand has access to relevant members of the multidisciplinary team, such as cancer care, dietitian or consultant to seek advice before discharge.
At the time this development was proposed, however, there was no suitable formal training course available. The suggestion met with some scepticism and trepidation from the senior nursing, medical and managerial personnel; they all required convincing that the role was viable. There was genuine concern for professional and legal liability, as well as concern about how acceptable the development would be to patients. The many issues which needed to be resolved have been highlighted in the BSG nurse endoscopist guidelines (British Society of Gastroenterology, 1994).
When expanding the scope of practice in this way it is essential to consider the legal implications of nurses crossing the boundaries of practice into what is traditionally considered to be a medical domain. The general public and professional bodies all have individual expectations and perceptions of what constitutes the nursing role.
In today’s climate of increasing litigation, nurses can feel vulnerable even when working within their ‘accepted’ nursing roles. When crossing the so-called medical boundaries it is essential that the nurse fully understands the implications and works within an agreed protocol for which the trust has vicarious liability. The UKCC could not give a view on this specific development, but referred to the document Scope of Professional Practice (UKCC, 1992). However, the RCN gave assurance that, providing practice was within agreed trust protocol, support would be given. The Medical Defence Union also agreed to cover nurses carrying out invasive investigations.
Is the general public ready to accept that nurses are capable of carrying out invasive investigations that were formerly carried out by medical staff? The results of the audit of our service suggest that they are. Can nurses make diagnoses? Should they be restricted to describing observations and findings? There was much debate on these issues, for example: Could a nurse make a diagnosis of an ulcer, or should it be described as ‘a ’cm crater covered in white matter that looks like slough with a dark spot in the center that could be a blood vessel’?
Common sense prevailed, and it was agreed that, once trained and competent, it would be acceptable for a skilled nurse endoscopist to make a diagnosis and report to the referring doctor who would take over the patient’s management.
Which patients would not be suitable for nurse endoscopy? The exclusions agreed for the west Dorset protocol were any patients presenting with dysphagia, acute GI haemorrhage and those with a severe previous medical history.
To achieve appropriate patient selection it is important that the correct information is given on the referral form. We were fortunate that a referral form developed two years earlier as a result of a regional audit ensured that all the relevant information was included. GPs were informed of the nurse endoscopist development and have cooperated and supported it from the outset.
If nurses are to perform endoscopy they need to obtain written patient consent. The nurse must fully understand what constitutes informed consent and patients’ rights. This has been an area of great scrutiny, and Hughes (1996) gives clear guidelines on consent to endoscopy.
It was agreed that, in line with the BSG recommendations, once training was complete a medical endoscopist would be available at all times during nurse endoscopy lists, in case support was required.
Practical and training issues
Again in line with British Society of Gastroenterology recommendations, it was agreed that a nurse wishing to train to perform endoscopies would have at least two years’ experience as an assisting endoscopy nurse, observed at least 1,000 upper endoscopies and be fully conversant with the endoscope and its maintenance. The nurse would also be trained in cardiopulmonary resuscitation and be conversant with safety procedures.
All patients would have pulse oxymetry, and oxygen would be available during the procedure. If sedation was given it would be in the presence of the gastroenterologist.
One hundred and fifty endoscopies would be performed under close supervision of the gastroenterologist, and the nurse would keep a record of all endoscopies, which would be agreed and signed by the supervising endoscopist.
A course of lectures revising the anatomy, physiology and pathology of the upper GI tract was to be provided by the gastroenterologist. On completion of training, the nurse would be assessed to ensure she or he had a good theoretical knowledge based on experience and formal teaching and would demonstrate endoscopy technique, assessment and diagnostic skills to the satisfaction of the gastroenterologist.
Eventually a protocol and training programme was drawn up to meet all the requirements of the trust board. By the time training was completed in December 1996 the protocol had undergone review to safeguard practice. There were 360 supervised nurse endoscopies in the logbook, and a consultant gastroenterologist from another trust was asked to make a formal independent assessment of the nurse’s skills and knowledge. The nurse endoscopist role, fully supported by the gastroenterologist, became operational from this date.
Since the role became operational the average time patients were on the waiting list fell from four to five months to three to four weeks. An audit was carried out recently to assess the safety and accuracy of the role.
The study period included all upper GI endoscopy carried out by the nurse endoscopist between January 1997 and December 1999, followed by a six-month period to allow any further follow-up or complication to become evident. Data was collected from the endoscopy reporting, pathology reporting, and patient administration systems.
Of the 2,038 patients, a total of eight died within 30 days of nurse endoscopy, four patients had metastatic tumors, one 86-year-old had a bleeding duodenal ulcer, two 91-year-olds died of MI within 30 days of endoscopyand one 94-year-old had a haematemesis 19 days post-endoscopy
There is no evidence that these complications are directly related to the endoscopy. The numbers are very small in relation to the size of the study and account for 1% of all patients.
All patients receive information before their endoscopy telling them that the procedure may be carried out by a nurse, and giving them the option of being seen by a doctor if they prefer. Only one patient in the past three years has requested this. There has been one formal complaint from a patient following nurse endoscopy. There was nothing about this person’s endoscopy that had caused any concern except that a ‘nurse’ had carried it out.
What concerns many is whether a nurse has the ability to make an accurate diagnosis. A recent study has been carried in which patients were given an endoscopy first by a nurse and then by a medical endoscopist. Comparisons of findings showed that the pick-up rate of abnormal pathology for nurses was higher than that of their medical colleagues (Schoenfield et al, 1999).
The introduction of the role in this trust has resulted in greatly reduced waiting times. GPs concerned about patients telephone the department and are usually able to schedule an endoscopy within a few days. It has enabled the introduction of the two-week wait for diagnosing upper GI cancer to be easily achieved. Where appropriate, patients are having an endoscopy before starting drug therapy, allowing curative advice and appropriate treatment to be given.
The National Patients Access Team (2000) suggests that 1-1.5% of the population will require upper or lower endoscopic investigation of the GI tract each year. For an NHS trust with a catchment of 500,000 that means that up to 7,500 diagnostic procedures are required each year.
The development of the nurse endoscopist role is now recognised and supported by nursing and medical governing bodies nationally, although formal training is still limited, particularly in the south of the country,
British Society of Gastroenterology guidelines (2001) identify that there are now nurse endoscopy training units where approximately 75 nurses per year receive accreditation. They also outline further recommendations for the development of the nurse endoscopist role and its place in the provision of a gastroenterology service to patients.Things have come a long way in five years.