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Extended training equips nurses to undertake diagnostic hysteroscopy

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VOL: 98, ISSUE: 34, PAGE NO: 38

Helen Ludkin, Dip Combined Health Studies, RGN, and Pam Quinn, Dip Combined Health Studies, RGN, are nurse hysteroscopists, Bradford Royal Infirmary

The government supports and encourages nurses to undertake advanced practice, an issue that is an important aspect of The NHS Plan. A multidisciplinary team from Bradford Hospitals NHS Trust and the University of Bradford has developed an advanced practice hysteroscopy module to educate and train nurses to the advanced level required to practise diagnostic hysteroscopy independently (UKCC, 1992). This ensures high standards of care for patients, and has many benefits.

The government supports and encourages nurses to undertake advanced practice, an issue that is an important aspect of The NHS Plan. A multidisciplinary team from Bradford Hospitals NHS Trust and the University of Bradford has developed an advanced practice hysteroscopy module to educate and train nurses to the advanced level required to practise diagnostic hysteroscopy independently (UKCC, 1992). This ensures high standards of care for patients, and has many benefits.

This article describes how the module was developed and evaluated; the nurses' experiences while training; and the impact of their new role within the hospital.

Background
Outpatient hysteroscopy is now the method of choice in the investigation of abnormal uterine bleeding (Lumsden et al, 1997). The nurse facilitators in Bradford's outpatient hysteroscopy service coordinate the service and counsel and support women before and after the hysteroscopy.

In 2001, the two consultant gynaecologists in the hysteroscopy clinic proposed extending the service from purely diagnostic to offering simple operative treatments. It was agreed that it would be a natural development for the nurse facilitators to take over the diagnostic work. This has benefits for patients, including:

- Treatment is provided by all-female team: this is particularly important in Bradford, which has a large population whose religious beliefs require this;

- Continuity of care: patients appreciate receiving the explanation and results of the procedure from the person who has performed it;

- Permanent hysteroscopists: because of the rotation of doctors, their experience in hysteroscopy and the treatments offered may be limited;

- Patients find it easier to talk to nurses: anecdotal evidence and patients' comments indicate that nurses are perceived as being approachable (Box 1).

Getting started
The nurse facilitators and one of the consultants looked at the nurse colposcopist training, which was judged to be an excellent model on which to base nurse hysteroscopy training. The British Society for Gynaecological Endoscopy (BSGE) agreed to accredit a training module and an RCN representative offered support throughout.

The proposal was presented to the trust's advanced practice steering group, which approved the development of an academically accredited module in liaison with the University of Bradford. Regular progress updates are fed back to this group. The module was developed by a steering group consisting of the consultant, the nurse facilitators, the nurse manager, the trust's head of professional development and a representative from the university.

Issues to consider in addition to the module outline included:

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

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

- Writing departmental protocols and amendments to existing documentation.

These issues were all resolved without problems.

Some concern has been expressed about the effect that nurses taking on extended roles might have on junior doctors' training (Newland and Burns, 2001). To address this issue, the nurses who undertake training share clinic sessions with junior doctors. On completion of training, the nurses go on to supervise the sessions.

The module
The first intake began their training in June last year and had nine participants from around the country. The entry requirements stipulated that entrants should have:

- Support from their nurse manager and consultant, who would also agree to be their local trainer;

- Evidence of recent study at level 2 and two years' recent experience in gynaecology;

- Membership of the BSGE.

The theoretical components of the module are delivered over a 10-day period which involves three separate visits to Bradford. They consist of lectures, problem-based learning and practical sessions, and are delivered by the consultant, a university lecturer and visiting speakers.

Practical training is undertaken in the trainee's hospital under the supervision of their local trainer, who should be a recognised BSGE preceptor. The trainee observes up to 50 hysteroscopies as a supernumerary member of staff before performing 50-100 under direct supervision, and a further 50-100 under indirect supervision.

The trainee completes logbooks that have both theoretical and practical components and they submit 10 case studies of around 500 words. Once all aspects of the training are complete, the logbooks are submitted to the university and an external examiner for marking. If the logbooks and case studies meet the required standard, the trainees can sit the final assessment, which is in the form of an objective structured clinical evaluation, which is offered every six months and provides 20 credits at level 3.

Evaluation
The module is evaluated by questionnaires, which are completed anonymously. Changes to the course delivery are made continually. Patients' views on nurse hysteroscopists are evaluated through patient satisfaction surveys (Box 2). Feedback from patients is generally positive (Box 1) and they appreciate the continuity of care being given by one carer. No patient in Bradford has refused to have a hysteroscopy undertaken by a nurse.

An audit of failure rates of doctors and nurses has shown that this is lower for nurses than for doctors. Nurses failed to perform the test in only 5% of patients, while doctors failed in 8.5%. This is thought to be because of the structured training given to nurses and the fact that the rotation of doctors leads to them each having less clinical experience in hysteroscopy.

Before studying the module, the nurses enhanced their experience by undertaking the ENB cervical screening module and visiting advanced practitioners in other specialties. They also attended theatre sessions to gain experience in undertaking pelvic examinations and working with gynaecology outpatients to develop history-taking skills.

Nurses found the start of their supervised practice to be nerve-racking. The fact that the patients were fully conscious made it difficult for the nurses to ask for help. They also found it difficult to concentrate on performing the procedure at the same time as reassuring the woman.

As the nurses gained experience, the consultant took a back seat, leaving them to think independently, and only offered help when asked. Once the nurses moved into unsupervised practice, the consultant remained in her office nearby where she could be contacted if needed. Every hysteroscopy was recorded on video, with the woman's consent, and findings and treatment recommendations were discussed with the consultant at the end of each clinic at a debriefing session.

The nurses met monthly with the consultant to discuss their progress and highlight things that needed to be done. They found this extremely useful and valued the consultant's support.

Conclusion
The training of the first intake has now been completed: eight students sat their final assessment last June, all of whom passed. The second intake began studying in January this year and the third in June. The nurse facilitators have acted as supporters to subsequent students.

The module has not been widely advertised to date, but it is proving extremely popular. Feedback from patients has been positive and now that the nurses are practising independently, a new clinic is being set up to increase flexibility of access and to reduce waiting times.

The development of this new role is an exciting challenge for the nurses. It will also empower them by giving them direct involvement in patient care. They appreciate the help and support given by the trust, their manager and, in particular, their trainer.

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.

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