- Email: [email protected]
The Nurse Colonoscopist—Training and Quality Assurance
Gastrointest Endoscopy Clin N Am 15 (2005) 829 – 837
The Nurse Colonoscopist—Training and Quality Assurance Margaret Vance, MSc, DIP, RGN Wolfson Unit for Endoscopy, St. Mark’s Hospital, Watford Road, Harrow, Middlesex HA1 3UK, UK
Specialist trained nurses have been performing flexible sigmoidoscopy as part of their nursing role since the 1970s in the United States [1]. As nurses have shown their efficacy and effectiveness in performing flexible sigmoidoscopy, this new nursing role has been adopted more globally in the United Kingdom and other European countries. In the United Kingdom, as the demand for endoscopic procedures has increased, nurses have developed their skills to include flexible sigmoidoscopy and gastroscopy, and this nursing role is established firmly in endoscopy units throughout the United Kingdom. Currently, there is a shortage of endoscopists to perform colonoscopy; this has been compounded by the proposed introduction of a national colorectal cancer screening program and an increasing demand for diagnostic colonoscopy. In the United Kingdom, a potential solution to this problem is to train established nurse endoscopists to perform colonoscopy. As this is a new nursing development specialty, colonoscopy training programs are required to train nurses to perform this advanced technical role. An example of a nurse colonoscopy training program, quality assurance measures, and clinical outcomes devised at St Mark’s hospital are presented in this article.
The nurse endoscopist—a global perspective The concept of the nurse endoscopist originated in the United States in 1977 to meet the increasing demand for flexible sigmoidoscopy screening [1]. Since this initial development, the role of nurse or nonphysician endoscopists has been
E-mail address: [email protected] 1052-5157/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.giec.2005.08.009 giendo.theclinics.com
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established widely in the United States, and studies conclude that nurses or nonphysicians can perform screening flexible sigmoidoscopy safely and effectively [2–4]. In studies comparing the effectiveness and accuracy of nurse endoscopists to clinicians, no significant clinical differences are found between nurses and clinicians in terms of cost effectiveness, detection of abnormalities, and procedure outcome. Patient satisfaction scores, however, were higher for those seen by a nurse endoscopist [5,6]. The American Society for Gastrointestinal Endoscopy recognizes this nursing role development and produced guidelines for training and monitoring of nurses’ performance. In the United States, the American Society for Gastrointestinal Endoscopy recommends the use of nurse endoscopists only for screening flexible sigmoidoscopy [7]. A barrier to nurses developing their practice to include colonoscopy is the current health insurance payment system of payment per procedure and direct reimbursement. Nurse endoscopists are not recognized in this health insurance system, preventing the development of an expanded role in the United States.
A United Kingdom perspective In the United Kingdom, the concept of the nurse endoscopist role was first introduced by the British Society of Gastroenterology in 1994 [8]. The initial impetus for the development of the nurse endoscopist in the United Kingdom was guided by a lack of medical endoscopists and increased demand for endoscopic procedures to assist in prevention and early detection of gastrointestinal cancer. This lack of manpower led to a national deficit in the provision of endoscopic services and to poor and variable standards of cancer care recorded locally and nationally within the National Health Service (NHS) [9]. The issue of colorectal cancer screening has increased the demand for trained endoscopists in the United Kingdom further. In the United Kingdom, colorectal cancer is the second leading cause of cancer death [10]. The demand for colonoscopy screening for symptomatic and high-risk patients is on the increase. In 2006, a national colorectal cancer-screening program will be introduced in the United Kingdom, initially using fecal occult blood testing followed by colonoscopy for screen positives. It is anticipated that this will lead to a demand for an extra 60,000 colonoscopies per year, a workload that will be difficult to accommodate given the existing number of trained colonoscopists. Hence, there is a push to maximize available manpower by developing existing practitioners, such as nurse endoscopists, to perform colonoscopy. This innovation has made a significant impact on the way endoscopic services now are provided. In the United Kingdom, the NHS is not insurance based and doctors and nurses receive an annual salary. Without the issues of direct reimbursement as a barrier, nurses recently have been able to expand their clinical role to include the advanced endoscopic skill of colonoscopy. Unlike in the United States, nurse endoscopists in the United Kingdom provide services for patients referred by their general physician who have gastrointestinal and colorectal symptoms [11]. The endo-
the nurse colonoscopist
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scopist component is only a small part of the nurse practitioner role. Nurses are trained to provide a clinical diagnosis and implement a treatment plan for patients who have a variety of disorders affecting the upper and lower gastrointestinal tract and are trained to perform gastroscopy and flexible sigmoidoscopy as part of their advanced nursing practice [8]. As the demand for endoscopic services has increased in the United Kingdom, nurse endoscopists have increased in numbers. There are approximately 200 endoscopy nurse practitioners that perform diagnostic and therapeutic procedures as part of their role, including polypectomy and management of gastrointestinal bleeding [12]. Although nurses initially were trained to perform diagnostic, gastroscopy, and flexible sigmoidoscopy, they have since moved on to provide advanced endoscopic procedures, including colonoscopy [12,13].
Nurse endoscopist training in the United Kingdom The United Kingdom has standardized national guidelines for the training of endoscopists developed by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG), a joint committee of gastroenterologists, surgeons, and nurses. The term, nurse endoscopist, is not recognized; nurses are described as practitioners who perform endoscopy as part of their clinical role. The generic term, endoscopist, is used and all allied health care professionals performing endoscopy must operate to the standards of medical endoscopists. All endoscopist training programs, hospital-based practical training programs or university-based degree programs, must include the core components of endoscopy training as described in the JAG guidelines for training, appraisal, and assessment of trainees in gastrointestinal endoscopy [14]. These core components for any endoscopist training program include knowledge of the structure, function, and decontamination of equipment, the medical and legal requirement of informed consent for the procedure, and the use and action of appropriate sedation and monitoring of patients during endoscopic procedures [14]. Although endoscopists, either nurses or doctors, are judged to the same standards of clinical practice, training programs in the United Kingdom recognize that the different clinical and educational background of nurses means that training programs have to allow for and provide the in-depth theory and knowledge development that nurses require to undertake this role [15].
Quality assurance in training nurse endoscopists As nurse colonoscopists are a recent development, the majority of training programs relate to the teaching and performance of gastroscopy and flexible sigmoidoscopy. Nurses can progress only to perform colonoscopy once they are competent at flexible sigmoidoscopy and demonstrate clinical accuracy and ef-
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fectiveness. Competence at performing flexible sigmoidoscopy is defined as achieving intubation of the descending colon in excess of 90% of all cases, excluding patients who have mechanical strictures [14]. Flexible sigmoidoscopy training programs consist of several stages, and several methods are used to assess the nurse endoscopists’ performance during and on completion of training. These methods have been tested and developed primarily during flexible sigmoidoscopy training and incorporated into colonoscopy training modules. A combination of observation, simulation, and hands-on training with formal assessment on completion of the training program is used to measure the accuracy and effectiveness of nurse endoscopists’ performance. Nurse endoscopy training is a step-by-step approach, enabling nurses to develop their clinical and endoscopic skills. The introduction of endoscopic simulation in training is recognized as a valuable tool for the teaching and assessment of endoscopic skills and is recommended for use in endoscopy training programs [16]. In the United Kingdom, simulation is used for training nurses in flexible sigmoidoscopy and colonoscopy [17,18]. Simulation is combined with observation of procedures to familiarize nurses with the endoscope and the procedure and teach the hands skills required to perform flexible sigmoidoscopy. Once competence is achieved on the simulator, nurses are taught under the direct supervision of a clinician how to withdraw the endoscope and examine the colon. Finally, nurses must perform a specific number of complete procedures under direct supervision of a clinician supervisor. During this stage, the theoretic knowledge required by nurses to underpin their endoscopic practice is assessed by the methods of written examination and multiple choice questionnaire assessments. On completion of training, the final assessment of nurse trainees involves an objective structured clinical examination, again with the use of endoscopic simulators. The purpose of this is to objectively assess the nurses’ history-taking assessment skills, preparation of the patients (including the process of obtaining informed consent), clinical psychomotor skills performing complete flexible sigmoidoscopy, and making an accurate diagnosis and appropriate plan of care for ‘‘patients.’’ This model of assessment ensures that nurses develop to become endoscopy nurse practitioners, not just technicians, with the appropriate level of clinical knowledge and skills to make clinical diagnoses and plan care before undertaking independent endoscopic practice on patients and progressing to perform colonoscopy. To ensure nurses are accurate and effective at performing endoscopy and making a clinical diagnosis, several methods are used to gain an objective measure of the accuracy of nurses in diagnosing and detecting abnormalities at flexible sigmoidoscopy. Studies have used barium enema and virtual colonoscopy in combination with flexible sigmoidoscopy to detect the accuracy of nurses in detecting the presence of distal colonic pathology. Findings from these studies conclude that no significant pathology was left undiagnosed by endoscopy nurse practitioners and that nurses were accurate in their reporting of these [15,19].
the nurse colonoscopist
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Colonoscopy training In 2004, the results of a British Society of Gastroenterology national audit examining the standards of colonoscopy in the United Kingdom were published [20]. There were reported variances in the standards of training, with only 17% of medical trainees having the recommended clinical supervision of colonoscopic procedures before undertaking clinical practice. Only 39.3% of clinicians had attended an endoscopy training course. Variable standards of procedure performance also were reported among all endoscopists, including consultants; an adjusted cecal intubation rate of 57% was reported when recognized landmarks were used to identify the cecum [16]. To improve colonoscopy training and performance standardized colonoscopy training, courses have been developed in combination with JAG. A generic core curriculum for colonoscopy training has been developed and recommendations for training unit standards devised. Colonoscopy curriculums have been developed for diagnostic and therapeutic colonoscopy and all other endoscopic procedures. Colonoscopy trainees must be supervised for a minimum of 100 procedures and, on completion of training, endoscopists must be able to reach the cecum in more than 90% of cases and be competent at taking biopsies and performing polypectomy. This program is generic for nurses and doctors.
Nurse colonoscopist training—methodology As the development of nurse colonoscopists is a new service development, there is little data available to enable assessment of nurse colonoscopists’ performance. A colonoscopy training program based on the JAG curriculum and guidelines was designed to assess if nurse endoscopists could perform colonoscopy and demonstrate safety and accuracy to the required medical standards. An experienced nurse endoscopist who has performed more than 3000 diagnostic and therapeutic flexible sigmoidoscopies and was trained to administer sedation commenced colonoscopy training under direct supervision of a consultant gastroenterologist and senior clinical specialist. In line with JAG guidelines, a logbook was developed to assess the nurse’s ability to perform skills and achieve competencies in colonoscopy; the aim of the logbook was to assess the nurse’s knowledge and colonoscopy performance (Table 1). This was used for the first 100 procedures as a record of practice. During this training program, all patients were informed that trainees might be performing or present during their procedure and consent for this was obtained. Exclusion criteria for this training program included patients under the age of 16, tertiary referrals, patients who had previous resections, and patients whose previous procedures previously were found technically difficult by expert endoscopists. All patients received standard bowel preparation, consisting of senna granules and two sachets of magnesium citrate, in accordance with standard unit practice. Patients were offered the choice of having sedation or not, and con-
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Table 1 Colonoscopy training logbook—summary of contents Criteria for assessment
Knowledge required
Referral indications
Demonstrate knowledge of symptoms ? Appropriateness of procedure Assess symptoms, onset, and duration Provide differential diagnosis Obtain informed consent Demonstrate knowledge of risks and complications Demonstrate safe conscious sedation techniques Demonstrate safe insertion to the cecum in N 90% of cases Terminal ileum intubation N 50% of cases Record findings accurately (photo and video analysis) Full examination of lumen on extubation—video analysis Demonstrate knowledge of management of complications Accurately report findings in medical notes—arrange follow-up procedures
Patient history Informed consent Sedation practices Insertion technique Findings Extubation technique Complications Communication
scious sedation was administered by the nurse in line with unit guidelines. A combination of opiates (pethidine, benzodiazepines, and midazolam) and the antispasmodic, Buscopan, was administered before the procedure. Oxygen supplementation was administered and pulse oximetry was recorded throughout the procedure. The following information was recorded for each procedure:
Indication for colonoscopy Sedation dosage administered Side effects and action taken Macroscopic findings Maximum depth of insertion Number of polypectomies (snare and hot biopsy) Number of immediate complications
Complete colonoscopy was measured by the identification of the ileocecal valve, appendiceal orifice, and intubation of the terminal ileum. Photodocumentation of these were required in all cases for assessment. In procedures where complete colonoscopy was not achieved, the nurse was asked to document the extent of maximum insertion, record the reasons for the failed procedure, and what plans were made for follow-up for the patient. All 100 procedures were performed under direct clinical supervision.
Nurse colonoscopy performance on completion of training On completion of this training program, the nurse colonoscopist achieved an overall adjusted total complete colonoscopy intubation rate of 92% (92/100),
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with assistance given in 8% of these cases because of looping of the colonoscope and fixed sigmoid. The nurse endoscopist completed all of the 92 procedures. Eight per cent (8/100) of procedures were abandoned because of: poor bowel preparation, 5% (5); obstructing carcinoma’s stricture, 2% (2); and fixed diverticular disease, 1% (1). These patients were referred for further investigations, including barium enema and surgical opinion. The nurse was accurate in recording the appropriate diagnosis for each case as judged by the clinical supervisor observing the cases. For conscious sedation, a combination of pethidine and midazolam was administered. The median sedation dose administered during procedures was 25 mg pethidine (range 0–75 mg) and 1.25 mg midazolam (range 0–2.5 mg). Buscopan was used in all cases unless contraindicated. The median dose for this was 20 mg (range 0–30 mg). Polypectomy was performed by the nurse endoscopist in 21 (14%) of cases with no complications. There were no complications of perforation or hemorrhage, during or after the procedures. None of the patients experienced side effects from their sedation.
Summary After completing a rigorous colonoscopy training program, the nurse endoscopist was competent in performing colonoscopy to the recommended standards. Providing a colonoscopy service does not just include the technical skill of colonoscopy, however. The logbook developed for assessment in this training program addressed clinical knowledge development and the nurse’s technical ability to perform the procedure. The ability to assess the patient, make clinical judgments, interpret the findings correctly, and plan follow-up care is an integral part of the procedure. For nurses to develop their practice to include colonoscopy, they must demonstrate clinical effectiveness in these areas to ensure that they, as endoscopists, are the appropriate persons to be performing this procedure. Competence in therapeutic interventions, specifically polypectomy, is required for any endoscopists who provide colonoscopy as part of their practice. Nurse endoscopists must, therefore, be willing to develop their practice to include the provision of therapy and embrace and accept the potential increased risks that undertaking these procedures involve. In any role development, however, the attitudes of lead clinicians must be taken into account. A recent study examining nurse endoscopy practice finds that clinicians gave a negative response to the idea of nurses performing advanced practice, including therapeutic colonoscopy [12]. An area of concern was linked to the level of nursing knowledge regarding management of potential complications and the levels of consultant cover required. Previous studies examined the standards of colonoscopy within the United Kingdom in relation to clinicians and documented the inadequacies in current training programs [20]. Training nurse endoscopists to
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provide a colonoscopy service will, in the short term, increase the pressure on clinicians who already are having difficulty in training their medical colleagues. Before 1994 in the United Kingdom, however, it was inconceivable that nurses could perform any kind of endoscopic procedure. The long-term investment and support given by clinicians to training and developing nurse endoscopists has proved successful, with nurse endoscopists providing gastroscopy and flexible sigmoidoscopy as part of their nursing practice to a high clinically effective standard. This investment in training nurse endoscopists has enabled clinicians to restructure their services to meet the demand for endoscopic procedures and manage patient care more effectively. As this study shows, nurse endoscopists, with the assistance of their medical colleagues and after receiving the appropriate training, can provide safe and effective colonoscopy service and assist in meeting the demand for colonoscopy in the future.
References [1] Spencer RJ, Ready RL. Utilisation of nurse endoscopists for sigmoidoscopic examinations. Dis Colon Rectum 1977;20:94 – 6. [2] Disario J, Sanowski R. Sigmoidoscopy training for nurses and resident physicians. Gastrointest Endosc 1993;39:29 – 32. [3] Rosevelt J, Frankl H. Colorectal cancer screening by nurse practitioner using 60-cm flexible fibreoptic sigmoidoscope. Dig Dis Sci 1984;29:161 – 3. [4] Maule WF. Screening for colorectal cancer by nurse endoscopists. N Engl J Med 1994;330: 183 – 6. [5] Schoenfeld PS, Cash B, Kita J, et al. Effectiveness and patient satisfaction with screening flexible sigmoidoscopy performed by registered nurses. Gastrointest Endosc 1999;49:158 – 62. [6] Schroy PC, Wiggins T, Winawar SJ, et al. Video endoscopy by nurse practitioners: a model for colorectal cancer screening. Gastrointest Endosc 1988;34:390 – 4. [7] American Society for Gastrointestinal Endoscopy. Guidelines for training non-specialists in screening flexible sigmoidoscopy. Manchester, MA7 ASGE; 2000. [8] British Society of Gastroenterology. The nurse endoscopist. London7 BSG; 1994. [9] Calman K, Hine D. A policy framework for commissioning cancer services. London7 DOH; 1995. [10] Rhodes JM. Colorectal cancer screening in the UK: Joint Position Statement by the British Society of Gastroenterology, the Royal College of Physicians, and the Association of Coloproctology of Great Britain and Ireland. Gut 2000;46:746 – 8. [11] British Society of Gastroenterology. Provision of endoscopy related services in district general hospitals. London7 BSG; 2001. [12] Pathmakanthan S, Murray I, Smith K, et al. Nurse endoscopists in the United Kingdom Health Care: a survey of prevalence, skills and attitudes. J Adv Nurs 2001;36:705 – 10. [13] Vance M. Advanced nursing practice—nurse colonoscopy; a review of nursing performance during and on completion of a colonoscopy training programme. Gastrointestinal Nursing 2003; 1:23 – 6. [14] Joint Advisory Group on Gastrointestinal Endoscopy. Guidelines for the training, appraisal and assessment of trainees in GI endoscopy 2001. London7 JAG; 2004. [15] Duthie GS, Drew PJ, Hughes MP, et al. A UK training programme for nurse practitioner flexible sigmoidoscopy and a prospective evaluation of the practice of the first UK trained nurse flexible sigmoidoscopist. Gut 1998;43:711 – 4. [16] Cass OW. Training to competence in gastrointestinal endoscopy: a plea for continuous measuring of objective end points. Endoscopy 1999;31:751 – 4.
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[17] Williams CB, Saunders BP, Bladen JS. Development of colonoscopy teaching simulation. Endoscopy 2000;32:1 – 5. [18] Kneebone RL, Nestel D, Moorthy K, et al. Learning the skills of flexible sigmoidoscopy— the wider perspective. Med Educ 2003;37:50 – 8. [19] Taylor SA, Halligan S, Vance M, et al. Use of multidetector-row computed tomographic colonography before flexible sigmoidoscopy in the investigation of rectal bleeding. Br J Surg 2003;90:1163 – 4. [20] Bowles CJA, Leicester R, Romaya C, et al. A perspective study of colonoscopy practice in the UK today: are we adequately prepared for colorectal cancer screening tomorrow? Gut 2004;53: 277 – 83.
The Nurse Colonoscopist—Training and Quality Assurance Margaret Vance, MSc, DIP, RGN Wolfson Unit for Endoscopy, St. Mark’s Hospital, Watford Road, Harrow, Middlesex HA1 3UK, UK
Specialist trained nurses have been performing flexible sigmoidoscopy as part of their nursing role since the 1970s in the United States [1]. As nurses have shown their efficacy and effectiveness in performing flexible sigmoidoscopy, this new nursing role has been adopted more globally in the United Kingdom and other European countries. In the United Kingdom, as the demand for endoscopic procedures has increased, nurses have developed their skills to include flexible sigmoidoscopy and gastroscopy, and this nursing role is established firmly in endoscopy units throughout the United Kingdom. Currently, there is a shortage of endoscopists to perform colonoscopy; this has been compounded by the proposed introduction of a national colorectal cancer screening program and an increasing demand for diagnostic colonoscopy. In the United Kingdom, a potential solution to this problem is to train established nurse endoscopists to perform colonoscopy. As this is a new nursing development specialty, colonoscopy training programs are required to train nurses to perform this advanced technical role. An example of a nurse colonoscopy training program, quality assurance measures, and clinical outcomes devised at St Mark’s hospital are presented in this article.
The nurse endoscopist—a global perspective The concept of the nurse endoscopist originated in the United States in 1977 to meet the increasing demand for flexible sigmoidoscopy screening [1]. Since this initial development, the role of nurse or nonphysician endoscopists has been
E-mail address: [email protected] 1052-5157/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.giec.2005.08.009 giendo.theclinics.com
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established widely in the United States, and studies conclude that nurses or nonphysicians can perform screening flexible sigmoidoscopy safely and effectively [2–4]. In studies comparing the effectiveness and accuracy of nurse endoscopists to clinicians, no significant clinical differences are found between nurses and clinicians in terms of cost effectiveness, detection of abnormalities, and procedure outcome. Patient satisfaction scores, however, were higher for those seen by a nurse endoscopist [5,6]. The American Society for Gastrointestinal Endoscopy recognizes this nursing role development and produced guidelines for training and monitoring of nurses’ performance. In the United States, the American Society for Gastrointestinal Endoscopy recommends the use of nurse endoscopists only for screening flexible sigmoidoscopy [7]. A barrier to nurses developing their practice to include colonoscopy is the current health insurance payment system of payment per procedure and direct reimbursement. Nurse endoscopists are not recognized in this health insurance system, preventing the development of an expanded role in the United States.
A United Kingdom perspective In the United Kingdom, the concept of the nurse endoscopist role was first introduced by the British Society of Gastroenterology in 1994 [8]. The initial impetus for the development of the nurse endoscopist in the United Kingdom was guided by a lack of medical endoscopists and increased demand for endoscopic procedures to assist in prevention and early detection of gastrointestinal cancer. This lack of manpower led to a national deficit in the provision of endoscopic services and to poor and variable standards of cancer care recorded locally and nationally within the National Health Service (NHS) [9]. The issue of colorectal cancer screening has increased the demand for trained endoscopists in the United Kingdom further. In the United Kingdom, colorectal cancer is the second leading cause of cancer death [10]. The demand for colonoscopy screening for symptomatic and high-risk patients is on the increase. In 2006, a national colorectal cancer-screening program will be introduced in the United Kingdom, initially using fecal occult blood testing followed by colonoscopy for screen positives. It is anticipated that this will lead to a demand for an extra 60,000 colonoscopies per year, a workload that will be difficult to accommodate given the existing number of trained colonoscopists. Hence, there is a push to maximize available manpower by developing existing practitioners, such as nurse endoscopists, to perform colonoscopy. This innovation has made a significant impact on the way endoscopic services now are provided. In the United Kingdom, the NHS is not insurance based and doctors and nurses receive an annual salary. Without the issues of direct reimbursement as a barrier, nurses recently have been able to expand their clinical role to include the advanced endoscopic skill of colonoscopy. Unlike in the United States, nurse endoscopists in the United Kingdom provide services for patients referred by their general physician who have gastrointestinal and colorectal symptoms [11]. The endo-
the nurse colonoscopist
831
scopist component is only a small part of the nurse practitioner role. Nurses are trained to provide a clinical diagnosis and implement a treatment plan for patients who have a variety of disorders affecting the upper and lower gastrointestinal tract and are trained to perform gastroscopy and flexible sigmoidoscopy as part of their advanced nursing practice [8]. As the demand for endoscopic services has increased in the United Kingdom, nurse endoscopists have increased in numbers. There are approximately 200 endoscopy nurse practitioners that perform diagnostic and therapeutic procedures as part of their role, including polypectomy and management of gastrointestinal bleeding [12]. Although nurses initially were trained to perform diagnostic, gastroscopy, and flexible sigmoidoscopy, they have since moved on to provide advanced endoscopic procedures, including colonoscopy [12,13].
Nurse endoscopist training in the United Kingdom The United Kingdom has standardized national guidelines for the training of endoscopists developed by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG), a joint committee of gastroenterologists, surgeons, and nurses. The term, nurse endoscopist, is not recognized; nurses are described as practitioners who perform endoscopy as part of their clinical role. The generic term, endoscopist, is used and all allied health care professionals performing endoscopy must operate to the standards of medical endoscopists. All endoscopist training programs, hospital-based practical training programs or university-based degree programs, must include the core components of endoscopy training as described in the JAG guidelines for training, appraisal, and assessment of trainees in gastrointestinal endoscopy [14]. These core components for any endoscopist training program include knowledge of the structure, function, and decontamination of equipment, the medical and legal requirement of informed consent for the procedure, and the use and action of appropriate sedation and monitoring of patients during endoscopic procedures [14]. Although endoscopists, either nurses or doctors, are judged to the same standards of clinical practice, training programs in the United Kingdom recognize that the different clinical and educational background of nurses means that training programs have to allow for and provide the in-depth theory and knowledge development that nurses require to undertake this role [15].
Quality assurance in training nurse endoscopists As nurse colonoscopists are a recent development, the majority of training programs relate to the teaching and performance of gastroscopy and flexible sigmoidoscopy. Nurses can progress only to perform colonoscopy once they are competent at flexible sigmoidoscopy and demonstrate clinical accuracy and ef-
832
vance
fectiveness. Competence at performing flexible sigmoidoscopy is defined as achieving intubation of the descending colon in excess of 90% of all cases, excluding patients who have mechanical strictures [14]. Flexible sigmoidoscopy training programs consist of several stages, and several methods are used to assess the nurse endoscopists’ performance during and on completion of training. These methods have been tested and developed primarily during flexible sigmoidoscopy training and incorporated into colonoscopy training modules. A combination of observation, simulation, and hands-on training with formal assessment on completion of the training program is used to measure the accuracy and effectiveness of nurse endoscopists’ performance. Nurse endoscopy training is a step-by-step approach, enabling nurses to develop their clinical and endoscopic skills. The introduction of endoscopic simulation in training is recognized as a valuable tool for the teaching and assessment of endoscopic skills and is recommended for use in endoscopy training programs [16]. In the United Kingdom, simulation is used for training nurses in flexible sigmoidoscopy and colonoscopy [17,18]. Simulation is combined with observation of procedures to familiarize nurses with the endoscope and the procedure and teach the hands skills required to perform flexible sigmoidoscopy. Once competence is achieved on the simulator, nurses are taught under the direct supervision of a clinician how to withdraw the endoscope and examine the colon. Finally, nurses must perform a specific number of complete procedures under direct supervision of a clinician supervisor. During this stage, the theoretic knowledge required by nurses to underpin their endoscopic practice is assessed by the methods of written examination and multiple choice questionnaire assessments. On completion of training, the final assessment of nurse trainees involves an objective structured clinical examination, again with the use of endoscopic simulators. The purpose of this is to objectively assess the nurses’ history-taking assessment skills, preparation of the patients (including the process of obtaining informed consent), clinical psychomotor skills performing complete flexible sigmoidoscopy, and making an accurate diagnosis and appropriate plan of care for ‘‘patients.’’ This model of assessment ensures that nurses develop to become endoscopy nurse practitioners, not just technicians, with the appropriate level of clinical knowledge and skills to make clinical diagnoses and plan care before undertaking independent endoscopic practice on patients and progressing to perform colonoscopy. To ensure nurses are accurate and effective at performing endoscopy and making a clinical diagnosis, several methods are used to gain an objective measure of the accuracy of nurses in diagnosing and detecting abnormalities at flexible sigmoidoscopy. Studies have used barium enema and virtual colonoscopy in combination with flexible sigmoidoscopy to detect the accuracy of nurses in detecting the presence of distal colonic pathology. Findings from these studies conclude that no significant pathology was left undiagnosed by endoscopy nurse practitioners and that nurses were accurate in their reporting of these [15,19].
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Colonoscopy training In 2004, the results of a British Society of Gastroenterology national audit examining the standards of colonoscopy in the United Kingdom were published [20]. There were reported variances in the standards of training, with only 17% of medical trainees having the recommended clinical supervision of colonoscopic procedures before undertaking clinical practice. Only 39.3% of clinicians had attended an endoscopy training course. Variable standards of procedure performance also were reported among all endoscopists, including consultants; an adjusted cecal intubation rate of 57% was reported when recognized landmarks were used to identify the cecum [16]. To improve colonoscopy training and performance standardized colonoscopy training, courses have been developed in combination with JAG. A generic core curriculum for colonoscopy training has been developed and recommendations for training unit standards devised. Colonoscopy curriculums have been developed for diagnostic and therapeutic colonoscopy and all other endoscopic procedures. Colonoscopy trainees must be supervised for a minimum of 100 procedures and, on completion of training, endoscopists must be able to reach the cecum in more than 90% of cases and be competent at taking biopsies and performing polypectomy. This program is generic for nurses and doctors.
Nurse colonoscopist training—methodology As the development of nurse colonoscopists is a new service development, there is little data available to enable assessment of nurse colonoscopists’ performance. A colonoscopy training program based on the JAG curriculum and guidelines was designed to assess if nurse endoscopists could perform colonoscopy and demonstrate safety and accuracy to the required medical standards. An experienced nurse endoscopist who has performed more than 3000 diagnostic and therapeutic flexible sigmoidoscopies and was trained to administer sedation commenced colonoscopy training under direct supervision of a consultant gastroenterologist and senior clinical specialist. In line with JAG guidelines, a logbook was developed to assess the nurse’s ability to perform skills and achieve competencies in colonoscopy; the aim of the logbook was to assess the nurse’s knowledge and colonoscopy performance (Table 1). This was used for the first 100 procedures as a record of practice. During this training program, all patients were informed that trainees might be performing or present during their procedure and consent for this was obtained. Exclusion criteria for this training program included patients under the age of 16, tertiary referrals, patients who had previous resections, and patients whose previous procedures previously were found technically difficult by expert endoscopists. All patients received standard bowel preparation, consisting of senna granules and two sachets of magnesium citrate, in accordance with standard unit practice. Patients were offered the choice of having sedation or not, and con-
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Table 1 Colonoscopy training logbook—summary of contents Criteria for assessment
Knowledge required
Referral indications
Demonstrate knowledge of symptoms ? Appropriateness of procedure Assess symptoms, onset, and duration Provide differential diagnosis Obtain informed consent Demonstrate knowledge of risks and complications Demonstrate safe conscious sedation techniques Demonstrate safe insertion to the cecum in N 90% of cases Terminal ileum intubation N 50% of cases Record findings accurately (photo and video analysis) Full examination of lumen on extubation—video analysis Demonstrate knowledge of management of complications Accurately report findings in medical notes—arrange follow-up procedures
Patient history Informed consent Sedation practices Insertion technique Findings Extubation technique Complications Communication
scious sedation was administered by the nurse in line with unit guidelines. A combination of opiates (pethidine, benzodiazepines, and midazolam) and the antispasmodic, Buscopan, was administered before the procedure. Oxygen supplementation was administered and pulse oximetry was recorded throughout the procedure. The following information was recorded for each procedure:
Indication for colonoscopy Sedation dosage administered Side effects and action taken Macroscopic findings Maximum depth of insertion Number of polypectomies (snare and hot biopsy) Number of immediate complications
Complete colonoscopy was measured by the identification of the ileocecal valve, appendiceal orifice, and intubation of the terminal ileum. Photodocumentation of these were required in all cases for assessment. In procedures where complete colonoscopy was not achieved, the nurse was asked to document the extent of maximum insertion, record the reasons for the failed procedure, and what plans were made for follow-up for the patient. All 100 procedures were performed under direct clinical supervision.
Nurse colonoscopy performance on completion of training On completion of this training program, the nurse colonoscopist achieved an overall adjusted total complete colonoscopy intubation rate of 92% (92/100),
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with assistance given in 8% of these cases because of looping of the colonoscope and fixed sigmoid. The nurse endoscopist completed all of the 92 procedures. Eight per cent (8/100) of procedures were abandoned because of: poor bowel preparation, 5% (5); obstructing carcinoma’s stricture, 2% (2); and fixed diverticular disease, 1% (1). These patients were referred for further investigations, including barium enema and surgical opinion. The nurse was accurate in recording the appropriate diagnosis for each case as judged by the clinical supervisor observing the cases. For conscious sedation, a combination of pethidine and midazolam was administered. The median sedation dose administered during procedures was 25 mg pethidine (range 0–75 mg) and 1.25 mg midazolam (range 0–2.5 mg). Buscopan was used in all cases unless contraindicated. The median dose for this was 20 mg (range 0–30 mg). Polypectomy was performed by the nurse endoscopist in 21 (14%) of cases with no complications. There were no complications of perforation or hemorrhage, during or after the procedures. None of the patients experienced side effects from their sedation.
Summary After completing a rigorous colonoscopy training program, the nurse endoscopist was competent in performing colonoscopy to the recommended standards. Providing a colonoscopy service does not just include the technical skill of colonoscopy, however. The logbook developed for assessment in this training program addressed clinical knowledge development and the nurse’s technical ability to perform the procedure. The ability to assess the patient, make clinical judgments, interpret the findings correctly, and plan follow-up care is an integral part of the procedure. For nurses to develop their practice to include colonoscopy, they must demonstrate clinical effectiveness in these areas to ensure that they, as endoscopists, are the appropriate persons to be performing this procedure. Competence in therapeutic interventions, specifically polypectomy, is required for any endoscopists who provide colonoscopy as part of their practice. Nurse endoscopists must, therefore, be willing to develop their practice to include the provision of therapy and embrace and accept the potential increased risks that undertaking these procedures involve. In any role development, however, the attitudes of lead clinicians must be taken into account. A recent study examining nurse endoscopy practice finds that clinicians gave a negative response to the idea of nurses performing advanced practice, including therapeutic colonoscopy [12]. An area of concern was linked to the level of nursing knowledge regarding management of potential complications and the levels of consultant cover required. Previous studies examined the standards of colonoscopy within the United Kingdom in relation to clinicians and documented the inadequacies in current training programs [20]. Training nurse endoscopists to
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provide a colonoscopy service will, in the short term, increase the pressure on clinicians who already are having difficulty in training their medical colleagues. Before 1994 in the United Kingdom, however, it was inconceivable that nurses could perform any kind of endoscopic procedure. The long-term investment and support given by clinicians to training and developing nurse endoscopists has proved successful, with nurse endoscopists providing gastroscopy and flexible sigmoidoscopy as part of their nursing practice to a high clinically effective standard. This investment in training nurse endoscopists has enabled clinicians to restructure their services to meet the demand for endoscopic procedures and manage patient care more effectively. As this study shows, nurse endoscopists, with the assistance of their medical colleagues and after receiving the appropriate training, can provide safe and effective colonoscopy service and assist in meeting the demand for colonoscopy in the future.
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[17] Williams CB, Saunders BP, Bladen JS. Development of colonoscopy teaching simulation. Endoscopy 2000;32:1 – 5. [18] Kneebone RL, Nestel D, Moorthy K, et al. Learning the skills of flexible sigmoidoscopy— the wider perspective. Med Educ 2003;37:50 – 8. [19] Taylor SA, Halligan S, Vance M, et al. Use of multidetector-row computed tomographic colonography before flexible sigmoidoscopy in the investigation of rectal bleeding. Br J Surg 2003;90:1163 – 4. [20] Bowles CJA, Leicester R, Romaya C, et al. A perspective study of colonoscopy practice in the UK today: are we adequately prepared for colorectal cancer screening tomorrow? Gut 2004;53: 277 – 83.