If New Zealand is to cut back the death rate from our second biggest cancer killer – bowel cancer – we need a bigger endoscopy workforce. After some years of investigation and preparation, Health Minister Tony Ryall fast-tracked the pace recently by announcing training of New Zealand’s first nurse endoscopists is to get underway early next year. FIONA CASSIE talks to Jenni Masters and Ruth Anderson about the big steps required to shift from wanting a new nursing role to making it a viable reality.
It sounds a no-brainer.
International evidence indicates that screening can reduce annual bowel cancer mortality by at least 14–16 per cent annually. The Waitemata screening pilot underway since 2011 has so far detected cancers in about 180 people before symptoms emerged.
Along with finding the approximately $60 million a year it would cost to screen all 50–74-year-olds, and ensuring the laboratory capacity to test for blood in faecal samples, more endoscopists would be needed to provide the possibly 50–75 per cent increase in demand for colonoscopies to diagnose whether cancer is present.
How can that increased demand be met? With nurse endoscopists already established in the UK, and training soon to be underway in Australia (see more online), training our own nurse endoscopists was soon bandied around as one possible answer.
But it wasn’t an easy answer. It raised questions about how willing and able our already pressured endoscopy services were to train nurse endoscopists on top of training more traditional gastroenterologist and general surgeon endoscopists. A survey in 2011 of the 84 medical endoscopists then working in public hospitals found just 30 per cent of respondents had a positive attitude towards introducing nurse endoscopists. A survey at the same time of the about 190 nurses working in public endoscopy services found that only 35 per cent of respondents were willing to consider training as nurse endoscopists.
New Zealand was also lacking a national quality and auditing programme for endoscopy and no competency framework for nurses working in the field (which didn’t help the proposal to recruit a UK-trained nurse endoscopist for a New Zealand pilot – the proposal eventually fizzled out).
Uneven quality and lack of national standards in endoscopy services
Things were not moving fast when Jenni Masters – now the National Endoscopy Service improvement lead – was appointed in 2010 with clinical director Dr David Theobald to the National Endoscopy Quality Improvement programme (NEQIP). The first focus of the programme was gauging the quality of endoscopy services already on offer as the Ministry of Health geared up to begin the Waitemata bowel screening pilot in 2011.
Masters’ own nursing background included gastroenterology and being a charge nurse manager in gerontology and committee member of the NZNO Gastroenterology Nurses Section.
She says NEQIP began by carrying out a national stocktake of public endoscopy services that found a wide variation in the way endoscopy services were being delivered across the country. Likewise, endoscopy nursing roles varied greatly, with some nurses assisting physician endoscopists with manipulating auxiliary equipment down the endoscope and others not (see sidebar and online only sidebar at www.nursingreview.co.nz).
The lack of consistency was further highlighted when NEQIP trialled in four DHBs – now rolled out nationally – the United Kingdom-based quality assurance system known as the Global Rating Scale (GRS) that has a set of quality standards for endoscopy services to be working towards, including workforce standards.
One need identified was for national consistency in assessment, education and training for endoscopy nurses and a project was set up, initially led by Megan Buckley of Tauranga Hospital, to develop a knowledge and skills competency framework for endoscopy nurses.
A competency framework was seen to improve not only the quality of endoscopy nursing but also the quantity, by providing a career path towards senior nursing roles – such as clinical nurse specialists in areas from hepatology to irritable bowel syndrome, and in time, nurse endoscopist and nurse practitioner roles – that could attract more nurses into the field.
Pro or anti-nurse endoscopist?
Difficulties in recruiting and retaining endoscopy nurses, along with the need for more gastroenterologist endoscopists, was noted in the 2011 report to Health Workforce New Zealand (HWNZ) by the Gastroenterology Workforce Service Review.
The review report noted not only the ageing endoscopy nurse workforce and the lack of appeal to younger nurses but also “major concerns with nurses currently performing extended roles with no recorded job description, no title, no competencies programme, and no reimbursement structure”.
In addition, there was “high awareness” that some within the medical profession were anti-nurse endoscopist.
With only an estimated 50 full-time equivalent gastroenterologists and general surgeons (a number work across both the public and private sectors) currently delivering endoscopy services in public hospitals, and with only a handful of gastroenterologists graduating each year, the report noted that there was only a limited pool of endoscopy training places available for gastroenterology registrars and general surgical registrars before adding trainee nurse endoscopists to the mix.
“In addition, doctors need to agree to training and overseeing nurse endoscopists, which is a barrier currently,” said the 2011 review document.
The workforce service review recommended that HWNZ work with the Nursing Council and other relevant bodies to set in place the means for RNs to train to become “nurse endoscopists in supervised roles in larger centres”.
In the wake of that recommendation, the New Zealand Society of Gastroenterology surveyed its membership and reported “more than half” supported the appointment of nurse endoscopists and “most” would be willing to train nurse endoscopists. In November 2012, the society came out with a revised position statement supporting the introduction of nurse endoscopists but said first an agreed practice framework had to be established and issues of safety and competencies had to be addressed.
Knowledge and skills framework for endoscopy nurses
By this time, work was well underway on the knowledge and skills framework, with good input from public and private sector endoscopy nurses keen to help.
Masters said this led to the first iteration of the framework, with ongoing development work picked up by Christchurch endoscopy nurse leader Gendy Bradford, who was employed last year by NEQIP as nursing workforce development lead (she was joined this year by MidCentral DHB gastroenterology clinical nurse specialist Anne Cleland).
To ensure the framework is practical and usable in the endoscopy workplace, it was decided some directly observed practical skills (DOPS) assessment tools for different types of endoscopies and pre- and post-procedural care were needed.
Feedback on how effective the assessment tools will be was gathered at a meeting with gastroenterology charge nurse managers in August, along with further discussion on when and how to launch the knowledge and skills framework.
The framework does create a path for endoscopy nurses from competent through proficient to expert but competencies and training standards for nurse endoscopists will not be just nurse-specific.
NEQUIP says its strategic goal is for New Zealand to train endoscopists and “not surgeons, physicians, or nurses who perform endoscopy”.
“Everyone should be trained in exactly the same way because they are doing exactly the same procedure,” says Masters.
So along with refining the endoscopy nursing framework, NEQIP has other work streams in enhancing endoscopy training overall and the setting up of a national governance body to oversee a new competence-based training and assessment platform for all endoscopists
Masters says the interdisciplinary governance body – with representatives from the relevant medical and nursing professional groups – would be a first for New Zealand.
The Nursing Council has now also approved processes for the credentialing of expanded practice in specialty nursing areas – though there were quibbles by some over whether endoscopy fitted the criteria and whether it was more a technical skill than expanded practice.
But others argue that nurse endoscopy is much more complex than skilfully inserting an endoscope into somebody.
Masters says nurse endoscopists need not only expert technical skills but also knowledge of histology and pathophysiology, along with high-level clinical decision-making abilities to ensure patient safety and good care. The next step is deciding on an education and training programme.
Nurse endoscopist training underway soon?
Laying the groundwork to build the quality and quantity of public endoscopy services has been steady to date but the training of nurse endoscopists now appears to be on the fast track.
The pace stepped up in March when Tony Ryall announced an April symposium looking at ways of boosting the colonoscopy workforce–and nurse endoscopists were definitely on the agenda.
Ruth Anderson, HWNZ’s manager of Workforce Education Intelligence Planning, says out of the symposium came several “pieces of work” around the “role of nurses performing endoscopy” i.e. nurse endoscopists – including establishing an advisory group which Anne Cleland of NEQIP and gastroenterologists group, of which are amongst the members.
Anderson says amongst advisory group purposes are finding the best ways of increasing the number of nurses able to do endoscopy and establishing education and training requirements.
“The development of that role (nurse endoscopist) and performing gastrointestinal procedures will be considered in a wider context of developing advanced nursing roles so that it contributes to a career pathway for nurses,” says Anderson.
But any training is also to come under the national governance body and training standards that are consistent and identical whether they are doctor or nurse endoscopist trainees.
“From the viewpoint of the patient, they will be able to have the same level of confidence in the endoscopic procedure, regardless of who carries it out, but recognising that follow-up work from nurse endoscopy would then be undertaken by a gastroenterologist.”
Anderson wanted to stress that the training of nurse endoscopists was to complement and not replace gastroenterologists and general surgeons carrying out endoscopy, with registrar training numbers in the two medical specialties also to be increased.
Nursing Review spoke to Anderson in early July prior to the Minister’s July 29 announcement that the first nurse endoscopists were to start training next year.
She said at the time that training processes were still under development and it was hoped to have an agreed training by the end of the year.
The aim for the theory side was likely to develop a postgraduate diploma with an endoscopy focus that was “professionally recognised, credentialed, portable, reflected best practice and absolutely demonstrated inter-professional learning”.
Asked when it was likely that a training programme was likely to be available to trainee nurse endoscopists, Anderson said at the time they were not certain and to get tertiary education providers on board could “take another year beyond next year” but the pace could depend on government decision-making.
She indicated that initial nurse endoscopist trainees are likely to be senior nurses who have already undertaken significant postgraduate study relevant to endoscopy.
Following the Minister’s announcement, his office was asked whether the qualification and training programme for nurses was now to be fast-tracked and give the go-ahead prior to setting up the national governance body.
His office declined to comment and referred all questions to HWNZ. Anderson said in a written response that “while final specifics such as available places are currently being developed, Health Workforce New Zealand expects to have nurses beginning postgraduate training to perform endoscopy from early 2015”.
So it looks like a matter of “watch this space”, but nurse endoscopists are on the way.
- Endoscopy is a medical procedure using an endoscope – a long, thin, flexible tube with a light and a video camera – to view internal organs. Endoscopy is also used for taking biopsy samples, removing polyps (polypectomies), and increasingly therapeutic interventions, such as stenting, by inserting auxiliary equipment down the endoscope.
- Colonoscopy is an endoscopic investigation of the lower gastrointestinal (lower GI) tract i.e. the large bowel (colon) via the anus.
- Gastroscopy investigates the upper gastrointestinal (upper GI) tract via the mouth to examine the oesophagus, stomach, and duodenum section of the small bowel.
- Sigmoidoscopy is an investigation of the rectum and the sigmoid (lower colon area) using a flexible sigmoidoscope. Commonly used to investigate rectal bleeding.
How long to train an endoscopist?
The NHS said in 2013 that it takes a year to build the skills to independently carry out flexible sigmoidoscopy and two years to be able to competently perform colonoscopy.
In 2011, the New Zealand Society of Gastroenterology said it took 12–18 months to become competent in routine gastroscopy, 18–24 months to be able to perform flexible sigmoidoscopy, three years to competently perform colonoscopy, and up to five years before being at a satisfactory level to carry out colonoscopy screening.
Nurse endoscopists around the world
First nurses carried out endoscopy (flexible sigmoidoscopy) in 1977.
Registered nurses have been performing endoscopies in the UK since the mid-1990s and by 2013 there were about 300 nurse endoscopists in NHS hospitals in England. The nurse endoscopist roles vary with fully qualified NEs carrying out flexible sigmoidoscopy to colonoscopy. In the UK all endoscopists – whether medical, nurse, or radiography trainees – have to meet the common training and assessment standards for endoscopy.
Nurse endoscopists are also common in the Netherlands and there are growing numbers in the US and Canada. Research has consistently backed that nurse endoscopists can perform procedures to international standards.
Across the Tasman
Health Workforce Australia gave funding in 2012 to five hospital sites to develop advanced practice in endoscopy nursing. In the state of Victoria, one health provider, Austin Health, is setting up a nurse endoscopy training centre.
Queensland has announced it wants to train up to 15 endoscopists at nurse specialist level and develop a postgraduate diploma for nurse endoscopists credentialed by a relevant nursing college or association. It is also proposing a Master’s path for nurses who not only want to do endoscopy but practice as a nurse practitioner across the wider continuum of gastroenterology care.
Roles can vary. Endoscopy nursing role include admitting, supporting, and monitoring patient before and during procedure (mostly done under conscious sedation) and be in charge of post-procedure recovery and discharge.
Another endoscopy nursing role is to work under the direction of the endoscopist to supply and manipulate auxiliary equipment that goes down the endoscope to assist in carrying out procedures like taking biopsies, polypectomies, and placing stents.
Endoscopy nurses or trained technicians carry out the cleaning and disinfecting of endoscopy equipment.
NB: gastroenterology nursing is not just endoscopy and gastroenterology nurses can specialise in areas like hepatitis, hepatology, and irritable bowel syndrome.