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| Journal of the New Zealand Medical Association,
29-June-2012, Vol 125 No 1357
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Mohammad I Khan, Robert Khan, Wanda Owen
The recent international trend of training and recruiting
non-medical personnel (mainly nurses) in different medical fields has two main
drivers. Firstly, there is a chronic shortage of doctors in certain specialities
and secondly, health economics has recently been playing an increasingly
important role in the healthcare industry. The possibility of cheaper healthcare
provision in times of harsh budgetary constraints has attracted many supporters.
In New Zealand (NZ), within the field of Gastroenterology,
nurses have taken up the role of Nurse Specialists and are running
‘Dyspepsia clinics’, Inflammatory Bowel diseases clinics’ and
‘Hepatitis Clinics’. However, unlike some of the other developed
countries like the United Kingdom and the United States of America, NZ, so far,
has no Nurse Endoscopist (NE)
NZ has an established shortage in the provision of
colonoscopy services in public hospitals.1
Although, free endoscopy unit sessions are available they are not utilized
because of a nationwide shortage of both trained endoscopy nursing staff and
endoscopists. This shortage is likely to increase with the launch of the
National Bowel Cancer Screening Programme. Yeoman and
Parry1 have briefly mentioned in their survey
that 25% of the NZ public hospitals (including only two of the main centres)
will be willing to employ non-medical endoscopists but did not elaborate further
on this topic.
The introduction of NEs in NZ can partly cover the capacity
shortage of endoscopy services. However, there is no evidence in literature that
the introduction of NEs can also save health dollars. The stepped up role of
nurses as NEs has created a lot of controversy, especially in medical circles.
We carried out a survey of doctors to obtain their views on the role of NEs in
NZ.
MethodsEthical approval for the survey was taken from
the Multi-region Ethics Committee. Twenty five public hospitals across all of
the 20 District Health Boards in NZ were selected for the study. Small
peripheral hospitals with only basic endoscopy facilities were excluded from the
study. The survey was carried out in July, 2011. The study population
included all of the Gastroenterologists currently working part time or full time
in the selected public hospitals. In hospitals without gastroenterologists, the
local surgeons providing the endoscopy services were included in the study.
Contact data on the participants were obtained from each endoscopy
unit. A postal letter with a web-link to the web-based survey (appendix) was
sent to each study participant. The letter included an introductory note and an
explanation of the anonymous and confidential nature of the survey.
Descriptive statistics were used to analyse the data.
ResultsEighty four study participants were identified. Two have
since left their public jobs and were removed from the study. Forty doctors
completed the survey (response rate of 47.5%). Eighty seven percent of the
doctors were male, 50% were working in tertiary centres and 59% percent were
practicing endoscopy both in public and private sector.
Sixty-two percent of the doctors thought that they will
offer better quality of endoscopy services compared to trained NEs. Reasons
included that endoscopy procedures are more than just a technical skill and
findings need to be co-related to the clinical scenarios and that NEs will have
a lower standard at trouble shooting. Thirty-two percent thought that there will
be no difference in the quality of services if the NEs are properly trained
(Figure 1).
Figure 1. Clinical quality of endoscopy
services
 Sixty-one percent of the doctors said that they expect no
difference in patient experiences between the services offered by the doctors or
NEs while the rest were almost evenly split between moderately better
performance by the NEs and doctors (Figure 2).
Figure 2. Patient’s experience of
endoscopy services
 Forty-seven percent of the doctors thought that there will
be no impact on the running cost of endoscopy services while 37% thought that
the overall cost will reduce with the introduction of NEs. Thirty-six percent
thought the endoscopy practice for nurses should be limited to diagnostic upper
endoscopy procedures only while 47% thought that it should be restricted to both
upper and lower diagnostic endoscopies. The rest were in favour of full
provision of both diagnostic and therapeutic upper and lower endoscopy
procedures by the NEs (Figure 3).
Figure 3. Delegation of endoscopy procedures to
NEs
 Forty-three percent of the doctors thought that it was
appropriate to enrol NEs in providing screening colonoscopies as part of the
National Bowel Cancer Screening Programme.. Forty-three percent thought it was
not appropriate while the rest were not sure (Figure 4).
Figure 4. Role of NEs in the National Bowel
Cancer Screening Programme
 Sixty-seven percent of the doctors were willing to provide
voluntary supervision if NEs were recruited in their department.
Forty-five percent of the doctors said that they have a neutral attitude
towards the introduction of NEs, 25% had a negative attitude and only 30% had a
positive attitude (Figure 5).
Figure 5. Attitude of Doctors to
NEs
 DiscussionWorldwide, the role of NEs in the delivery of endoscopy
services has probably caused more controversy than the role of any other Nurse
Specialist in the field of Gastroenterology.
In some countries, like the UK and the US, NEs have expanded
their role to both academic and district level
hospitals.2 The span of procedures they are
allowed to perform has also increased from simple diagnostic procedures to a
wider array of both diagnostic and therapeutic
procedures.3,4
However, in other countries, like Australia and New Zealand,
the role of NEs has not established at all. The reasons for these variations in
the individual health care systems are unclear. Our survey shows that at present
there is little enthusiasm among doctor for the role of NEs in NZ.
There have been many studies on the quality, safety and
efficacy of endoscopies delivered by NEs. There is more data in literature for
support of the role of NEs in upper gastrointestinal endoscopies and flexible
sigmoidoscopies.5,6 Data from such studies have
shown that NEs are comparable to doctors in terms of the quality, safety and
efficacy of endoscopic procedures.
Our survey shows that majority of our doctors want the role
of NE to be limited to the diagnostic upper and lower endoscopy. This may be
because almost 62% of the participants thought that, in terms of the quality of
endoscopy services, the doctors will perform better than NEs and hence their
reluctance to allow NEs the full scope of endoscopic practice. There is no
robust literature to support this viewpoint
A recent feasibility study by Koonstra et al showed that the
learning curve of a nurse for training in colonoscopy is similar to that of a
doctor trainee and involves 150 supervised
colonoscopies.7 The colonoscopy procedure
generally requires the patient to be sedated and again the evidence so far is
that nurses are as good as doctors in supervising
sedation.8 Dellon, Lippmann, Sandler, &
Shaheen, have reported that procedures staffed by less-experienced
gastrointestinal endoscopy nurses have increased odds of missing
polyps.9 However, a different study of well
trained NEs has reported a higher adenoma detection rate by the
NEs.10
Our survey shows that only 43% of the doctors thought that
it is appropriate to enrol NEs in the National Bowel Cancer Screening programme
if they meet accredited standards. Forty-one percent were against it and the
rest were not sure. This is less than the 2009 survey of US Gastroenterologist,
where the majority were supportive of the role of NE in screening
endoscopies.11
In our survey majority of the doctors did not believe that
endoscopy costs will decrease with the introduction of NEs. In their open
comments they have pointed to two specific issues relevant to the health
economics of introducing NEs. Firstly, there will be at least initially, a spike
in cost as the training programme for NE is established. Secondly, NEs will
still require supervision from doctors (and hence their time) even if they are
fully accredited as is happening in other developed countries.
In public hospitals, the reimbursement rate for the
endoscopist is a small proportion of the overall cost of endoscopy. Therefore,
the potentially lower reimbursement rate for NEs is unlikely to influence the
overall cost of delivery of endoscopy services.
Richardson et al, in their MINuEt study, conclude that
endoscopy delivered by nurses are unlikely to be more cost effective than
doctors.12 In their analysis, although
endoscopies by doctors were more costly, patients in the doctors group also
gained more Quality Adjusted Life Years (QALY) than those in the nurses group.
Potential areas of cost cutting in endoscopy services in
certain countries include registered nurse-administered propofol sedation for
endoscopy instead of anaesthesiologists.13
This, however, does not apply to NZ as conscious sedation is administered in NZ
by the doctors performing the procedure and not by the anaesthesiologists.
Patient satisfaction with NEs has been studied in
literature with patient satisfaction rates comparable or even better in some
surveys, than those of doctors.14 Majority of
the doctors (62%) in our survey also thought that patient satisfaction rates
will be the same with NEs as for doctors. However, the same number of doctors
also thought that the clinical quality of services will be better delivered by
the doctors.
Only 28% of the doctors had a positive attitude towards the
introduction of NE in the provision of endoscopy services. One of the objections
was the lack of teaching slots for such trainees as they will have to compete
with medical/surgical trainees for such positions. Another potential reason may
be their perception that NEs will deliver inferior quality of endoscopy services
compared to doctors, although, there is clear support for that in literature.
At present, few of the doctors in NZ have exposure to NEs.
It will be interesting to observe that, if NEs are introduced in the NZ setting,
whether a subsequent survey of doctors will show any change in their opinion.
Health Work Force New Zealand (HWNZ) recommends facilitation of nurse
specialization including training NEs to free up doctors to do high level
procedures but acknowledge that significant barriers have to be
overcome.15 HWNZ recommends close collaboration
between the involved stakeholders to develop the role of NEs in NZ.
It is important to end the discussion on the potential
limitations of the study. It was not possible to obtain an in-depth and wide
ranging qualitative data from each respondent. The quantitative nature of the
study and the use of survey strategy to obtain data precluded that. The
questionnaire was deliberately kept short for a better response rate.
The survey was restricted to the public sector and mainly to
the Gastroenterologists, except for the smaller public hospitals without the
services of Gastroenterologists, where the surgeons providing the endoscopy
services were included in the study. Also, because of the basic version of the
survey tool used (Survey monkey) it was not possible to compare the opinions of
the respondent Gastroenterologists with the respondent surgeons.
Competing interests: This survey was
carried out as a part of a ‘Masters’ degree with the Massey
University.
Author information: Mohammad Imran Khan,
Gastroenterologist, Tauranga Public Hospital, Tauranga; Robert Khan, School of
Management, Massey University Palmerston North; Wanda Owen, Senior Endoscopy
Nurse, Tauranga Public Hospital, Tauranga
Correspondence: Dr Mohammad Imran Khan,
Gastroenterologist, Tauranga Public Hospital, Tauranga, New Zealand. Email:
imran.khan@bopdhb.govt.nz
References:
APPENDIX
1. Gender
|
  No
differenceBetter
performance by the doctors |
|
Any comment
 |
5. Your expectation of the patient experiences of endoscopy services
provided by the Nurse Endoscopist compared to medical endoscopists
|
Moderately
better performance by the Nurse endoscopist.No
differenceModerately
better performance by the Medical endoscopistSubstantially
better performance by the Medical endoscopist. |
|
Any comment
|
6. The expected impact on cost upon introduction of Nurse Endoscopists to
the endoscopy service
7. In your opinion the appropriate procedures that could be delegated to
Nurse endoscopist are
|
Diagnostic and
therapeutic upper endoscopy onlyDiagnostic
upper and lower endoscopy onlyDiagnostic and
therapeutic upper and lower endoscopy |
|
Other (please specify)
|
8. In your opinion, is it appropriate to enrol Nurse endoscopist in the
National Bowel Cancer Screening programme.
9. Your attitude towards the introduction of Nurse endoscopist
10. Will you be willing to provide voluntary supervision for Nurse
endoscopist if they are recruited in your department.
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