Dr P. G. van Putten, Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, Room Ba 393 A, 3015 GD, Rotterdam, The Netherlands. E-mail: email@example.com
Background Nurse endoscopists may provide a solution for the insufficient endoscopic capacity in colorectal cancer (CRC) screening.
Aim To determine the views of gastroenterologists about the potential role of nurse endoscopists in gastrointestinal endoscopy.
Methods A postal questionnaire was sent to all registered gastroenterologists (n = 301) and gastroenterology residents (n = 79) in the Netherlands.
Results Two hundred and thirty five of 380 (62%) gastroenterologists and residents completed the questionnaire. Overall, 48% were positive towards introduction of nurse endoscopists, whereas 18% were neutral and 34% negative. Respondents expected no major differences in endoscopic quality between physicians and nurse endoscopists. Nevertheless, 69% expected that patient experiences would be better met by physicians. Multivariate analysis showed that actual experience with nurse endoscopists and beliefs that nurse endoscopists are able to provide adequate endoscopic quality and good patient experiences, were independent predictors for a positive attitude towards introduction of nurse endoscopists [OR 6.6 (2.3–18.4), OR 1.9 (1.2–3.5) and OR 2.1 (1.2–2.9), respectively]. Respectively 89% and 66% of the respondents considered sigmoidoscopy and colonoscopy for CRC screening as appropriate procedures to be performed by nurse endoscopists. Diagnostic and therapeutic endoscopies were considered less appropriate.
Conclusion A majority of gastroenterologists have a positive attitude towards introduction of nurse endoscopists, especially for CRC screening endoscopies.
There is increasing interest and growing demand for nurses to perform gastrointestinal endoscopy. This is, among other factors, driven by the increased endoscopic demand resulting from colorectal cancer (CRC) screening programmes.
Colorectal cancer is the third most commonly diagnosed cancer and the second leading cause of cancer-related death in the Western world.1, 2 Screening has been shown to reduce CRC incidence and mortality.3, 4 Various countries have therefore implemented national CRC screening programmes, while many others are about to follow. However, to date, more than half of the eligible population of the European Union is not being offered any form of screening for CRC.5
Colorectal cancer screening can be performed with a variety of methods, in particular; stool tests, flexible sigmoidoscopy, colonoscopy and computed tomographic colonography.3 Irrespective of the chosen method for primary screening, any CRC screening programme considerably increases endoscopic demand either for primary screening or for secondary evaluation of patients with a positive primary screening test and finally for surveillance of patients who were identified with a neoplastic lesion. The endoscopic demand in many countries outweighs the current supply. This is a major hurdle for the introduction as well as continuation of CRC screening in many Western countries.6–11
Nurse endoscopists (NE) may provide a solution for these capacity problems. NE have been shown to be competent endoscopists.12, 13 In the UK, they form an integral part of the national gastrointestinal service and, among others, contribute significantly to the CRC screening programme. The British Society of Gastroenterology (BSG) has approved the role of NE for various endoscopic procedures provided they are adequately trained.14 In 2005, over 200 NE were practising in the UK. Their number had significantly increased in only 5 years.14–16 The American Society for Gastrointestinal Endoscopy (ASGE) supports the use of NE for screening sigmoidoscopy.17 In 2002, 6.1% of all screening sigmoidoscopies in the USA were performed by nonphysician endoscopists.18 While the role of NE in the UK and USA is expected to further expand, other countries are considering the introduction of NE.
The speed and success of such a process will probably depend on the opinions, expectations and experiences of physician endoscopists who are to train and supervise NE. However, to date, little is known about the attitude of gastroenterologists towards nurse endoscopy. The aim of the present study was to determine the views of gastroenterologists with respect to the role of NE in gastrointestinal endoscopy in a Western European community.
A postal questionnaire was sent to all registered gastroenterologists (n = 301) and gastroenterology residents (n = 79) in the Netherlands in November 2007. The questionnaire consisted of four sections. The questionnaire first asked for background information, including actual experience of the respondent with NE or the plan to start with nurse endoscopy. The second part of the questionnaire focused on the expectations of the respondent regarding the quality of and patient experiences with endoscopic services provided by NE compared to physician endoscopists. With respect to endoscopic quality, the following items had to be scored; caecal intubation rates, the number of detected lesions and complications. With respect to patient experiences, the items were: pain, stress, satisfaction and patient preferences. Responses had to be given in a closed format with scores of 1 to 5, representing substantially or moderately better performance by NE, no difference between NE and physician endoscopists or a moderately or substantially better performance by physician endoscopists respectively. The total scores for endoscopic quality and for patient experiences were combined. A mean score less than 3 meant expectations of better performance by NE, a score of 3 meant an expected similar performance and a score >3 meant expectations of better performance by physicians. In addition, the questionnaire asked for the expected effect of NE on costs of endoscopic services, to be scored as: a decrease, no effect or an expected increase of costs.
The third section of the questionnaire determined the attitude of the respondent towards the introduction of NE. Respondents could express a positive, neutral or negative attitude. The last section of the questionnaire focused on respondents’ opinions regarding appropriate screening, diagnostic and therapeutic endoscopic procedures for NE.
Statistical analysis was performed using the spss 15.0 program (SPSS Inc. Chicago, IL, USA). Descriptive statistics were used to analyse and report the data. Chi-square tests were used, where appropriate. Multivariate logistic regression analyses were performed to determine which factors predicted a positive response towards nurse endoscopy. A two-sided P-value of <0.05 was considered statistically significant.
A total of 235 questionnaires were returned, corresponding with a response rate of 62%. Gastroenterologists had a higher response rate than gastroenterology residents (64% vs. 53%). Of all respondents, 82% was gastroenterologist and 18% was resident. The distribution of academic vs. general hospital employees was 30 vs. 70%. The mean age of the respondents was 46 years (SD ± 10 years) and 77% was male. This reflects the distribution of age, sex and work setting of registered gastroenterologists and residents in our country. The responses covered all 94 hospitals in the Netherlands. Eleven (12%) hospitals already employed a total of 17 NE. Twenty-two percent of all respondents worked in a hospital with NE. Eight additional hospitals were considering introduction of nurse endoscopy.
Endoscopic quality, patient experiences and costs of NE
Forty-three percent of the respondents expected no difference in endoscopic quality between physicians and NE, 37% expected physicians to perform better and 20% expected nurses to perform better. With regard to patient experiences, 69% of the respondents expected physicians to perform better, 19% expected no difference and 12% expected that patients would be more satisfied with NE than with physician-endoscopists. The individual responses for each of the quality and patient experience parameters are listed in Table 1. Of note, the majority of respondents expected no difference in the number of detected lesions and number of complications between nurse and physician endoscopists. However, 43% of the respondents expected that physicians would have higher caecal intubation rates. With regard to pain, stress and satisfaction experienced by patients, the majority of the respondents expected no difference between nurse and physician endoscopists. Nevertheless, 84% of the respondents expected that patients would prefer a physician over a nurse endoscopist. Forty-nine percent of respondents expected that NE would reduce costs, whereas 41% expected no effect on costs. Respondents’ age, gender, type of hospital (academic or general), or position (resident or gastroenterologist) were not related with the expected overall performances of NE, except that female gastroenterologists more often than their male colleagues, expected better patient experiences for physicians (84% vs. 65%, P = 0.016). The expectations with respect to endoscopic quality, patient experiences and costs did not differ between respondents from hospitals that already employed NE and respondents with no nurse endoscopy experience (P = 0.22, P = 0.34, and P = 0.17, respectively).
Table 1. Individual responses for each of the expected quality and patient experience parameters (%)
Lesions detection rates
Caecal intubation rates
Attitude towards nurse endoscopy
Figure 1 illustrates the attitude of gastroenterologists towards the introduction of NE. Overall, 48.5% had a positive attitude towards such an introduction. Multivariate analysis showed that respondents who actually (had) worked with NE were significantly more often positive towards introduction of NE than those who lacked such experience [OR 6.6 (2.3–18.4)]. In addition, beliefs that NE are able to provide adequate endoscopic quality accompanied by optimal patient experiences were independent predictors for a positive attitude towards introduction of NE [OR 1.9 (1.2–3.5) and OR 2.1 (1.2–2.9), respectively). Respondents’ age, gender, type of hospital, position and expectation about costs were not related to the attitude towards nurse endoscopy.
Potential appropriate procedures for NE
The responses regarding potential appropriate procedures to be performed by NE are listed in Table 2. Of note, screening sigmoidoscopy and colonoscopy were considered appropriate procedures for NE, by respectively 89% and 66% of the respondents. In contrast, only 47% and 45% of the respondents judged diagnostic gastroscopy and colonoscopy appropriate for NE, respectively. Furthermore, only 42% considered removal of polypoid lesions smaller than 10 mm an appropriate intervention for NE. Other therapeutic procedures were considered not to be appropriate at all for NE.
Table 2. Potential appropriate procedures for nurse endoscopists (%)
* Other therapeutic procedures including: injection of ulcers, banding and injection of varices, dilatation of strictures, stent insertion and hot biopsy.
Polyp < 10 mm
Polyp ≥ 10 mm
Other therapeutic procedures*
This study reports the views of gastroenterologists and gastroenterology fellows with respect to the potential role of NE in gastrointestinal endoscopy in a Western country. Despite the limitations of a postal questionnaire, a representative and reliable overview was obtained. The response rate among all Dutch gastroenterologists and residents was, with 62%, acceptable.
Our results show that a majority of gastroenterologists have a positive attitude towards introduction of NE for sigmoidoscopy and colonoscopy within a CRC population screening programme (89% and 66% of the respondents, respectively). In contrast, diagnostic endoscopies were considered less appropriate and therapeutic procedures were considered not appropriate for NE. Actual experience with NE and beliefs that NE are able to provide adequate endoscopic quality or good patient experiences were independent predictors for a positive attitude towards introduction of NE.
These results are in agreement with those of a survey in the UK, which predicted an important albeit restricted role for NE. Clinicians from the UK considered diagnostic gastroscopy and sigmoidoscopy appropriate and diagnostic colonoscopy and therapeutic endoscopies inappropriate for NE. The UK audit however did not specifically investigate the attitude towards screening endoscopies.16
We obtained our results in the setting of a country in Western Europe with a considerable shortage in trained endoscopists. This shortage is expected to further increase in the next few years, with the pending decision to introduce a nationwide colorectal cancer screening programme. In the Netherlands, the Individual Health Care Professionals Act authorizes nurses to perform endoscopies, provided they do so according to the standards of a competent endoscopist as laid down in the regulations of the Dutch Society of Gastroenterology. These regulations are endorsed and the adherence to it is regularly checked in all Dutch centers by the Dutch Society of Gastroenterologists.
Endoscopic capacity studies performed to date have shown that the currently available capacity is not sufficient for the increased demand resulting from CRC screening programmes. The magnitude of the capacity problem depends on the chosen modality of primary screening, the target population, population adherence with the screening programme and finally the surveillance protocol.6–10 For the Netherlands, recent calculations have shown that even with the most restrictive screening approach, the number of required colonoscopies is likely to double from the current 120.000 to 240.000 per annum on a population of 16 million, including 4.4 million inhabitants in the age range of 50–75 years (data not published). The shortage in endoscopic capacity also varies between different regions.10, 19 Together, this asks for more accurate data regarding the insufficient endoscopic capacity and the impact of locally chosen solutions.
There are several ways to close the gap between the required and available endoscopy resources, respectively focusing on strategies that reduce demand or increase supply. Studies have shown that at present 23% to 39% of all gastrointestinal endoscopies are being performed for inappropriate indications or at inappropriate surveillance intervals when compared to guidelines.20–22 Reduction in these unneeded procedures would free capacity for other purposes. On the other hand, endoscopic capacity can be increased by training of additional endoscopists. However, training of physicians is expensive and fellowship programmes in gastroenterology are sparse and slow to respond to changes in the need for gastroenterologists.23 In addition, it has been suggested that the need for additional gastroenterologists for endoscopy should be balanced with the need for other aspects of gastroenterology care.7 A more effective way to increase endoscopic capacity would be to increase productivity and efficiency of currently available gastroenterologists.6, 23 This could be accomplished in a strategy where multiple adequately trained and productive NE are supervised by an experienced gastroenterologist.
Studies that have investigated the endoscopic skills of NE concluded that NE are effective and can safely perform procedures such as diagnostic gastroscopy and sigmoidoscopy. However, most of these studies were criticized for methodological flaws.12, 24 Only four randomized controlled trials comparing physicians and NE have been performed to date.13, 25–27 In most studies, the methods of training of NE was either not specified or considered inadequate according to current endoscopic training guidelines. Apart from gastroscopy and sigmoidoscopy, nurse endoscopy studies have so far not elucidated the possibilities and limitations of NE performing colonoscopy. Such information is urgently required in view of the widespread introduction of CRC screening.
With all these developments, guidelines for NE training and criteria to maintain procedural competence after training should be defined. These guidelines should rely on available and future studies regarding the endoscopic skills of NE and should be well defined for specific procedures. In the UK, the Joint Advisory Group on Gastrointestinal Endoscopy already developed such guidelines.28 If competence has been demonstrated, individual endoscopists should be credentialed by local institutions to perform the respective endoscopic procedures. In addition, clear job descriptions must define the scope of practice and specific responsibilities for NE and their supervisors. This will also clarify the legal implications and effectiveness for the proposed strategy where gastroenterologists supervise multiple NE. Furthermore, reimbursement policies should be adapted to facilitate a cost-effective and adequate reimbursement. Overcoming these issues will allow introduction of NE in the gastrointestinal endoscopic service.
We conclude that a majority of gastroenterologists have a positive attitude towards introduction of NE, especially for CRC screening endoscopies. To define the exact role of NE, precise assessment of endoscopic quality, patient experiences and cost-effectiveness is needed. There is especially a need for studies evaluating NE performing colonoscopy.
Declaration of personal and funding interests: None.