In the 75 years since the foundation of the British Society of Gastroenterology (BSG), one of the major changes in the care of patients with gastrointestinal disorders has been the emergence of the role of specialist nurses. Three-quarters of a century ago nurses were still very much in the ‘handmaiden to doctors’ role, carrying out medical instructions and keeping patients clean and tidy. This has now been transformed, in the UK at least, into a range of nurse-led services managed by nurses who, with appropriate training, can prescribe all licensed medications (on completion of a separate qualification that is registered nationally), order and conduct the full range of investigations and often manage whole episodes of specialist hospital care without patients ever seeing a doctor at all. Even compared with a decade ago,1 2 there has been a rapid expansion in both the scope of practice and in the number of nurses involved.
This has often been driven by organisational and financial constraints. As the UK has salaried healthcare professionals and a national health service, the competition between professionals that has arisen in systems in which loss of a patient consultation equates to loss of income, has not generally arisen. Doctors have usually been more than happy to cooperate in training nurses to take over the more routine aspects of medical care. This, together with a European working time directive that has restricted junior doctors' hours, has seen a huge expansion of the scope of nursing practice in gastroenterology and elsewhere in the health economy. Nurses (in non-gastroenterology care) have been found often to be cheaper than doctors, even if they take longer with each patient and order more investigations, and to be no less effective clinically in consultations.3 Often patient satisfaction is higher with nurses.4 5
At the same time the academic basis in terms of both research and training has been expanding. There is a range of increasingly advanced specialist training courses for nurses to support new skills and roles, with academically accredited courses at degree and/or masters level for nurses in most specialist aspects of gastrointestinal care. Clinical nurse specialists in the UK do not currently have a mandatory level of qualification, but most will have undertaken at least an academically accredited module in their specialist area of practice, and some in current practice will have received training ad hoc on the job from a medical colleague. This is no longer seen as acceptable. Some will undertake a formal nurse practitioner course, which includes prescribing and full physical assessment as well as specialist practice. There are numerous textbooks on gastrointestinal nursing practice, mostly written by nurses for nurses,6 7 specialist topic books,8 and at least two specialist journals: Gastrointestinal Nursing in the UK and Gastroenterology Nursing in the USA.
Organisations where gastroenterology nurses can network to exchange ideas, learn and support each other have also flourished, with a gastroenterology and stoma care forum within the Royal College of Nursing, an endoscopy associates group in the BSG and a nurses group with the European Crohn's and Colitis Organisation.
Nurses have developed specialist practice throughout gastroenterology and hepatology, caring for most major diagnostic patient groups, including intestinal failure and gastrointestinal cancers. Nurses are the most usual coordinators for cancer multidisciplinary teams and are the key point of contact for patients on a wide variety of care pathways. However, this article will focus on four key areas of practice.
Endoscopy
This was the first area of gastroenterology practice that nurses adopted on a large scale. Nurses have been trained as independent upper and lower gastrointestinal endoscopists since the early 1990s,4 and are delivering both diagnostic and screening endoscopy throughout the UK, with over 300 nurse endsocopists currently accredited by the joint advisory group on gastrointestinal endoscopy. The training is the same as for a medical endoscopist and practice is expected to be to the same standard. Appropriately trained nurses are increasingly safely administering their own sedation,9 and venturing into therapeutic endoscopy, such as polypectomy, and full colonoscopy, as well as participating in emergency on-call endoscopy rotas and interpretation of tests such as capsule endoscopy.10 Many nurse endoscopists have expanded their practice into managing whole episodes of care for specific patient groups, such as testing for Helicobacter pylori and administering eradication therapy, or running iron deficiency anaemia clinics in conjunction with upper gastrointestinal endoscopy; or rectal bleeding clinics where patients found to have benign disorders might, in addition to the endoscopy, also receive injection or banding treatment for haemorrhoids or counselling on diet and lifestyle advice to treat or prevent symptoms.
Nurse follow-up for endoscopy patients found to have benign disease has been found to be safe and cost effective,11 and nurses generally find the endoscopist role satisfying, although some feel that they are at times given lower priority than medical colleagues when it comes to the organisation of endoscopy lists.12 Nurse endoscopy is discussed in more detail elsewhere in this issue.13
Inflammatory bowel disease nursing
Inflammatory bowel disease (IBD) nurse specialists have become well established in the UK and are particularly popular with patients. Part of the growth has been linked to the increasing use of relatively expensive biological medications, which have, at least initially, required hospital-based infusions and close patient monitoring. Nurse-led infusion services have been set up as a way of delivering a service in a cost-efficient manner, including phial-sharing of biological medications when a patient does not require a full dose. Services very often also include nurse-led clinics for IBD patient follow-up, rapid access clinics, telephone clinics, immunosuppression monitoring, and a telephone helpline to enable rapid access to advice and attempt to pre-empt hospital attendance or even admission. Models of integrated care for IBD patients across hospital and community are reported to improve care pathways in several different healthcare systems and multidisciplinary working is recommended by experts as best practice.14 Patient groups have campaigned for more IBD nurse specialists. See for example Colitis and Crohn's UK's campaign for nurse specialists (http://www.nacc.org.uk/downloads/media/NACCSurveyRelease.pdf).
Early audits suggested that an IBD nurse could reduce the length of hospital stay and improve patient care while independently managing the majority of problems presenting to a helpline.15 However, rigorous prospective evaluations of the role are awaited and the evidence base for clinical or cost-effectiveness of an IBD specialist nurse is up to now sparse at best.16 There is a need for research to establish both clinical and cost-effectiveness of the IBD nurse role.
Stoma care nursing
Stoma care nursing, the longest established specialised nurse role in gastrointestinal nursing, has expanded well beyond the initial role of fitting patients with the most appropriate stoma bag.17 Specialist nurses undertake preoperative counselling and education, helping patients come to genuinely informed decision-making when faced with dilemmas and real choices (such as between an ileo-anal pouch and an ileostomy). Siting the most appropriate position is crucial to later quality of life with a stoma, as are postoperative support and rehabilitation. Stoma care nurses are typically experts on skin care, advising patients with diarrhoea-related soreness, perianal or abdominal fistulae and pyoderma. Many work across the hospital–community divide, visiting new stoma patients or those with problems, in their own home. Some have specialised in supporting people with an ileo-anal pouch and subsequent complications such as pouchitis, evacuation difficulties and faecal incontinence.18 Others have expanded the role to take on new patient groups such as teaching rectal irrigation to patients with functional bowel disorders (see below), or transforming the role into a more generic colorectal nurse, managing benign anorectal conditions and undertaking biofeedback.
Functional bowel disorders
Nurses are increasingly taking a lead in managing patients who present with functional bowel disorders such as constipation or faecal incontinence. Originally, this was often under the aegis of ‘biofeedback’. A range of therapeutic options has now been developed, which includes biofeedback, but also encompasses bowel retraining, behaviour modification, rectal irrigation, use of neuromuscular stimulation, peripheral tibial nerve stimulation, hypnotherapy for irritable bowel syndrome, specialist dietary advice and a range of emerging options.
The next 25 years
What will the issue celebrating the 100th anniversary of the BSG have to say about nurses? In both the UK and the USA19 it is predicted that the role of nurse practitioners or specialist nurses delivering protocol-guided care will both continue to grow and to improve patient outcomes and drive down healthcare costs. In the future it will increasingly be expected that such nurses are prepared to at least masters level and a few are already undertaking doctoral level study.
Is this a threat or an asset to the medical practice of gastroenterology? It could be seen as threatening the range and depth of experience for medical trainees in gastroenterology, who might seldom see the more straightforward patients or those with benign disorders and be less experienced as endoscopists. It will certainly lead to the need for increased teamwork and probably multidisciplinary learning. Already we have examples of nurses training doctors in skills such as endoscopy.
Does this mean that specialist nurses are becoming ‘mini-doctors’? In this author's opinion, definitely not. A nurse retains a different and unique contribution to multidisciplinary holistic care, bringing something different from medical and other colleagues to both the team and to the patient. Nurses are often seen as the natural leaders in the management of chronic diseases, which, with excellent medical care, many gastrointestinal diseases have become. Guided self-management for early management of flare-ups and chronic symptoms such as pain fatigue and incontinence in IBD20 is just one example, which is ideal for a nurse-led approach to care. Nurses are also the natural case managers for care that will inevitably become more primary care and less hospital focused, with the nurse acting as the liaison between general practitioners and gastroenterologists.
There is at present no consensus on what specialist nurses a ‘good’ gastrointestinal service should include. Probably at a minimum some nurse endoscopists offering diagnostic, screening and therapeutic services, one to two IBD nurse specialists, a colorectal cancer nurse to coordinate the multidisciplinary team, and a stoma care team who have expanded the role to manage benign anorectal conditions. Other team members are likely to depend on local specialist interests and caseloads. Historically, many roles have developed in a very ad-hoc fashion, often starting on ‘soft’ money and only later being adopted on a permanent basis. It is to be hoped that in future developments will be planned to optimise timely patient access and community liaison. However, in times of financial constraint, there may be battles to be fought simply to maintain the current number of posts.
Good research will be crucial to safeguarding and developing specialist nurse posts in the future. There is an urgent need to demonstrate that posts are both clinically and cost effective, and to test a range of interventions for clinical symptoms. The transferability of techniques used with good effect in other chronic disease management but as yet relatively unexplored in gastrointestinal conditions is an obvious example (eg, techniques for managing pain and fatigue). It is to be hoped that the next 25 years sees the emergence of a strong research basis to underpin the role of the gastrointestinal nurse, to the ultimate benefit of patients, and hopefully medical colleagues as well. Strong medical support has enabled pioneers to develop new roles. Continued support will be needed to sustain and expand specialist nurse roles in the challenging times ahead.
Footnotes
Competing interests: None.
Provenance and peer review: Commissioned; internally peer reviewed.
References
- 1.Mayberry MK, Mayberry JF. The status of nurse practitioners in gastroenterology. Clin Med 2003;3:37–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Norton C, Kamm MA. Specialist nurses in gastroenterology. J R Soc Med 2002;95:331–5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Laurant M, Reeves D, Hermens R, et al. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev 2004;4:CD001271. [DOI] [PubMed] [Google Scholar]
- 4.Maule WF. Screening for colorectal cancer by nurse endoscopists. N Engl J Med 1994;330:183–7. [DOI] [PubMed] [Google Scholar]
- 5.Williams J, Russell I, Durai D, et al. Effectiveness of nurse-delivered endoscopy: findings from randomised Multi-Institution Nurse Endoscopy Trial (MINuET). BMJ 2009;338doi: 10.1136/bmj.b231. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Smith G, Watson R. Gastrointestinal Nursing. Oxford: Blackwell Science, 2005. [Google Scholar]
- 7.Norton C, Williams J, Taylor C, et al. Oxford Handbook of Gastrointestinal Nursing. Oxford: Oxford University Press, 2008. [Google Scholar]
- 8.Duncan J, Whayman K, O'Connor M. Inflammatory Bowel Disease Nursing. London: Quay Books, 2011. [Google Scholar]
- 9.Walker JA, McIntyre RD, Schleinitz PF, et al. Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center. Am J Gastroenterol 2003;98:1750. [DOI] [PubMed] [Google Scholar]
- 10.Levinthal GN, Burke CA, Santisi JM. The accuracy of an endoscopy nurse in interpreting capsule endoscopy. Am J Gastroenterol 2003;98:2669–71. [DOI] [PubMed] [Google Scholar]
- 11.Chan D, Harris S, Roderick P, et al. A randomised controlled trial of structured nurse-led outpatient clinic follow-up for dyspeptic patients after direct access gastroscopy. Gastroenterology 2009;9:9–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Chapman W, Cooper B. Exploring the nurse endoscopist role: a qualitative approach. Br J Nursing 2009;18: 1378–84. [DOI] [PubMed] [Google Scholar]
- 13.Dekker E, Fockens P, Denters M, et al. Patient satisfaction with the colonoscopy procedure: endoscopists overestimate the importance of adverse physical symptoms. Frontline Gastroenterology 2012. doi: 10.1136/flgastro-2012-100150. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Mikocka-Walus AA, Andrews JM, Bernstein CN, et al. Integrated models of care in managing inflammatory bowel disease: a discussion. Inflamm Bowel Dis. Published Online First: 12 Jan 2012. doi: 10.1002/ibd.22877. [DOI] [PubMed] [Google Scholar]
- 15.Nightingale A. Audit of guided patient-managed care. In: Rampton D, ed. IBD: Clinical Diagnosis and Management. London: Martin Dunitz, 2000. [Google Scholar]
- 16.Belling R, McLaren S, Woods L. Specialist nursing interventions for inflammatory bowel disease. Cochrane Database Syst Rev 2009;4:CD006597. [DOI] [PubMed] [Google Scholar]
- 17.Myers C. Stoma Care Nursing. London: Arnold, 1996. [Google Scholar]
- 18.Williams JM. The essentials of pouch care nursing. London: Whurr Publishers, 2002. [Google Scholar]
- 19.Dorn SD. Mid-level providers in gastroenterology. Am J Gastroenterol 2010;105:246–51. [DOI] [PubMed] [Google Scholar]
- 20.Robinson A, Thompson DG, Wilkin D, et al. Guided self-management and patient-directed follow-up of ulcerative colitis: a randomised trial. Lancet 2001;358:981. [DOI] [PubMed] [Google Scholar]