Exploratory study describing current and future roles of advanced practice registered nurses associated with gastrointestinal specialty areas

In gastrointestinal (GI) specialty areas, advanced practice registered nurses (APRN) are currently performing flexible sigmoidoscopy (FS) for diagnosing colon cancer. Should other endoscopic procedures, i.e., colonoscopy and esophagogastroduodenoscopy (EGD), also be considered part of the APRN role? Questionnaires were mailed to APRNs belonging to the National Society of Gastrointestinal Nurses and Assistants. Questions pertained to current activities, interest in performing GI endoscopic procedures, and barriers to performing GI endoscopic procedures along with participants demographics. Over 70% of respondents approved of nurses performing diagnostic endoscopic procedures, yet 80.6% did not think that APRNs should perform therapeutic endoscopic procedures. Training opportunities were limited but most common for FS (n = 19). Five of the respondents were performing endoscopic procedures, mainly FS, with two of these performing colonoscopy and EGD. The barriers listed as the number one barrier to performing endoscopic procedures included liability (n = 24), third-party reimbursement (n = 14), lack of physician support (n = 11), lack of policies (n = 8); and lack of education (n = 7). APRNs should develop policies and establish acceptable training guidelines and competency rates in performing GI endoscopic procedures.

EXPLORATORY STUDY DESCRIBING CURRENT AND FUTURE ROLES OF ADVANCED PRACTICE REGISTERED NURSES ASSOCIATED WITH GASTROINTESTINAL SPECIALTY AREAS by Roxanne Froerer A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science Department of Nursing The University of Utah August 1997 Copyright ©Roxanne Froerer 1997 All Rights Reserved THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Roxanne Froerer This thesis has been read by each member of the following supervisory committee and by majority vote has been found to be satisfactory. Chair: Karin T. Kirchhoff Kathleen M. Baldwin JoAnn Rolando THE UNIVERSITY OF UTAH GRADUATE SCHOOL FINAL READING APPROVAL To the Graduate Council of the University of Utah: I have read the thesis of Roxanne Froerer in its fmal form and have found that (1) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place; and (3) the final manuscript is satisfactory to the supervisory committee and is ready for submission to The Graduate School. Karin Kirchhoff Chair, Supervisory Committee cfI'C:lf the Major Department Linda K. Amos ChairlDean Approved for the Graduate Council Ann W. Hart Dean of The Graduate School ABSTRACT In gastrointestinal (GI) specialty areas, advanced practice registered nurses (APRN) are currently performing flexible sigmoidoscopy (FS) for diagnosing colon cancer. Should other endoscopic procedures, i.e., colonoscopy and esophagogastroduodenoscopy (EGD), also be considered part of the APRN role? Questionnaires were mailed to APRNs belonging to the National Society of Gastrointestinal Nurses and Assistants. Questions pertained to current activities, interest in performing GI endoscopic procedures, and barriers to performing GI endoscopic procedures along with participants demographics. Over 70% of respondents approved of nurses performing diagnostic endoscopic procedures, yet 80.6% did not think that APRNs should perform therapeutic endoscopic procedures. Training opportunities were limited but most common for FS (n=19). Five of the respondents were performing endoscopic procedures, mainly FS, with two of these performing colonoscopy and EGD. The barriers listed as the number one barrier to performing endoscopic procedures included liability (n=24), third-party reimbursement (n=14), lack of physician support (n= 11 ), lack of policies (n=8), and lack of education (n= 7). APRNs should develop policies and establish acceptable training guidelines and competency rates in performing GI endoscopic procedures. CONTENTS ABSTRACT ............................................................................................................... iv ACKNOWLEDGMENTS .......................................................................................... vi INTRODUCTION ...................................................................................................... 1 Statement of problem ...................................................................................... 3 Purpose of study .............................................................................................. 3 REVIEW OF LITERATURE ...................................................................................... 4 APRN s in specialty areas ................................................................................. 4 Competency in endoscopy ............................................................................... 6 APRNs and endoscopy .................................................................................... 8 Research questions .......................................................................................... 10 METHODS ................................................................................................................. 11 Sample ............................................................................................................ 11 Methods and instruments ................................................................................ 11 Reliability and validity .................................................................................... 12 Data analysis .................................................................................................... 12 RESULTS ................................................................................................................... 14 DISCUSSION ............................................................................................................. 23 Limitations of study ......................................................................................... 27 Conclusion ....................................................................................................... 27 APPENDIX A: LETTER ............................................................................................. 28 APPENDIX B: QUESTIONNAIRE ............................................................................ 29 REFERENCES ............................................................................................................ 33 ACKNOWLEDGMENTS Thanks to Karin, Kathy, and JoAnn for their patience, willingness to help, and thoughtful recommendations. Special thanks to Dr. DiSario for his time and willingness to promote the role of nurse endoscopist. INTRODUCTION Advanced practice registered nurses (APRN) are used in a variety of health care settings including specialty areas like pediatrics, neonatology, and cardiology. Activities of APRNs in specialty areas vary but usually include initial health history and physical examination of the patient, patient and family education, health promotion, collaboration between specialists, medical staff and referring physicians, discharge planning, and follow­up treatment and management (Bowey & Caballero, 1996; Callahan, 1996; Genet et aI., 1995; Leung, Davis, Arnold, Hamdy, & Neal, 1996). No studies have been published discussing the utilization of an APRN in the specialty area of gastrointestinal (GI) endoscopy other than in the performance of flexible sigmoidoscopy (FS) for colon cancer screening (Gruber,1996; Rosevelt & Frankl, 1984). The role of the APRN in gastroenterology, hepatology, and endoscopy was just recently defined by the Society of Gastrointestinal Nurses and Associates (SGNA) (SGNA, 1996) and is similar to APRN roles in other specialty areas. Included in this role is the performance of diagnostic studies, but what diagnostic studies refers to is not defined. Performance of most diagnostic studies in GI endoscopic specialty areas have routinely been performed by gastroenterologists, surgeons, and family practice physicians. GI nurses have performed limited diagnostic procedures, i.e., esophageal manometry and acid perfusion studies, with physicians usually interpreting these studies. GI nurses are· performing FS with no physician assistance or interpretation of findings (Gruber, 1996; 2 Maule, 1994). Diagnostic studies could also include esophagogastroduodenoscopy (EGD) and colonoscopy. Determining which patients are in need of diagnostic procedures versus therapeutic procedures requires advanced health assessment skills. With a careful health history, patients requiring therapeutic interventions, i.e., esophageal dilation, cauterizing bleeding sites, or sclerotherapy, etc., during their endoscopic procedure can usually be identified prior to their procedure, whereas patients requiring polypectomy during colonoscopy are not identifiable prior to the examination. The question arises, "Should APRNs perform all diagnostic studies within the GI endoscopic unitT' Controversies arise with this additional role of the APRN. These controversies include obtaining adequate training, licensure, along with identifying the need. Competition currently exists among health care providers performing GI endoscopic diagnostic studies which could limit the expansion of the APRN role. Gastroenterologists and surgeons have long battled over who should perform endoscopic procedures. Family practice physicians joined the battle as the use of nonphysician personnel to perform FS became published. The use of technicians, medics, nurses and APRNs for FS has been explored extensively (DiSario & Sanowski, 1993; Gilbert, Cherry, Downing, & Anema, 1974; Gruber, 1996; Maule, 1994; Norfleet, Johnson, Mulholland, Philo, Saviage, & Skerven, 1980; Rosevelt & Frankl, 1984). All studies concluded that trained individuals other than physicians can be taught to competently perform FS. Family practice physicians have commenced performing colonoscopy, and, most recently, EGD with no further formal education or training (Dervin, 1986; Hocutt, Rodney, Zurad, Tucker, & Norris, 1994; Pope, Mayeaux, & 3 Harper, 1995). Statement of problem The role of the APRN performing endoscopic procedures has not been defined nor accepted other than in performing FS. Training guidelines for physicians to perform endoscopic procedures are ambiguous. Recognizing pathology is a critical aspect of performing endoscopic procedures. Many GI APRNs have far more experience in observing GI endoscopy procedures, pathology, and complications than family practice physicians. How best to utilize the valuable resource of GI APRNs to provide another source of quality endoscopic care to the public remains a problem. How can GI APRNs receive the additional training they need to be technically skilled? Because GI APRNs have an excellent background to perfonn GI endoscopy procedures, does this mean they want to? Which APRNs are the most interested in advancing their skills to include endoscopic procedures? Is there a relationship between years of experience in GI nursing and interest level in performing diagnostic GI procedures? What barriers do APRNs face to perform endoscopic procedures? Purpose of study The main purpose of this study is to explore the expansion of the GI APRN role to include all GI diagnostic or therapeutic endoscopy or both. To accomplish this, the study will (a) describe current activities of GI APRNs and their desire to perform endoscopic procedures, (b) assess GI APRNs perceptions of availability and type of training needed and (c) define barriers to performing endoscopic procedures. REVIEW OF LITERATURE APRNs in specialty areas In the past, clinical nurse specialists have primarily been utilized in hospital environments and nurse practitioners have been associated with direct patient care in outpatient settings. These two roles are merging as the expertise of these masters prepared nurses is needed in both settings (Callahan, 1996; Williams & Valdivieso, 1994). For the purpose of this study, the tenn APRN will be used in reference to the master's degree nurse whose license and educational experience go beyond traditional RN functions to include diagnosing, physical examination, prescriptive practice, etc. APRNs have been utilized in pediatric medicine and surgery, cardiology and cardiovascular surgery, general surgery, neurological surgery, urology, and pain management areas (Busch, 1995; Leung et al., 1996). APRNs have demonstrated competency at perfonning a variety of medical and surgical procedures. Among these procedures are suturing lacerations, biopsy and removal of skin lesions, cervical colposcopies with biopsy, endometrial biopsies, casting, removing toenails, inserting and removing intrauterine devices, aspirating and injecting joints, first assistant in laparoscopic surgery, flexible sigmoidoscopy, vasectomy, and inserting chest tubes (Bowey & Caballero, 1996; Gruber, 1996; Smithing & Wiley, 1996). APRNs working in specialty areas frequently have had previous nursing experience 5 with that specific patient population. This experience provides them with a holistic approach in their patient management plans. They know what to expect following specific procedures and can implement this knowledge with their patient education. Expert registered nurses have the skill known as "the early warning signal" (Benner, 1984). They recognize deterioration in a patient's condition before changes in vital signs occur. These nurses with advanced education have much to contribute to specialty areas. The GI endoscopy clinic is a specialty area that can benefit from the utilization of APRNs. An APRN may perform the initial assessment and physical examination of referred patients to the GI endoscopic clinic, allowing the gastroenterologist more time with difficult cases. Depending on state licensing, the APRN may administer conscious sedation prior to procedures. Following the procedure, APRN s can educate the patient and family regarding the diagnosis and treatment plan. They can prescribe appropriate pharmacologic treatments, along with conducting the majority of follow-up care for the GI patient. Prior to his death in 1973, Dr. Strode, an early gastroenterologist, wrote about the benefits of using trained individuals to perform FS. He strongly recommended the use of individuals other than physicians to better utilize the physician's time, reduce costs, and improve efficiency (Strode, 1973). A variety of papers, editorials, and studies have been written supporting this idea. By performing routine diagnostic procedures, APRNs can reduce the resident workload (Genet et aI., 1995) and allow more time for training with difficult cases. Overall financial savings have been calculated to be as high as 240/0 by utilizing APRNs 6 instead of physicians in primary care (McGrath, 1990). APRNs were 200/0 less costly in their overall care of two specific conditions than physicians in a study by Salkever (1992). APRN s with a background of assisting with G1 endoscopic procedures are in an excellent position to promote the role of the nurse endoscopist. They have assisted with endoscopic procedures, are familiar with the instruments, and, in areas where video endoscopy is employed, are familiar with common gastrointestinal pathology (Hughes, 1996). They have witnessed complications and have participated in their management. Many G1 nurses advance the endoscope for the physician during colonoscopy resulting in familiarity with intubation and extubation. Currently, there are no guidelines or training programs available in the United States to provide formal endoscopic training for APRNs. What constitutes adequate training to perform G1 endoscopic procedures is a debatable issue. Competency in endoscopy Schapiro (1984) documented that he found negligible difference between physician assistants and trained endoscopists performing FS. Rosevelt and Frankl (1984) trained a nurse practitioner in 1 month to be competent with this examination. The most recent study conducted by DiSario and Sanowski (1993) compared G1 nurses with medical residents; no statistical differences were found between groups in learning the skills involved with FS. The American Society of Gastrointestinal Endoscopy (ASGE) guidelines state that training for Gr endoscopic procedures consists of a formal fellowship or residency in 7 gastroenterology or surgery which would consist of adequate training, endoscopic experience, and certification. An alternative to this would be training and experience outside of a formal fellowship or residency program which would include a detailed description of the informal training, the number of procedures performed with and without supervision, and the actual observed competency of the applicant. The ASGE recommends a minimum of 100 EGDs and colonoscopies to reach competency (ASGE Standards of Training and Practice Committee). The American College of Physicians (ACP) defined competence as the "education, .training, experience .and cognitive and technical skills" necessary to perform endoscopic procedures. Fifty EGDs and colonoscopies are recommended by the ACP to obtain competency. One study used specific objective criteria to determine competency. They concluded that 100 or more supervised colonoscopies or upper gastrointestinal endoscopies are necessary to obtain competency (Cass, Freeman, Peine, Zera, & Onstad, 1993). Their study demonstrated that gastroenterology fellows in training reached the cecum during colonoscopy 80% of the time after 50 cases. Family practitioners accept cumulative rates of reaching the cecum of 54%-93% as being competent (Rodney, Dabov, & Cronin, 1991) whereas gastroenterologists do not set a competency level but publish findings of reaching the cecum in 98.8% of cases (Church, 1994). The difficulty of performing colonoscopy compared to gastroscopy has not been documented, but the two procedures are frequently discussed together regarding training and the required number of procedures are the same. Colonoscopies are more time consuming than EGDs and have higher morbidity rates. In the on-going study by Hocutt 8 et al. (1994), family physicians, some experienced in flexible sigmoidoscopy, completed an average of eight supervised EGDs before performing these procedures independently. Levels of competency and morbidity rates were not reported. Interestingly, the British Society of Gastroenterology (BSG, 1994) approved specially trained registered nurses to perform FS and EGD but made no mention of colonoscopy. Complication rates in performing EGD and colonoscopy are relatively low when performed by experienced gastroenterologists. Coleman (1988) estimates morbidity of EGD at 2 cases per 1,000 and mortality as 1 case per 20,000 (Coleman, 1988). Serious complications with diagnostic colonoscopy occur in 0.1 % to 0.2 % of cases (Bond, 1993). Serious complications with either EGD or colonoscopy include perforation, bleeding, aspiration, and respiratory distress. APRNs and endoscopy Is there a need for APRNs to perform diagnostic GJ endoscopic procedures? In England, the demand for GJ endoscopy procedures is beginning to exceed the ability of trained physicians to perform the procedures (BSG, 1994). One V A medical center in the United States documented a threefold increase in EGDs and a sevenfold increase in colonoscopies in the last decade with no increase in personnel (Smith, 1992). One area that will definitely require the services of the nurse endoscopist is colon cancer screening. Colon cancer is the second highest cause of cancer-related death in the United States. Appropriate screening for colon cancer has been debated for years. The controversy of rigid versus flexible sigmoidoscopy was settled primarily by patient acceptance and distance of colon that could be examined by the 60cm flexible sigmoidoscope. The American Cancer Society now recommends digital rectal exam annually after age 40, stool testing for occult blood annually after age 50 and sigmoidoscopy every 3 to 5 years after age 50 (American Cancer Society, 1996). 9 Currently, there is discussion as to the sensitivity of screening FS. Even though FS has been documented to lower death rates from colorectal cancer by 30%-59% (Selby, Friedman, Quesenberry, & Weiss, 1993; U.S. Department of Health & Human Services, 1996), several studies have documented a rate of 42%-55% of tumors or polyps or both beyond the reach of the FS (Cooper, Yuan, Landefeld, Johanson, & Rimm, 1995; Lieberman & Smith, 1991). Colonoscopy would be the next step in colorectal cancer screening. Colonoscopy has a sensitivity rate of 97.3% when performed by gastroenterologists and 87% when performed by nongastroenterologists (Rex et aI., 1997). Longo, Ballantyne, and Modlin (1988) suggested aggressive colonoscopy screening because of their findings which concluded that patients with early cancers were asymptomatic. The ASGE recommends offering colonoscopy as a screening examination for colon cancer once every 10 years after age 50 (Winawer et aI., 1997). Colonoscopy meets the criteria for a good screening examination with its high sensitivity and specificity but fails on grounds of complications and cost (Stevenson & Hernandez, 1991). Lieberman's (1991) study concluded colonoscopy was more cost effective in the prevention of colon cancer death than FS. In order to be a more feasible screening examination, colonoscopy needs to be more accessible and less costly. One way to accomplish this is to utilize nonphysician endoscopists to perform colonoscopy to (Liebennan & Smith, 1991). Research questions No literature has been written regarding APRN's desires to pursue an endoscopist career. Even though experienced GI APRNs are in an excellent positi~n to take on this new role, the question arises, "Do they want to?" In this descriptive study, these questions will be addressed: (a) Which GI APRNs are interested in becoming nurse endoscopists? (b) Is training available to perform GI endoscopic procedures? (c) What barriers do APRNs perceive in regards to performing endoscopic procedures? METHODS A descriptive study was used to explore current activities of GI APRNs. This study describes activities of GI APRNs and identified which APRNs are interested in performing endoscopic procedures. The opportunity to explore type and availability of training for APRN s exists along with identifying barriers. Sample The target population who belong to the National Society of Gastrointestinal Nurses and Assistants (SGNA), from which the sample for this study was recruited, was APRNs. The SGNA consists of over 6,000 nurses who are associated with gastrointestinal endoscopy nursing. The population consisted of all APRN members on the SGNA mailing list Cn=125). Methods and instruments GI APRN questionnaire was used to collect data regarding GI APRNs activities in the role of the nurse endoscopist. The four-page questionnaire consisted of 22 questions addressing experience, along with desires for performing endoscopic procedures and availability of training. Barriers to performing endoscopic procedures were also assessed. The respondent task was to check or mark a rating scale. The questionnaires were mailed with a cover letter. A ren1inder letter and a second copy of the questionnaire were sent to 12 those who had not responded within 2 weeks. Data were collected by me. The Institutional Review Board approval was granted from the University of Utah. Informed consent was implied by the return of the questionnaire. Reliability and validity The questionnaire was pretested by 30 regional SGNA members who were eliminated from the final sample. Respondents were asked to list barriers. The six most frequently listed barriers were included in the final questionnaire with a rating scale. All questions not understood on pretest were clarified or explanations given or both to help clarify the meaning of the question. Data from the study questionnaire were entered directly into SPSS for Windows. Data analysis All three of the research questions were analyzed by descriptive statistics, i.e., means, standard deviations. Demographic information such as age, nUluber of years in GI nursing, and total number of years in nursing were correlated to interest in performing endoscopic procedures by Spearman Rho analysis. Relationship of approval to perform diagnostic procedures with interest level and available training were assessed by Spearman Rho correlational coefficient. Percentages and frequencies for the responses are reported for each item in the questionnaire. Two items in the questionnaire related to training: specifically, is training available and what type of training is it? These questions were analyzed by descriptive statistics, i.e., frequencies, means, and standard deviations. Six different barriers were listed in the tool along with a scale asking for rankings of barriers. The highest ranked barriers were then compared and ranked by frequencies. Questions pertaining to activities of APRN s were analyzed by comparing frequencies and percentages. Significance level was set at alpha .05. 13 RESULTS One hundred twenty-five questionnaires were mailed. Eighty-seven questionnaires were returned within the specified time. Of these, 26 were ineligible for inclusion since the respondent was not employed in an endoscopic area (n=21), the mail went to the wrong address (n=3), or the respondent was not a APRN (n= 1). This left 61 eligible questionnaires out of 99 (125-26 ineligibles) for a response rate of 61.6%. All respondents listing gender were female, with 2 not identified. Age ranged from 31 to 59 years with 45.22 as the mean. Years of experience as a nurse ranged from 10 to 39 with 22.8 as the mean. Clinical nurse specialists were the most represented type of APRN (41.7%), followed by managers (28.3%), staff nurses (13.3%), nurse practitioners (11.7%), and educators (5%) (see Figure 1). Thirty-eight respondents (62.3%) had 6 or more years of experience as a GI nurse. Ten (16.4%) respondents had 4-5 years of experience, and 13 (21.3%) had 2-3 years of GI nursing experience. The only variable correlated to level of interest in performing endoscopic procedures was availability of training for colonoscopy. Correlations between desire to perform endoscopic procedures, age, years of nursing experience, or years of GI nursing experience were not statistically significant. Interest level was not significantly correlated to availability of training for FS or EGD or ability to recognize pathology. Sixteen (28.1 %) respondents expressed no desire to perform endoscopic procedures with ratings at£ llUL3!=-> 8/13% Inanaqer 17/28% educatoL 3/5% Figure 1 nurse practi t j on(~ l- 7/12% eNS 25/42% Type of APRN in GI Endoscopy Areas Surveyed N=61 1I1 of less than 10 on a scale from 0 to 100. An equal number of respondents (n=16) listed a desire of greater than 70 on the scale. The mean score was 42.77 with a SD of 35.93 (see Figure 2). 16 Interest level in performing endoscopic procedures varied among types of APRN s. Clinical nurse specialists were most interested with a mean of 54.16 (SD 36.03), followed by managers with a mean 37.38 (SD 34.82). Nurse practitioners were third, with a mean of 32.33 (SD 41.73), educators were fourth with mean of 28.33 (SD 30.11), and staff nurses reported mean interest of 19.83 (SD 21.25) (see Figure 3), Experience in the GI field was not significantly correlated with APRNs' approving of nurses performing endoscopic procedures. Forty-one (70.7%) of the nurses responded that APRN s should perfonn diagnostic procedures. Nurses with 6 or more years of experience responded positively in 69.4% (n=25) of cases and nurses with 5 or less years of experience responded positively in 72.7% (n=23) of the cases. Eighty-one percent (n=47) of the nurses responded that APRNs should not perfonn therapeutic procedures. Nurses with 6 or more years of experience (n=29) responded no (80.6%) to performing therapeutic procedures, slightly less than nurses with 5 or less years of experience (n=26, 81.8%). There was no significant relationship between nurses' positive responses to performing diagnostic procedures and level of interest in performing procedures. Twenty-three respondents listed some type of training available to them to perform endoscopic procedures. More than one source of available training was listed by 5 respondents. Training was most commonly available for FS. Nineteen respondents listed physicians willing to teach FS, 4 listed training available at a university or college, and 3 18 16 14 12 10 8 en ~ 6 ~ 4-4 4 0 I-< (j) ..c 2 § Z 0 0-9 20-29 40-49 60-69 80-89 10-19 30-39 50-59 70-79 90-100 Interest level in perfonning procedures Figure 2 APRN Interest Level in Perfonning Endoscopic Procedures N=61 ---J GO 50 40 rl Q) :> (l) rl .+J 30 (J) (]) ~ (lJ .+J C -r1 20 C ru ([) :z: 10 -'-__ ,_ nurse practitioner eNS educator manager staff nurse type of APRN Figure 3 Mean Interest Level in Perfonning Endoscopic Procedures by Type of APRN N=61 co listed training available through an ASGE course. Training was listed as being available for EGD by physicians (n=10), university or college (n=2), and ASGE course (n=2). Colonoscopy training was available to 34% of the sample, consisting of training by physicians (20%), university or college (7%), and ASGE course (30/0). 19 APRNs believed they could competently perform FS if they received training by a physician (81 %, n=47), followed equally by current experience and an ASGE course (41.4%, n=24), and then by university training (34.5%, n=20). A combination of these training modalities were recommended by 82.7% of the respondents to be adequately trained in FS. Six respondents reported they did not believe that any of the above would train them adequately. To perform EGD and colonoscopy competently, the APRNs listed more than one modality in 82.1 % and 76.3% respectively. Proctoring by a physician to perform EGD and colonoscopy (60.3%, n=35 and 55.2%, n=32, respectively) was listed most often, with training at a university second (67.2%, n=39 equally between EGD and colonoscopy). The third highest ranking was that none of the listed training methods would be adequate for EGD (n=18) or colonoscopy (n=19). ASGE courses and current experience ranked last with range of 29.3% (n=17) to 20.7% (n=12) (see Table 1). Respondents ranked the six barriers from 1 to 6 and then rated how much the number 1 barrier was an obstacle. Rankings ranged from 0 to 99 with 67.96 the mean and SD 31.46. The barrier listed most often as the number 1 barrier was liability (n=24), followed by third-party reimbursement (n=14), physician support (n= 11), lack of policies (0=8), lack of education (n=7), and lack of proctor (n=O). The barriers ranked slightly different if the number of times the barrier was selected number 1 and number 2 are 20 Table 1 Training Necessary to Obtain Competency for Esophagogastroduodenoscopy (EGD), Colonoscopy and Flexible Sigmoidoscopy (FS) by Advanced Practice Registered Nurses N=58 EGD Colonoscopy FS % D % n % n Train with physician 60.3 35 55.2 32 81.0 47 Current experience 25.9 15 24.1 14 41.4 24 Professional course 29.3 17 20.7 12 41.4 24 University 32.8 19 32.8 19 34.5 20 No training adequate 31.0 18 32.7 19 10.3 6 Combinations of above modalities recommended for competency One modality 17.9 7 23.7 9 17.3 9 Two modalities 48.7 19 50.0 19 51.9 27 Three modalities 28.2 11 23.7 9 21.2 11 Four modalities 5.1 2 2.6 1 9.6 5 21 combined. Liability still is ranked the number 1 barrier (n=33), followed by third-party reimbursement (n=24), physician support (n=23), lack of education (n=17), lack of policies (n= 15), and lack of proctor (n=5). Although physician support was ranked third in barriers, 13 respondents listed physician support as no barrier. Activities in which APRNs currently participate varied. Seventy-seven percent (n=47) assist with endoscopic procedures, 70.5% (n=43) assist with FS, 73.8% (n=45) with EGD, and 73.8% (n=45) with colonoscopy. The most commonly listed activity was taking a health history from patients with 81.4% (n=48) APRNs participating. Discussing diagnosis and treatment plan with patient and family following GI procedures was listed next by 67.8% (n=40) APRNs. Ordering diagnostic studies ranked third with 35.6% (n=21) respondents participating. Twenty (33.9%) APRNs perfonn physical examination and follow-up care of the GI patient. Sixteen (27.1 %) perfonn manometric and perfusion studies, and only 15.3% (n=9) prescribe pharmacologic treatment for GI patients (see Figure 4). Two APRNs replied that they were currently performing FS, EGD, and colonoscopy. Both had been performing these procedures for 15 years. Performing FS and colonoscopy for 2.5 to 3 years were 2 APRNs, and 1 APRN had performed FS for 2 years. Four of the APRNs were trained by a physician proctor. with 2 of these receiving additional training with a university or college, and 1 was self taught. The APRNs perfonning procedures for 15 years responded that APRNs should perform therapeutic procedures as well as diagnostic. 22 Assist with sigamidoscopy 43 Assist with gastroscopy 45 Assist with colonoscopy Prescribe medications 0 t3 Perform perfusion studies ~ ",::t :~ < Perform manorDetric studies ! ~ Perform physical exam 1 20 1 Order diagnostic studies Take ahea1th history Manage fullow-up care Teaching patient Number of APRNs Participating Figure 4 Reported Current Activities of GI APRNs N=61 DISCUSSION The study used a national sample population. This sample should consist of the most interested group of APRNs in performing endoscopic procedures assuming that professionals interested in promoting advancement of their profession are involved in the national societies of their particular interest group. The sample may not reflect the opinions of the general population of APRN s. There may be registered nurses without their advanced practice degree currently performing FS who may feel differently than this population sample also. The sample also represents a group of APRN s who have had years of experience in watching nursing practices change. Many characteristics were shown not to be correlated to a higher interest level in performing endoscopic procedures. One would expect APRNs not participating in direct patient care to have less interest in perfonning procedures since they have chosen positions not involved in direct patient care. From analyzing only the eNS and NP, the mean interest level increases to 49.94 from 42.77 for the general study population. One would think a high-interest level must be present to obtain the highest competency rates. The nurses in DiSario and Sanowski's study (1993) who were not interested in performing FS were not competent after training. Training is only available to a minority of the APRNs, with training to perform FS the Inost (:~ommon. Since the most COlnmon type of training for FS was with a physician, 24 one could question if these physicians would be willing to train any APRN or just the APRN with whom they are familiar. The same question might apply to university training or ASGE course. Is this training available to everyone or only a select few? ASGE courses are usually aimed at the trained endoscopist and do not involve basic endoscopy skills. Training to perform EGD and colonoscopy certainly was not as available as for FS. To meet current recommendations for colon cancer screening, some type of training will need to be made available to provide an adequate number of providers. Considering the number of GI APRNs expressing interest in performing diagnostic procedures, a shortage of providers would still be a problem if all interested APRNs in this study were trained to perform colonoscopy. Predetermining if a procedure will be diagnostic or therapeutic is not a black-and­white decision. Are biopsies considered diagnostic or therapeutic? Polyps can easily be found on asymptomatic patients. Once colonoscopy is performed and a polyp found, removal of the polyp presents a problem if GI APRNs are only to perform diagnostic procedures. Would a physician be nearby to remove any polyps or should GI APRNs be trained in polypectomy also? Certainly, APRNs should not be utilized in evaluating patients with GI bleeding or dysphagia or in performing difficult procedures, i.e., cannulation of the common bile duct or sclerotherapy. The APRNs currently performing colonoscopy were in favor of nurses performing therapeutic procedures. This might reflect the need to perform polypectomy with colonoscopy or could also represent frustration that occurs when discovering therapeutic measures are required in the middle of a diagnostic procedure. Specific therapeutic interventions should be discussed on an 25 individual basis as policies are developed to detennine which interventions are within the scope of the G I APRN. Training recommendations for competency by GI APRNs were varied. Collaboration between physicians and GI APRNs may help to establish unified training guidelines. Training guidelines have been slow coming from collaboration between gastroenterologists and family practice physicians. Possibly from the results of this study, physicians may recognized the potential benefits of using APRNs, and progress can be made in establishing training guidelines. The SGNA must also be proactive in establishing guidelines and recommendations pertaining to GI endoscopy by APRNs. Barriers to performing endoscopic procedures appear to be significant to a large portion of GI APRNs. The reason liability was listed as the number 1 barrier may be because the majority of nurses have no access to adequate training or education. Also, surgical procedures, i.e., endoscopic procedures, are not usually covered under the Nurse Practice Act. Each State Board of Nursing must first give approval which usually would include some type of physician support. Physician support may be difficult to obtain if competition is an issue. With the approval of the State Board of Nursing and evidence of competency, the nurse is as safe to perform those procedures as any other nursing procedure covered under the individual state nursing act. Nurses exempt from this procedure are those employed in Veteran Administration Hospital settings where approval to perform procedures comes from within the institution. Third-party reimbursement may become even less of an issue as more third-party payers recognize APRN s as valuable providers and reimburse them as sllch. In some 26 states, APRNs are reimbursed equally with physicians whereas other states reimburse at a percentage of the physician rate (Pearson, 1997). If reimbursed equally, the cost containment expectations of using APRNs is diminished. Should APRNs bill less for equal services because of less educational costs? These questions remain to be answered. Physician support may remain an issue without the continual educational efforts by the APRN. Many physicians are not aware of the APRN role and how this role can complement their own role as providers. Policies, lack of education, and lack of a proctor remain issues for Gl APRN s to work on collectively and individually. As a group, 01 APRNs can prepare policies that will guide their practice in the future. They can also determine what type of training will provide competency and help determine adequate education to perform procedures. APRNs must decide what level of competency they are willing to accept. To provide the best quality of care, APRN s should strive for competency levels equal to gastroenterologists, but is it possible to obtain the same sensitivity, competency, and morbidity rates as gastroenterologists with less education? Individually, APRN scan identify competent and willing proctors and maintain competency in performing procedures within their scope of practice. Current activities of Gl APRNs appear to be within the stated role by the SGNA. Although many of the respondents were in managerial positions, one could question how many APRNs remain involved in patient care after postgraduate education. 27 Limitations of study The questionnaire did not address specific therapeutic procedures, i.e., biopsy, polypectomy, cautery, cannulating the sphincter of Oddi, etc. The responses to performing therapeutic procedures may have been different if specific procedures were identified. Diagnostic procedures also were not specifically identified in the questionnaire. Would more nurses approve of perfornring FS compared to EGD and colonoscopy since many RN s are currently perfornring FS? Conclusion The role of APRN s in many areas is just being developed and a broad spectrum of possibilities lies in the future. With the majority of GI APRN s supporting the performance of diagnostic procedures by APRNs, those interested should make the necessary efforts to develop policies and procedures to enhance this role. The SGNA must assist in establishing these guidelines and making recommendations to establish competency. APRNs must make every effort to establish guidelines in performing GI endoscopic procedures to insure quality care and optimal safety for the patient. By identifying the interest of other GI APRNs in perfornring GI endoscopic procedures, individual GI APRNs may pursue this aspect of nursing more vigorously due to this study. Performing GI endoscopic procedures is certainly not a goal for every GI APRN. This may represent stepping beyond the role of APRNs to many individuals. On the other hand, many acceptable roles of APRN s today were originally viewed as stepping beyond the acceptable role at the time they were initiated. APPENDIX A LETTER Dear Advanced Practice SGNA Member, Many studies have been conducted determining what roles advanced practice registered nurses (APRN) have in specialty areas. As part of my thesis, I am conducting a study to examine APRNs role in gastrointestinal (GI) endoscopy units and their thoughts about performing endoscopic procedures. Please take a few moments to answer the following questions. I will greatly appreciate the prompt return of the questionnaire in the prestamped, addressed envelope within 1 week of your receipt. Sincerely, Roxanne Froerer, R.N. APPENDIXB GI APRN QUESTIONNAIRE Please check the most appropriate answer. 1. Are you currently employed in an area associated with GI endoscopic procedures? __ yes __ no--Thank you. You are finished with this questionnaire. 2. How long have you been employed in this field of nursing? 0-1 years __ 2-3 years __ 4-5 years __ 6 or more years 3. Do you assist physicians with: (please check all that apply) __ flexible sigmoidoscopy __ esophagogastroduodenoscopy (EGD) __ colonoscopy __ no procedures 4. The following are a list of activities that an advanced practice registered nurse might be responsible for in a GI endoscopy area. Please check all activities that you are currently responsible for. __ take health history from patient __ perform physical examination of patient __ order diagnostic studies on GI patients __ prescribe pharmacologic treatment for GI patient __ manage follow up care of GI patient __ discuss diagnosis and treatment plan with GI ~atient and family following GI procedure __ perform manometric studies __ perform acid perfusion studies 5. In some areas, APRNs are actually performing procedures. Do you perform: (please check all that apply) flexible sigmoidoscopy __ esophagogastroduodenoscopy (EGD) __ colonoscopy __ no procedures. Please skip to question #'1<. 6. Where did you receive training to perform the above procedures: __ Physician __ University and/or College ASGE approved course __ Self-taught 7. How many years have you been performing Gl endoscopic procedures? 8. Do you feel that APRNs should perform diagnostic Gl endoscopic procedures? __ yes no 9. Do you feel that APRNs should perfonn therapeutic Gl endoscopic procedures:? yes no 10. If you wanted [0 perfonn Gl endoscopic procedures, is training available to perfonn: 11. ( check that apply) yes no __ flexible sigmoidoscopy EGD __ colonoscopy Is this training with a: Physician ASGE course University and/or College other. Please list _______ _ 12. With your current experience, do you feel that you could competently recognize pathology in: (check all that apply) yes no __ flexible sigmoidoscopy EGD __ colonoscopy 30 13. Do you feel that you could competently perfonn flexible sigmoidoscopy with: (check all that apply) your current experience an ASGE mini course __ a fonnal training program at a university or college __ the proctoring of a physician for a number of cases other. Please .. ~." ____________ _ not at all 14. Do you feel that you could competently perform EGO with: (check all that apply) your current experience __ an ASGE mini course ___ a formal training program at a university or college __ the proctoring of a physician for a number of cases other. Please list ____________ _ not at all 15. Do you feel that you could competently perform colonoscopy with: (check all that apply) __ your current experience an ASGE mini course __ a formal training program at a university or college __ the proctoring of a physician for a number of cases other. Please list'--___________ _ not at all 16. How interested are you in performing GI endoscopic procedures? Place a vertical mark through the line indicating interest level. no interest very interested 17. Listed below are problems you might encounter in performing GI endoscopic procedures. Please rank in order with the most problematic being #1, next problematic #2 and so on. 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