As I was reviewing the Society of Gastroenterology Nurses and Associates (SGNA) online discussion forum, I was surprised by the amount of interest in scope advancement by nurses and technicians. Several people were interested in developing competencies for scope advancement. Many nurses have been doing scope advancement for years and feel comfortable with this practice, whereas many gastrointestinal (GI) units are hiring new personnel who are not.
In my earlier years as a gastroenterology staff nurse, the gastroenterologists and surgeons I worked with advanced their own scopes. Unfortunately, one of the surgeons sustained a life-altering injury that ended his surgical career. He wanted, however, to continue to do endoscopic procedures in which he could manipulate the controls of the endoscope with one hand while someone else advanced the scope. Keep in mind these were the days before video endoscopy, and we could not see what the endoscopist was seeing. This caused quite a bit of debate about using staff to advance the scope.
As a result of this issue in our department, a great deal of investigation was done, and many other endoscopy units were queried about this topic. Some units did not allow anyone who was not a physician to advance the scope, whereas others thought scope advancement should be determined according to the unique skills and expertise of the individual doing the advancement.
Because the institution I worked for did not have a policy regarding this situation, we went to the Board of Nursing to see if they thought scope advancement was within the scope of nursing practice. The Board of Nursing reviewed our request and issued a Declaratory Ruling in which they said it was within the scope of nursing practice for a nurse to advance the scope if the nurse would visualize the lumen by means such as using a teaching head.
In 1991, SGNA issued a position statement (revised in 1998) that "supports the position that the gastroenterology nurse or associate educated and experienced in endoscopy may assist the endoscopist by manipulating the endoscope when required to facilitate an endoscopic procedure." The terms "educated" and "experienced" are terms the institution must define. The position statement also notes the person manipulating the scope must understand the possible complications of performing scope advancement and be aware of needed interventions if complications should occur. The position statement also noted "the nurse or associate manipulating the endoscope has full view of the lumen by way of a teaching head or video screen."
I suggest a competency for advancing scopes would need to address the following:
* For whom are you trying to validate this skill (nurse or technician)?
* Is this simply a skill that can be taught to anyone, or do you believe only a particular group should be given the responsibility for scope advancement?
* How much education or GI experience is needed? For instance, does having a nursing degree make someone competent to perform this skill, or does 1 year of experience in an endoscopy department determine competency? Do we assume with education or experience the person is knowledgeable, or would this be validated by testing?
Some areas to consider in competency testing are:
* Anatomy and physiology of the GI tract
* Possible consequences of scope advancement
* Management of complications
* Effect of medications and sedation on GI procedures (e.g., sedation decreases the pain threshold and can, therefore, contribute to perforation)
* Liability issues
* Documentation
A registered nurse or licensed vocational nurse practices under a license issued by the state in which he/she practices. A technician or medical assistant operates under someone else's license-either a physician or nurse. Malpractice issues would often be directed toward the person under whose license these acts were permitted. Do the supervising individuals wants to assume the liability? And if a nurse or technician is advancing the scope, is someone else monitoring the patient for sedation and assisting the physician during the procedure?
These issues must be considered in developing a competency for scope advancement in the practice setting. Remember, standards vary between states. You need to initially check with your Board of Nursing to see if scope advancement is within the scope of nursing practice; however, because technicians are not licensed, this requirement would not be applicable to them.
Check with your institution to see if it will support scope advancement by someone who is not a physician. Who will assume the liability in the event of a complication? Ideally, if I was practicing, I would request to have this agreement in writing.
Good luck, and do your research in the development of competencies. Remember, what is acceptable for one GI unit may not be practical or acceptable for another. We all want the best outcome for our staff and patients.