1. Baker, Kathy A. PhD, RN, ACNS-BC, CGRN, FAAN

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Recent conversations with nursing colleagues in numerous practice venues have raised my awareness that not all of us recognize the opportunities we have as nurses related to our scope of practice. With the recent Institute of Medicine (IOM) (2010) report, The Future of Nursing: Leading Change, Advancing Health, the first of the four key elements deals directly with scope of practice issues. The first key element declares nurses should practice to the full extent of their education and training. Unfortunately, some states restrict nursing practice through antiquated laws that do not acknowledge the education and training that nurses obtain both prior to and after licensure.

Kathy A. Baker, PhD,... - Click to enlarge in new windowKathy A. Baker, PhD, RN, ACNS-BC, CGRN, FAAN

Physician organizations have been slow to recognize the importance of enabling all healthcare providers to practice to the full extent of their educational preparation and training, citing concerns about patient safety and quality. These groups fail, however, to cite the evidence that demonstrates other healthcare providers, particularly nurses, are also concerned about safety and quality in the delivery of patient care, resulting in high patient satisfaction and cost effective, quality outcomes (Budzi, Lurie, Singh, & Hooker, 2010; Conlon, 2010; Jennings, Lee, Chao, & Keating, 2009; Laurant et al., 2005).


For example, in looking at the contributions that advanced practice nurses could make to minimizing the access to care challenges rampant in the United States, it is inexcusable to see the number of states that present regulatory barriers to advanced practice nurses despite the fact there are no data to suggest that advanced practice nurses who practice in restrictive states provide safer or better care than those in less restrictive states. In fact, no state that has empowered advanced practice nurses to practice to the full extent of their educational preparation and licensure has rescinded that decision due to poor patient outcomes from care delivered by advanced practice nurses. And, there is no evidence to suggest that expanding a nurse's scope of practice to be consistent with educational preparation and training negatively impacts a physician's economic status (the real issue, I think, behind the physician organizations' fight to prevent enactment of full scope of practice for nurses).


In the state of Texas, where I reside, for example, dozens of rural Texas counties have no primary care doctors, no hospitals, and no pharmacies. In two of these counties, advanced practice nurses attempted to open clinics to deliver primary care to these underserved areas; yet, because Texas laws require nurse practitioners to have a "supervising physician" (note: these "supervising" physicians charge unrealistic fees to "supervise" advanced practice nurses who are already educated and fully licensed to provide primary care to patients) and no physician was willing to drive from their county to the clinic in the underserved county to provide this regulated supervision, these clinics were unable to open-a tragedy for the citizens who live in these counties and a waste of educational preparation for these advanced practice providers who are capable and committed to caring for the underserved. Instead, advanced practice nurses are limited to practice in environments where physician "supervisors" are not inconvenienced to oversee the advanced practice nurses' delivery of care.


In our own specialty, the literature demonstrates that nurse endoscopists deliver safe, highly satisfying, quality care (Maruthachalam, Stoker, Nicholson, & Horgan, 2006; Maslekar, Hughes, Gardiner, Monson, Duthie, 2010; Meaden, Joshi, Hollis, Higham, & Lynch, 2006; Schoenfeld et al., 1999), yet few nurse endoscopists are seen in gastroenterology settings across the United States. Why are nurse endoscopists not being utilized to provide endoscopic services to patients with low risk, facilitating timely access to endoscopic care? And are these nurses reimbursed appropriately for the care they deliver?


I understand the argument that teaching hospitals need to provide training opportunities for gastroenterology fellows, but even in these settings, patient wait lists for basic endoscopic screening usually extend for 6 months or longer. This is unacceptable when studies have demonstrated that safe, effective care can be provided in our healthcare system using other healthcare providers, often at lower costs. Capsule endoscopy is another area where the literature supports that nurses can facilitate faster, cost-effective delivery of care through reviewing and identifying abnormalities noted on exam (Bossa, Cocomazzi, Valvano, Andriulli, & Annese, 2006; Dokoutsidou et al., 2011; Sidhu et al., 2011; Riphaus, Richter, Vonderach, & Wehrmann, 2009).


Nurses have the educational preparation and commitment to assist in improving access to care for the citizens of the United States while minimizing costs. Our discipline has always been collaborative in nature so that practicing to the full extent of our scope of practice does not mean we intend to practice in isolation. Indeed, I think our current practice in the endoscopy setting demonstrates nurses' collaborative nature, asking other healthcare providers for input or opinions regarding a particular patient issue and, in turn, offering our input and opinion when other healthcare providers need advice or validation for a decision they need to make regarding patient care. Nurses do not seek to replace physicians; they do want to be part of the solution to an overwhelming problem of lack of access to care in our country.


Each healthcare provider has selected and prepared educationally for the discipline they chose as their life's work. Differences in our scope of practice delineate these choices and allow each of us as members of the healthcare team to bring our unique philosophies, skills, and expertise to the healthcare setting as we provide safe, quality care for the patients we serve. Extending or supporting current scope of practice for nurses, however, does not negate the value of other healthcare providers; it does improve access to care and assure safe, cost-effective delivery of quality of care to the right person at the right time.


Gastroenterology nurses must be actively engaged at the local, state, and national levels to influence scope of practice regulations and educate society on the educational preparation, training, and contributions that nurses make to the delivery of safe, cost-effective quality care, particularly when we are empowered to do so. Don't forget the importance of practicing to the full extent of your scope of practice considering your educational preparation and licensure. Stay current on issues affecting nursing regulation and reimbursement in your institution as well as at the state and national level. Look for opportunities to maximize your scope of practice-not so that nurses can say they have attained a certain status in healthcare, but because our patients deserve timely access to safe, cost-effective, quality of care.




Bossa F., Cocomazzi G., Valvano M. R., Andriulli A., Annese V. (2006). Detection of abnormal lesions recorded by capsule endoscopy. A prospective study comparing endoscopist's and nurse's accuracy. Digestive and Liver Disease, 38(8), 599-602. [Context Link]


Budzi D., Lurie S., Singh K., Hooker R. (2010). Veterans' perceptions of care by nurse practitioners, physician assistants, and physicians: A comparison from satisfaction surveys. Journal of the American Academy of Nurse Practitioners, 22(3), 170-176. [Context Link]


Conlon P. (2010). Diabetes outcomes in primary care: Evaluation of the diabetes nurse practitioner compared to the physician Primary Health Care, 20(5), 26-31. [Context Link]


Dokoutsidou H., Karagiannis S., Giannakoulopoulou E., Galanis P., Kyriakos N., Liatsos C., Faiss S., Mavrogiannis C. (2011). A study comparing an endoscopy nurse and an endoscopy physician in capsule endoscopy interpretation. European Journal of Gastroenterology & Hepatology, 23(2), 166-170. [Context Link]


Institute of Medicine (IOM). (2010). The future of nursing: Leading change, advancing health. Washington, DC: Author. [Context Link]


Jennings N., Lee G., Chao K., Keating S. (2009). A survey of patient satisfaction in a metropolitan emergency department: Comparing nurse practitioners and emergency physicians. International Journal of Nursing Practice, 15(3), 213-218. [Context Link]


Laurant M., Reeves D., Hermens R., Braspenning J., Grol R., Sibbald B. (2005). Substitution of doctors by nurses in primary care. Cochrane Database of Systemic Reviews, 2, CD001271. [Context Link]


Maruthachalam K., Stoker E., Nicholson G., Horgan A. F. (2006). Nurse led flexible sigmoidoscopy in primary care: The first thousand patients. Colorectal Disease, 8(7), 557-562. [Context Link]


Maslekar S., Hughes M., Gardiner A., Monson J. R., Duthie G. S. (2010). Patient satisfaction with lower gastrointestinal endoscopy: Doctors, nurse and nonmedical endoscopists. Colorectal Disease, 12(10), 1033-1038. [Context Link]


Meaden C., Joshi M., Hollis S., Higham A., Lynch D. (2006). A randomized controlled trial comparing the accuracy of general diagnostic upper gastrointestinal endoscopy performed by nurse or medical endoscopists. Endoscopy, 38(6), 553-560. [Context Link]


Riphaus A., Richter S., Vonderach M., Wehrmann T. (2009). Capsule endoscopy interpretation by an endoscopy nurse: A comparative trial. Zeitschrift Fur Gastroenterologie, 47(3), 273-276. [Context Link]


Schoenfeld P., Lipscomb S., Crook J., Dominguez J., Butler J., Holmes L., Cruess D., Rex D. G. (1999). Accuracy of polyp detection by gastroenterologists and nurse endoscopists during flexible sigmoidoscopy: A randomized trial. Gastroenterology, 117(2), 312-318. [Context Link]


Sidhu R., Sanders D. S., Kapur K., Marshall L., Hurlstone D. P., McAlindon M. E. (2007). Capsule endoscopy: Is there a role for nurses as physician extenders? Gastroenterology Nursing, 30(1), 45-48.

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