Enhancing Collaboration in the Endoscopy Suite: Challenges, Perspectives, and Solutions.

Introduction

As the field of gastroenterology has evolved in recent years, one constant to providing excellent patient care has been the effective collaboration between physicians and nurses in the endoscopy suite. The endoscopy suite is a unique collaborative environment, with multiple providers equipped with different skillsets, all working toward the common goal of a safe and effective endoscopy procedure. Though some endoscopic procedures can be completed with only a physician and nurse present, often there may be the addition of an anesthesia team which may include a certified registered nurse anesthetist (CRNA) and additional nurses, endoscopy technicians, and trainees. The presence of such a complex team requires all team members—led by the gastroenterologist and endoscopy nurse in the suite—to devote particular attention to effective collaboration to achieve the best possible clinical outcomes. In this paper, we describe the difficulties in attaining this level of collaboration before sharing our perspectives on optimizing the physician–nurse relationship in the endoscopy suite and opportunities to further improve this partnership.

Challenges to Effective Collaboration in Endoscopy

One of the greatest challenges to effective collaboration in the endoscopy suite is the pressure to complete procedures within the time allotted, which can increase stress and strain relationships among endoscopy team members. Other constraints can also affect the quality of patient care, such as when the schedule does not allow adequate time for providers to discuss findings and next steps with patients [1]. The presence of a gastroenterology fellow adds another efficiency consideration, in addition to adding challenges regarding the familiarity between nurses and fellows, trust during the procedure, and effective communication among the team.

Differences in personality, communication style, and training backgrounds are common in the endoscopy suite. As a result, the suboptimal relationships between nurses and physicians that may form not only create an unwelcome working environment, but can also directly impact patient care. For example, nurses may be less willing to speak up when the patient has a clinical status change if there is a poor relationship between the physician and nurse [2]. Further, since new challenges to effective collaboration will continue to arise, such as the COVID-19 pandemic, it is of utmost importance to adopt robust and flexible best-practices for endoscopy collaboration that can mitigate these challenges [3].

A Fellow’s Perspective (RF)

When starting gastroenterology fellowship, I initially found the endoscopy suite to be an unfamiliar and daunting place that soon became one of the most exciting and educational loci of my entire medical training. I found the most important aspect to a safe learning environment was the dedication of both the attending and nurse to set expectations, ensure clear direction and communication, and provide high-quality teaching during the procedure. Specific successful techniques include a pre-sedation huddle to discuss necessary equipment and anticipated challenges, closed-loop communication (the recipient acknowledging the receipt of information and clarifying with the sender that the received information is the same as the original information) during complex coordinated tasks such as snare polypectomy, and explicit discussion of post-procedural steps. At the start of an endoscopy session, I always introduce myself to the nurse if I have not worked with them before and ask how I can be most helpful throughout the session—particularly by facilitating discussion of preferences before, during, and after the procedure and setting expectations for responsibilities throughout. Nurses have frequently contributed to my learning by pointing out inconspicuous polyps, offering tips or techniques they have seen from other endoscopists, and troubleshooting malfunctioning equipment. By keeping an open mind and accepting feedback from nurses, I have certainly grown to be a better endoscopist. Over time, I have formed close relationships with many of the nurses in our department through working with them during multiple procedures, experiencing challenging cases or complications, and building upon previous experiences. This longitudinal building of trust and mutual understanding provides the basis for many fulfilling work relationships with my nursing colleagues.

An RN’s Perspective (CW)

Over the past 30 years as an endoscopy nurse, I have realized that two of the most important contributors to my success have been obtaining GI nursing training and prioritizing collaboration in the endoscopy suite. When I first started in endoscopy, I immediately began working toward the Certified Gastroenterology Registered Nurse (CGRN) credential offered through the American Board of Certification for Gastroenterology Nurses (ABCGN). This process takes two years and requires a certification examination covering four domains: general nursing care, gastroenterological procedures, patient care interventions, and environmental safety and infection prevention and control. This certification along with becoming the President-Elect of ABCGN has kept me connected to the wider nursing community and has ensured quality training and patient care.

In addition to my CGRN certification and training, there are a variety of steps I take in the endoscopy room during every procedure to ensure effective collaboration with my team. By speaking with the physician prior to the procedure and listening to the consent process, I can ensure that the room is ready with all necessary equipment. Using closed-loop communication, being present next to the patient’s bed, limiting unnecessary distractions, and focusing on the procedure are all important steps to ensure effective communication and quality patient care. Being an active participant in the patient’s care and forming meaningful relationships with my physician colleagues have been two of the most satisfying parts of my job.

An Attending’s Perspective (NK)

One of my favorite parts about being an attending gastroenterologist is the opportunity to develop meaningful longitudinal connections with the staff in the endoscopy suite. It brings great satisfaction to not only know your patients well but also the team with whom you work—and this is certainly true in the procedure room. Developing these positive relationships, however, does not just naturally happen over time—you must work at it, just as you would with any other relationship. For me, this starts with gaining an appreciation for all the work that needs to occur for my procedure to go smoothly. I am constantly amazed by the amount of work our nurses do before, during, and after a procedure to ensure the patient receives the highest quality of care. As an early attending, I would pay close attention to each of these nursing tasks so that I could better understand their many obligations, identify rate-limiting steps to finishing on time, and finding areas where I could help. For example, I quickly learned that by pre-washing the upper endoscope during the “turn” of a double procedure and setting up the colonoscope myself, I afforded the nurse the time to focus on preparing the patient for the lower procedure and catch up on documentation. As a result, the nurse was ready to assist me throughout the second procedure and had less documentation to complete at the end, which decreased turnover time. Above all, it demonstrated my willingness to help and my appreciation for all the nurse was doing for our patient. By starting from this foundational level of respect for nursing and the work of the endoscopy staff, I have been able to work most effectively in the endoscopy suite while also developing meaningful relationships with each of them.

Opportunities for Enhancing Collaboration

Though effective collaboration can be defined in many ways, common themes in the literature include shared decision making, teamwork, and communication [2, 4]. Although challenges to effective collaboration persist, there are many opportunities to enhance collaboration in the endoscopy suite (Table 1). Building a positive departmental culture and strong personal relationships between the nurses and physicians is of the utmost importance since this is the basis for collaboration during endoscopy procedures. Specific methods of achieving this positive culture include shared professional development activities, social gatherings, and integrated leadership positions for both nurses and physicians in the endoscopy unit. Research and quality improvement projects at academic centers should include contributions from nurses, given the unique perspective and training that they can provide to these initiatives. As highlighted in our perspectives, dedicated pre-procedure discussions about the procedural plan, closed-loop communication, and effective use of every team member’s time can greatly improve procedural efficiency and lead to improved working relationships.

Table 1

Challenges to effective collaboration in endoscopy and potential solutions

Challenge	Solution
Large complex team with different training backgrounds	Ensure all providers in the room have been introduced prior to the procedure; can be done during procedural timeout
Complex multistep procedures with risks for miscommunication	Closed-loop communication at all times for every step of a complicated procedure (e.g., hot snare polypectomy)
Limited time and need for balance of efficiency vs. teaching for GI fellows	Explicit expectations between all providers about anticipated time needs and time limits for fellow involvement in a procedure (e.g., 10 min to reach the cecum before attending controls the colonoscope)
Lack of familiarity between providers in a large academic setting	Shared professional development initiatives and social gatherings
Novel or unanticipated challenges (e.g., COVID-19 pandemic)	Ongoing study of effective strategies via continuous quality improvement projects with MD and RN representation

Conclusion

Effective collaboration in the endoscopy suite between physicians and nurses can improve patient care and job satisfaction. Despite persistent and novel challenges, departments should focus on building a culture of safety and mutual respect, which promotes teamwork and shared responsibility. By developing longitudinal relationships and having a shared experience, physicians and nurses can better understand how they can effectively collaborate during an endoscopy procedure.

Key Messages

There are persistent and novel challenges to effective collaboration between physicians and nurses in endoscopy.

Specific strategies such as pre-procedure discussions, closed-loop communication, departmental social gatherings, and QI initiatives can be used to improve collaboration in endoscopy with the goal of improving endoscopic outcomes.