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Bowel screening programme increases nursing skills: nursing skills will be in much demand, should the pilot bowel screening programme be rolled out nationally.

A four-year pilot programme to screen for bowel cancer was launched at Waitemata District Health Board (WDHB) last October. The goal is to determine whether organised bowel screening could be introduced in New Zealand in an effective, safe and acceptable way for the participants, while being both equitable and cost effective.

If/when bowel screening is rolled out nationally, many more skilled endoscopists and endoscopy nurses will be needed. The level of nursing intervention at colonoscopy is very high in the pilot programme and the nurses involved have been on a very steep learning curve.

A screening programme must show that early diagnosis and treatment increases people's chances of successfully treating or managing the disease. No screening test is 100 per cent accurate, which is why it is important to be screened at regular intervals. (1)

Bowel cancer is the second most common cancer in New Zealand and the second highest cause of cancer death. Our death rate from bowel cancer is one of the highest in the developed world. In 2008, 2801 people were diagnosed with bowel cancer, and 1280 people died from the disease. New Zealand has the third highest mortality rate in the OECD for women and the sixth highest for men. (2)

There is a strong association between the stage (extent) of bowel cancer at diagnosis and eventual survival Those with localised disease have a 95 per cent chance of a five-year survival. Those with distant spread (metastases) have only a 10 per cent five-year survival rate. (3)

The population in the WDHB area met the Ministry of Health's (MoH) criteria for the pilot programme, with an eligible population of 137,000, including European, Maori, Asian, Indian, Pacific and other groups. Residents aged 50 to 74, and who meet the criteria, are sent a letter inviting them to participate in the bowel screening programme (BSP). Four weeks later, if they have not opted out of the programme, they receive an immunochemical faecal occult blood test (iFOBT) kit which they complete at home and post to LabPlus in a specifically designed pre-paid envelope. The iFOBT is a specific and very sensitive test for human haemoglobin in the stool.

LabPlus enters the test results on the register and informs the participant's GP. The Takapuna co-ordination centre sends out letters informing participants with a negative result that they will be re-invited for screening in two years. GPs refer participants with a positive result to WDHB for colonoscopy. All screening colonoscopies are performed at Waitakere Hospital in a dedicated screening procedure room, by a team of endoscopists from the greater Auckland region.

As the clinical nurse specialist (CNS) for bowel screening, I contact participants who do not have a GP or who are not referred within 10 working days. All participants are pre-assessed and given an appointment for a colonoscopy. Participants with no histology are re-invited to screening in five years; participants with histology are managed according to New Zealand guidelines and may move onto the WDHB surveillance list; and participants with a lesion follow an appropriate treatment pathway.

Although it is too early to make assumptions from the limited numbers we have screened so far, we appear to have a high rate of adenoma detection, in comparison with some overseas screening programmes. This has a flow on effect, increasing the work load of existing endoscopy and surgical services, and it is being closely monitored and planned for.

CNS role continues to grow

My CNS role was poorly defined when I started with the programme late last year, but it has developed and grown, and continues to grow week by week! My nursing background has been varied. After five years working in both private and public endoscopy, I completed a postgraduate gastroenterology course through the Queensland University of Technology and applied for the CNS position with the BSP.

In spite of studying overseas programmes and endless planning, no one anticipated the diverse array of issues that crop up daily. My responsibilities include:

* Pre-assessment and referral management--identifying and managing complex cases with guidance from the Lead endoscopist. Liaising with primary care. Contacting participants and informing them of +iFOBT result when there is no GP involvement or a referral has not been received within 10 days of the result. Conducting a medical pre-assessment and booking participant for colonoscopy.

* Active follow-up and community/cultural support--we have a team of support workers, including Maori, Pacific, Chinese and Korean, who I refer to as appropriate.

* Policy and guideline development, and risk/incident management--I work closely with our quality lead to develop, implement and review BSP policies. I notify her of all incidents or identified risks, which she enters on the appropriate register. Following investigation, we implement improvements to resolve and prevent reoccurrences. We are looking at training senior nurses to interpret histology results so participants are informed in a more timely manner.

* Endoscopy unit--provide clinical support to the four other members of the BSP nursing team, including training and education sessions. Monitor quality and audit criteria in line with Moll guidelines. I also recruit and schedule endoscopists, maintain a record of their credentials and provide support around specific BSP processes.

* BSP Register--as a participant moves along the pathway, data is entered onto the register, including pre-assessment dates, diagnostic information, histology results and other investigation options.

* Nursing representation--I attend various BSP management and quality meetings as the nurse representative.

My role is diverse, evolving, sometimes surprising and always interesting. The demand for endoscopy nurses will inevitably increase and it is Likely their roles will expand to meet requirements. This may follow overseas examples of nurses becoming "nurse endoscopists" There is also going to be a need for more nurses to take up roles such as CNS within endoscopy.


(1) Ministry of Health, (2012) Governance of New Zealand Bowel Screening Pilot for 2012 and Future years, Provider%20Resource%20Guide_2012.pdf. Retrieved 18/06/12.

(2) Ministry of Health. (2012) Bowel screeing: check yourself out. Retrieved 18/06/12.

(3) Ministry of Health (2012) Final Service Delivery Model--Version 4.0. conditions/cancer-programme/bowel-cancer-programme. Retrieved 18/06/12.

Thelma Turner, RN, PGDip Gastroenterology, is the clinical nurse specialist on the bowel screening programme at the Waitakere Surgical Unit.
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Title Annotation:PRACTICE
Author:Turner, Thelma
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Jul 1, 2012
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