Patient satisfaction and safety in the administration of sedation by nursing staff in the digestive endoscopy service: a cross-sectional study

Gastrointestinal (GI) endoscopy is an essential technique for the diagnosis and treatment of diseases of the digestive system. This method significantly reduces the incidence and mortality of cancers such as colorectal and gastric cancer [1, 2]. As an invasive procedure, however, it can cause significant discomfort. While the use of sedatives such as propofol has improved patient comfort, certain barriers still hinder its widespread adoption. These include concerns about sedation and its side effects, as well as anxiety about the diagnosis and the procedure itself [3]. These concerns, which can increase the use of sedatives and complicate the procedure, underscore the importance of proper evaluation and management of patient anxiety before gastrointestinal endoscopy [4].

Sedation has become a standard practice in digestive endoscopy, ensuring both patient comfort and procedural effectiveness. In this context, the role of the nurse in the administration of sedation is crucial, but it also has specific challenges and responsibilities [5]. Traditionally, sedation was administered by anesthesiologists, but the increasing demand for endoscopic procedures has led to a shift, with nurses increasingly assuming this role [6]. This shift underscores the growing need for specialized training to ensure nurses administering sedation in digestive endoscopy acquire the necessary skills, especially in the environment of digestive endoscopy [7]. According to Sneyd [8], another important aspect is the legal framework that constrains the practice of sedation by nurses.

The role of the nurse anesthetist has evolved significantly, playing a crucial role in the administration of anesthesia and pain management [9]. The nurse anesthetist is an advanced practice nurse who, after specific training and certification, is trained to provide anesthesia in a variety of clinical settings [10]. Their responsibilities encompass pre-procedural assessments, intra-procedural care, pain management, and post-anesthesia recovery, ensuring patient safety throughout the process [10]. Nurse anesthetists work in diverse settings, including hospitals, ambulatory surgical centers, and clinics, providing care for a wide range of procedures across specialties such as gastrointestinal, cardiac, and trauma surgeries [9, 10].

In the case of Spain, the competences and functions of anesthesia nurses were defined by the Spanish Association of Anesthesia, Resuscitation and Pain Therapy Nurses (ASEEDAR-TD) as those of a specialist nurse [11]. These competencies of nurse anesthetists in Spain coincide to a large extent with those defined by the International Federation of Nurse Anesthetists [12]. Currently, different universities in Spain offer postgraduate training with a Master’s degree in the field of anesthesia, resuscitation and pain therapy. However, although the speciality is not recognised, there is a large number of nurses working in the field of anesthesia and their functions and competences include pre-anesthesia assessments, perioperative nursing, sedation outside the surgical area, resuscitation units, acute pain units and chronic pain units, coinciding with the role of a nurse specialist [12, 13].

Nurse prescribing in Spain is regulated and does not include the drugs needed for sedation. Some scientific societies (especially those in Gastroenterology) have developed their guidelines/protocols, unlike those referring to anesthesiology. Training is also not regulated in Spain, which is a pending issue, as there are established criteria by the International Council of Nurses and the International Federation of Nurse Anesthetists [11‐13].

Nurses’ interventions in this context go beyond the simple administration of drugs, encompassing preprocedure evaluation, continuous monitoring and management of possible complications, and control of pain and sedation during the procedure [14, 15]. This is because acute pain can trigger an inflammatory response to stress, negatively affecting the patient’s progression [16]. In fact, current clinical practice guidelines recommend prioritizing sedation strategies based on analgesia and the administration of minimal doses of sedatives, with the aim of maintaining superficial or conscious sedation [17].

Safety and patient satisfaction are key metrics for assessing the quality of digestive endoscopy services. Regarding safety, ensuring minimal complications associated with nurse-administered sedation. Serious complications are relatively rare but require a high level of preparation and rapid response by the nurses involved [18]. The complications include risks of cardiopulmonary events such as hypoventilation, respiratory depression, apnea, hypotension, and bradycardia [19]. In this sense, sedative medications can cause muscle relaxation, compromising the ability to keep the airways open, while painkillers, especially opioids, can slow breathing. These complications can lead to hypoxemia, which if not detected and corrected in time can result in permanent damage to vital organs or even death [20].

Patient satisfaction is another crucial metric of the quality and successful nurse-administered sedation. Patient satisfaction is measured through post-procedure surveys, assessing aspects such as comfort during sedation and the quality of information provided before and after the procedure. Patients receiving sedation by nurses span a broad spectrum, from individuals with chronic conditions, including chronic diseases such as diabetes or heart disease, to acute cases. These patients may require sedation for a variety of procedures [21, 22]. Patients sedated by competent nurses report high levels of satisfaction and low perceived pain during the procedure [23]. Hoshijima et al. [24] reported that sedation-induced amnesia may be a contributing factor to greater patient satisfaction. In fact, it is recommended that nurses invest adequate time in offering personalized verbal advice, adapted to the educational level of the patient, to reinforce their understanding before undergoing an endoscopic procedure [25].

As we can see, sedation by the nursing staff play a central role in both maintaining safety and achieving high satisfaction levels. One of the most frequently performed diagnostic and therapeutic tests requiring sedation are digestive endoscopies. In Spain, although the nurse usually performs sedation in endoscopy services, few studies have been carried out in a representative sample to analyze the satisfaction of these patients with the care received and safety in the administration of sedation by nursing staff [26, 27]. Therefore, it is necessary to know the satisfaction of patients and safety with the administration of sedation in digestive endoscopies in a representative sample.

The main objective of this study was to determine the levels of patient satisfaction with the practice of sedation by the nurses in digestive endoscopies. The secondary objectives were to determine the safety of sedation practice by analyzing complication rates and doses used for sedation in endoscopic procedures.

The reference population was adult users over 18 years of age who attended the digestive endoscopy service of Toledo University Hospital to perform endoscopies with sedation.

The inclusion criteria were as follows:

The exclusion criteria were:

The study was carried out at the University Hospital of Toledo, located southeast of the city of Toledo (Spain). It is a third level hospital inaugurated in 2020, designed to offer advanced and accessible healthcare services, with technologically equipped facilities and ample space for medical care.

The study area was the endoscopy service of Toledo University Hospital. In this service, endoscopies are performed (gastroscopies, colonoscopies, and digestive echo endoscopies) with sedation by the endoscopy staff only on those over 18 years of age. Therefore, the study population was all legal adults.

The sampling was carried out with the GRANMO program for population estimation, taking as a reference the previous study by Veldhuijzen et al. [31], in which users reported a total satisfaction score of 79.6 out of 100 points. Therefore, a random sample of 278 individuals would be enough to estimate, with a confidence of 95% and a precision of ± 5% points, a population percentage that will foreseeably be around 79.6%. A replacement rate of 10% was established. However, to ensure the representativeness of the sample, 660 people finally participated. Consecutive sampling was carried out until the desired sample was reached.

In our study, the vast majority of patients were satisfied with the sedation administered by nurses in digestive endoscopy. Patient satisfaction with digestive endoscopy services with sedation administered by nurses is positive, as has also been shown by other previous studies carried out by has been found to be positive, as in previous studies [24, 25, 27, 37, 38]. Although these studies were carried out in other countries and had different geographical distributions and used different tools, the results were similar, so it would be important to implement universal tools to make comparisons. This high patient satisfaction with the technique applied by nurses may reflect the efficacy and acceptance of the practice of sedation administered by nurses. These results align with those of Minciullo and Filomeno [39], who reviewed patient satisfaction in digestive endoscopy and obtained the same results: patient satisfaction and a low number of acceptable complications.

However, there are studies that have applied new technologies, such as the use of educational videos, to improve patient satisfaction in digestive endoscopies. In fact, recent studies have shown that patients who viewed videos were more satisfied than patients who only received standard information. These results suggest that educational videos can be an effective tool for improving patient satisfaction with endoscopy [40]. Another study implemented virtual reality in children between 5 and 16 years old who underwent upper-digestive endoscopies, reducing pain by the use of virtual reality and registering a high degree of satisfaction [41].

Though patient satisfaction is a crucial indicator of quality of care, it is influenced by numerous factors, including personal and contextual factors such as bowel preparation for colonoscopy, hours of fasting, therapeutic procedures, the performance of the techniques by residents and/or students, the degree of baseline anxiety, the lack of knowledge, and the unsafe environment, among others [42]. Patient satisfaction is also closely related to waiting times, both waiting for the day of the appointment and waiting on the day of the procedure itself, as was the case in similar studies [26, 31, 42, 43]. Long times lead to a lower satisfaction that can affect the overall assessment. In this sense, the adoption of measures to solve these problems should be valued, such as working on the management of agendas.

Regarding safety, the anesthetic of choice was 1% propofol, with minimal complications (2%). The most common complication being transient desaturation, similar to others [37], where the percentage of complications was slightly higher at 3.05% and the most common complication was also transient desaturation and lower than others [44, 45], where the percentage of complications was 16%. With these data we can indicate that the practice of nurse sedation is a safe practice, as also indicated by other studies [46].

Regarding the use and doses of propofol, there are various methods for administering propofol for sedation by nurses in endoscopic procedures that depend on the duration of the examination, the complexity of the examination, and the personnel available in the unit [44]. In our study, the only anesthetic used was 1% propofol, with differences between the doses administered according to the procedure. These dose variations are influenced by multiple factors, including patient characteristics (age, weight, comorbidities due to associated diseases), the complexity of the procedure, and institutional policies. This percentage is above that of some studies and below that of others [37]. The use of other types of drugs in combination with propofol, such as midazolam and lidocaine, does not indicate the type or complexity of the test performed or the characteristics of the patient, so it is difficult to compare. Some studies have used lower doses of propofol in combination with other sedatives or analgesics to achieve a synergistic effect [5]. This practice seeks to reduce the side effects associated with higher doses of propofol, such as respiratory depression. The choice of sedative and the depth of sedation must be carefully considered to maximize patient satisfaction. Other studies indicate that the use of alternative drugs to propofol, such as fospropofol and ciprofol, show promise [2]. Fospropofol offers a slower onset of action and less pain during application, while ciprofol is characterized by a rapid onset of action and a lower incidence of pain at the injection site. Additional studies are needed to determine the most recommended doses and anesthetics needed to improve patient safety and comfort.

Continuous monitoring of the patient during sedation is essential to adjust the dosage of propofol and to intervene quickly in cases of complications, such as respiratory or hemodynamic depression. The experience and training of the nursing staff who administer propofol are crucial to ensure safe and effective sedation. Nurses should be trained in the management of respiratory and cardiovascular emergencies associated with sedation [2]. However, the role of nursing in endoscopy sedation has been widely studied and documented in the literature. Nurses play a crucial role in the administration and monitoring of sedation, ensuring the safety and comfort of patients during the procedure. In clinical practice, nurses are responsible for assessing the patient’s condition before the procedure, preparing and administering sedative medications, and constantly monitoring vital signs and the patient’s response to sedation [46, 47]. The training and experience of nurses in the administration of sedatives and in the management of possible complications are vital for the success of endoscopic procedures. In fact, the Spanish Association of Digestive Endoscopy provides doctors and nurses of digestive endoscopies with the necessary training through courses that it organizes in different Spanish hospitals throughout the year [44]. The participation of nurses in the recovery phase of patients is also a fundamental aspect of their role. They monitor the patient’s recovery from sedation by evaluating their ability to return to normal activities [39, 48‐51].

As implications for clinical practice, this study has shown that patients are satisfied with the sedation offered by the nurses of the digestive endoscopy service. This can help to improve the quality of care and patient safety, since, as we have seen, the complications of the procedure were minimal. Likewise, this satisfaction also helps nurse-patient communication, which can lead to greater trust and cooperation. Likewise, knowledge of sedation techniques can help in designing interventions to reduce anxiety. Likewise, efficient sedation administered by nursing staff can reduce the need for more specialized staff and free up resources. Finally, further progress is needed to create regulations and policies to regulate the practice of sedation by nurses and to advance the specialty of nurse anesthetists.

User satisfaction with the sedation done by nurses for endoscopy was high. This indicates that patients are satisfied with the service received. The drug used for sedation was 1% propofol in all the examinations and there were minimal complications (2%). Regarding the diversity of patients treated, they had different comorbidities, and a high percentage took medication daily. Based on the results, sedation administered by nurses in the endoscopy service is a safe and effective technique since there are few complications.

Future studies should be done in different geographical areas with the same tools to globally assess patient satisfaction. Such studies would allow us to detect opportunities for improvement, seeking solutions to the problems encountered and therefore improving the quality of services.

Patient satisfaction is one of the key pillars of quality care management programs. It should be taken into account that satisfied patients better comply with the indications and follow-up and better tolerate the different treatments, while patients dissatisfied with the care received may suffer anxiety and stress, making them not respond fully or correctly to the proposed treatments.

This study highlights the satisfaction of patients with sedation by nursing staff. Although no European or international regulations regulate the competences of the administration of sedation by nurses in digestive endoscopy services, some recommendations and quality standards have been developed by different European scientific organizations and societies, such as the European Society of Gastrointestinal Endoscopy and the European Society of Gastroenterology and Endoscopy Nurses and Associates. These recommendations and standards address aspects such as the training and competence of personnel, the criteria and procedures for sedation, the monitoring and safety of patients, and the documentation and recording of data. The application of such recommendations depends on the legislation and practice of each member country of the European Union. Therefore, formulators of health policies must write specific legislation so that nurses can administer sedation in this service legally internationally.