Post on 15-Dec-2015
Bone Marrow Biopsy Training For Nurses
Louise McNamaraMatron / Nurse Practitioner for Haemato-Oncology
Background
• Incidence of haem malignancies in Europe– ~230,000 / year
• Routinely need bone marrow biopsies– Diagnosis, staging, disease evaluation
• Settings– Haematology– Oncology
• Breast, lung, neuroblastoma
– General Medicine• Unexplained low blood counts, fungal disease, miliary TB
Benefits of nurse advanced practice
• Nurse led services in the UK encouraged– Dissatisfaction with traditional models– Junior doctors hours– Treatment waiting times– Nurses’ willingness to adopt advanced roles– NHS clinicians not competing for income– Attempts to improve patient experience /
quality of care– Increased patient satisfaction– Increasing patient numbers
Need new ways of working / professional boundaries blurred
Best opportunities for nurse-led services
• Low-risk areas / narrow spectrum of high tech care e.g. nurse endoscopist
– Improves efficiency– Enhances care– Little difference in
performance– Higher patient
satisfaction
The Haem-Onc setting
• BM’s traditionally performed by physicians• Better scheduling can reduce waiting times• Positive correlation between volume of
procedures undertaken and patient outcome
• Trainee doctors rotate• Senior nurses bring holistic approach• Nurses implement quality framework
– Operations, training, care package, consent, information, documentation
Definition
• Removal of haematopoietic tissue from medullary cavity of bone
• Involves 2 specimens: 1. Aspiration
• Cytologic preparation• cell morphology
2. Trephine• assess overall marrow
architecture• bone marrow cellularity• fibrosis• infections • infiltrative diseases
The RM experience
• Nurses perform – ~80 - 100 BM’s / month
• Nurse-led service – Started by a NP– Trained by physician
• Developed workbook – Underpin practice with theory
• Enquiries from nurses at other UK hospitals– BM training course for nurses
Course aim
• Theoretical knowledge
• Practical experience
• Ensure safe and confident practitioners– 2 days of theory and
simulated practice– 1 day observing clinical
practice
Theoretical framework
• Workbook– Key learning outcomes– Self assessment to
benchmark knowledge– Theoretical worksheets
• Indications• Anatomy and
physiology• Legal and professional• Patient preparation
and aftercare• Problem prevention
and resolution• Dealing with
complications
• Theory– RM manual of clinical
nursing procedures (2011)
– Additional reading list
• Practice assessment guide
• Practice supervisor and clinical manager
Competency
• Core competencies set out in workbook
• Trainee retains workbook as evidence
• Manager maintains central register
• Maintain ongoing competency against procedure guideline– Peer review– Annual audit– Annual appraisal
Course contentDay 1 (Classroom)
– What is a BM?• Definition,
indications, contraindications, A&P, site selection
– Legal / Professional• Competencies,
Regulations, Accountability, Consent
– Procedure prep• Equipment,
documentation, pharmacology, non-pharmacological support, patient education
–Workshop
Day 2 (Classroom)– Procedure guideline
– Problem-solving
– Post procedure care
– Complications
– Practical simulation
– Workbook review
Day 3 (Observation)– Patient preparation
– The anxious patient
– Education
– Consent
– Sedation
– Procedure guideline
Practical issues to consider
• Advanced nursing care policy?
• Stakeholders? – Potential resistors
• How will they agree competence?
• Job description?
• Service cover? – Contingency? – Succession planning?
• Environment
• Job plan
• Administrative support
• Further role development– Non-medical prescribing /
ALS– Administration of
medication with consideration to the law
Course evaluation
• To date– 3 courses– 15 delegates
• Feedback positive– Translating theory into practice– Ensuring they acquire competency to protect
patients and practitioners– Being trained by nurse colleague who
understands role– Simulated training
• Helps overcome fear and enables transition from assistant to practitioner
Conclusion
• Nurses can be supported to undertake BM’s and obtain specimens of satisfactory quality– Motivated staff– Structured training programme
• Nurse-led services are likely to be holistic– Able to identify patient needs not met in the past
• Likely to consider broader aspects of health care– Service management
• Justification of any new service must be thoroughly explored– Primary aim to improve patient care