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

Questions?