According to former IBMS transfusion science specialist advisor Joan Jones, there are many benefits to patients from nurse-led transfusion care she outlines. “Nurse prescribing of blood components has the potential greatly to improve the patient experience. The framework document provides robust governance to help ensure that those nurses and midwives who wish to undertake this role practise safely. It is hoped that biomedical scientists in particular will embrace this opportunity of being key enablers in helping their nursing colleagues extend their roles within this field.”
To further understand the background to this development, Pathology in Practice spoke recently to both Liz and Jan to gain greater insight into the initiative and its likely impact on the transfusion profession.
Jan Green is an experienced haematology nurse who has worked for the NHS Blood and Transplant (NHSBT) transfusion liaison team for the past six years. Jan’s role entails supporting the initiatives of the Better Blood Transfusion Health Service Circulars, thereby promoting the safe and appropriate use of blood. Additionally, Jan supports hospitals with information, facilitates local study days and arranges regional education events and transfusion meetings. Jan sees herself as a conduit for information between transfusion practitioners, the blood service and the regional blood transfusion committee.
Liz Pirie is transfusion education specialist and team leader with the Scottish National Blood Transfusion Service (SNBTS) Better Blood Transfusion team. Liz has a varied clinical background with experience in vascular surgery, intensive care, haematology and infection control. Liz also supports initiatives aimed at driving forward improvements in safe and appropriate use of blood, a role within which she also has special responsibility for the development of education resources for transfusion.
PIP What prompted this framework document and what were your personal involvements?
LP The background to the framework document was a three-year collaborative project between NHSBT and SNBTS to explore the feasibility of nurses and midwives prescribing blood components. The project was in response to reports of fragmentation in care, treatment delays and concern over the safety of patients who required blood transfusion support. Our role was to lead the project and our fist step was to identify current practice and to canvas the opinion of doctors, nurses and midwives on this role development.
To do this we undertook a UK wide survey. The results identified that in relation to normal practice, nurses were undertaking many aspects of transfusion care. They assessed the patient’s clinical needs and transfusion requirements, influenced the decision to transfuse, made referrals and admission arrangements, but were unable to actually prescribe the component. The survey also identified that there was support for further investigation into this role development.
JG During the course if our initial investigations we also identified ambiguity in the status of blood components and conflicting advice about whether or not nurses and midwives would be permitted to undertake this role. To take this forward together we enlisted on the Royal College of Nursing (RCN) political leadership programme. This gave us access to advisors who worked with us to find the answers to these issues. Legal advice was received from the RCN and the Medicines and Healthcare products Regulatory Agency (MHRA), who clarified that the 1968 Medicines Act had been amended by the recent Blood Safety and Quality Regulations (BSQR 2005). The effect of this amendment was to exclude human blood and blood components from a legal definition of medicinal products, resulting in there being no legal barriers to appropriately trained nurse or midwife undertaking this role.
Our next step was to issue a briefing paper to all key stakeholders, suggesting the development of a governance framework to support nurses and midwives undertaking this role. A multidisciplinary workshop was set up to consult on the content of the document. The workshop took place in October 2008 and was attended by practitioners and representatives from the RCN, Nursing Midwifery Council (NMC), Royal College of Midwives, British Blood Transfusion Society, Serious Hazards of Transfusion (SHOT) scheme, Department of Health, the British Committee for Standards in Haematology, BBTS Professional Affairs and Education Committee, National Blood Transfusion Committee (England) Regional Transfusion Committee (Northern Ireland) and the Welsh Clinical Advisory Group.
PIP Why would you say it is necessary for nurses and midwives to able to prescribe blood components for patients? What, in your opinion, are the advantages?
LP Reports of fragmentation in care, treatment delays and concern about the safety of patients receiving blood transfusion suggest that we should consider different ways of providing transfusion care. Over the past 20 years, nurses and midwives have led the way in practice development and there are now nurses who have advanced skills working in many diverse fields. Using the untapped knowledge and expertise of these experienced nurses and midwives, some of the issues identified could be addressed. The SHOT scheme has reported cases where patients have received inappropriate or unnecessary transfusions, highlighting the fact that decisions about transfusion had been made without adequate basic knowledge or experience. The nurse or midwife with advanced skills also brings advantages to the wider team; for example, providing stability to rotating teams, acute assessment and problem-solving skills, the ability to respond rapidly and initiate interventions to adverse events and supporting the clinical team.
PIP Are their any drawbacks that you can foresee with this development? For example, what about training and legal or indemnity considerations?
JG Legally, the concern is not whether a task or activity is carried out by a doctor, nurse or midwife (except where there are statutory requirements), it is whether or not the patient received care to the expected standard. Standards of conduct, performance and ethics for nurses and midwives state that they are accountable for their actions or omissions in practice and must always be able to justify decisions, regardless of advice or directions from other professionals. Currently, nurses and midwives are covered for vicarious liability by their employer and it is recommended that the registered nurse and midwife advising, treating and caring for patients has additional professional indemnity insurance by means of membership of a professional organisation or trades union. As this is a new initiative, there is no education programme available, but this has not hindered role development in other areas of practice.
Educational needs were met by the individual practitioner working with a clinical mentor within their specialty to identify their learning needs and develop a learning plan to meet any knowledge gaps. The nurse or midwife then develops a portfolio of evidence to demonstrate that competences have been met; however, there must also be a period of mentorship and clinical supervision.
PIP Patient safety is obviously the overriding concern. Can you foresee any problems in this area, and is patient selection criteria a factor?
LP Ensuring the safety of patients is one of the most important challenges facing health professionals today, which is why the framework document supports service development only where patient care is improved without compromising patient safety. Patient selection criteria are outlined in the document; however, it was agreed that ownership of this role development belongs to the staff in each clinical specialty. It is their responsibility to explore the potential role development with their clinical team and other key stakeholders (eg line manager, Director of Nursing or supervisor of midwives, medical consultant) to ensure that change to service delivery is appropriate, and that there is agreement and support for implementation.
The document states that to deliver high-quality and safe care, nurses and midwives must demonstrate that they have the requisite knowledge and skills, there must be clinical governance procedures, and risk management strategies must be in place. There must also be an evaluation strategy built in to the proposal for service development, as this will assist with the process of continuous quality improvement, ensuring that the service is monitored and reviewed.
PIP What about informed consent? Do you see this being an issue for certain patients?
LP The issue of consent for blood transfusion is currently being considered by the Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO). Although to obtain written consent for transfusion is not a legal requirement, the nurse and midwife must practise in accordance with local policy and national guidance. Obtaining valid consent for treatment is a matter of common courtesy between health professionals, patients and their carers, and this forms an essential part of explaining the benefits of the treatment and ensuring that the patient is aware of any risks and available alternatives. However, there will always be some patients unable to give consent (eg paediatric patients or those in intensive care), as well as those patients who refuse treatment or have advance directives. Local policies must be in place to take account of these issues.
PIP Has the document been well received by the blood transfusion community as a whole and what support does the framework have from other organisations?
LP The document has been very well received by all the major stakeholders. As a result, several hospitals have begun to develop local services and guidelines. We tried to make the development of the framework as inclusive a process as possible and the consultation period was extensive, thereby giving ownership of the document to the clinical users. There are always some people who have concerns about any new development or change.
Patient safety is our priority and the Framework document recommends that this role be undertaken only by senior, experienced nurses or midwives who can demonstrate that they have the knowledge, skills and competences required to undertake the role. Once trained, they will be required to keep their skills up to date to ensure that patients receive the highest standards of care.
PIP Why do you think biomedical scientists would benefit from some insight in to this framework document?
JG Biomedical scientists need to be aware of changes in the clinical arena, as they must be able to liaise with and support appropriate staff who are authorising the transfusion of blood and other components.
PIP Finally, what is next in relation to moving this process forward? How long before we could see this practice becoming commonplace?
LP There is support in Scotland for the implementation of this initiative from the Chief Nursing Officer and nurse directors of NHSS boards. To date, the clinical areas that have shown interested in piloting this role development are specialist areas (eg haematology, neonatal and intensive care). The nurses are experienced senior nurses working at advanced practice level. We do not envisage this changing in the short term.
Preliminary work has been undertaken by the Scottish Government Health Department (SGHD) to look at the feasibility of developing a multiprofessional educational resource. This may, however, take time to come to fruition. In the meantime, I am working with the SGHD to help support these pilot sites by coordinating the sharing of experiences and resources.
JG There is no coordinated approach in England, as it is up to each individual NHS trust to take this forward. However, I am aware that several hospitals have already begun to develop guidelines based on the framework to progress the service delivery, where appropriate.