1. Bone Marrow Biopsy Training For Nurses Louise McNamara Matron / Nurse Practitioner for Haemato-Oncology

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. Course aim Theoretical knowledge Practical experience Ensure safe and confident practitioners –2 days of theory and simulated practice –1 day observing clinical practice

9. 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

10. 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

11. Course content Day 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

13. 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

14. 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

15. 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

16. Questions?