Bone Marrow Biopsy Training For
Nurses
Louise McNamara
Matron / 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
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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 content
Day 1 (Classroom)
– What is a BM?
• Definition,
indications,
contraindications,
A&P, site selection
– Legal /
Professional
• Competencies,
Regulations,
Accountability,
Consent
Day 2 (Classroom)
– Procedure
guideline
– Problem-solving
Day 3 (Observation)
– Patient
preparation
– The anxious
patient
– Post procedure
care
– Education
– Complications
– Consent
– Practical simulation
– Sedation
– Workbook review
– Procedure
guideline
– Procedure prep
• Equipment,
documentation,
pharmacology, nonpharmacological
support, patient
education
–Workshop
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?