DIONISIO, Jan Nadine M.
Fundamentals of the Nursing Practice
Ma’am Jurado
Training advanced practitioners to perform lumbar puncture
By Joanna Lavery & Tracy Whitaker
Nursing Times (November 2018)
In the last decade, it has been recognized that the scope of nursing practice is
widely expanding. From being able to provide clinical interventions previously attributed
to doctors, nurses are now acknowledged for their proficiency and skills to take the
initiatives. One innovations in the nursing practice is promulgated by the advanced
nurse practitioners (ANPs) of Aintree University Hospital. Along with the authors, they
have expanded they roles and are now trained to perform lumbar punctures.
A lumbar puncture a diagnostic procedure performed for patients with sudden
onset severe headaches whose computed tomography (CT) scans do now show
anything abnormal. It is done by using a hollow needle and inserting it in the spinal
canal to get a cerebrospinal fluid (CSF) sample. The procedure is usually done by junior
doctors but with the shortage of doctors in general medicine, there is a need to improve
their workforce to further improve the care they are providing.
Since lumbar puncture is a complex technical procedure, it must be done by welltrained practitioners. Unfortunately, doctors learn to perform them while ‘on the job’.
Thus, patients may be receiving suboptimal care and may experience discomfort and
complications such as bleeding and pain. If lumbar punctures are only to be performed
by proficient practitioners, then there may be a lack of staff and a delay in the
procedure. The ANPs of hospital recognized these problems and have wanted to be
able to perform the procedure independently to improve their care and patient
experience, to reduce the risks and failed attempts, to train junior doctors in the
procedure, and a lot more.
Summary – Methodology, findings, conclusion
The ANPs attend clinical skills medical training session for foundation doctors to
learn the lumbar puncture technique. They train by practicing on a model and observing
at least fiver lumbar punctures. After that, the trainees can now perform the procedure
given that they are under direct medical supervision, and each procedure done is
recorded and assessed. Once they have finished five lumbar punctures under
supervision, they will be observed by a consultant or a medical trainer competent in the
procedure who will then determine if the trainees have achieved competency.
A competency framework was also developed to ensure a pathway for ANPs to
perform the lumbar puncture safely and independently. It is expected that the
competency framework would verify that the ANPs competency, serve as framework for
future members, and be developed to include other advanced skills. The framework
requires the ANPs to demonstrate their knowledge and understanding in the anatomy,
pharmacology, orientation, preparation, and possible complications of the procedure.
Currently, the lumbar puncture technique is being done by three ANPs who have
completed their training, and one ANP is currently being trained. There was a 40%
increase in the lumbar punctures perform by ANPs in two years from March-May 2015
to March-May 2017. Along with that, a reduction of 12% in the number of attempts per
patient was observed. While in March-May 2017, it was recorded that there were
successful attempts done only once with 75% of the patients. The ANPs are also being
able to train and supervise junior in performing the procedure. In conclusion, there is an
average 12-hour reduction in the patients’ length of stay as well as chances of
experiencing multiple attempts in obtaining the CSF sample.
Implications – Nursing practice, education, research
The three ANPs of the Aintree University Hospital with the competence to
perform the lumbar puncture procedure normally appointed to junior doctors has once
again expanded the scope or nursing care and capabilities. This could pave way to
more opportunities for other ANPs who are in a continuous learning experience.
Normally, nurses go to trainings in hope of improving their practice and updating their
knowledge, but with this newly found and proven skill, nurses can now explore more
areas not normally expected as parts of their scope. If widely promulgated, this research
will inspire other health institutions to offer trainings to ANPs which can further improve
the experiences and stay of the patients in hospitals.
Having read this study, I feel more empowered as a future nurse. It is important
for students to constantly feel inspired to train at their best and to look forward to their
future professions. These innovations are what improves nursing practice and these
innovations are what empowers learners to learn and achieve more. Researchers can
also be inspired to gain more ideas from these three ANPs who are pioneers of lumbar
puncture technique in the nursing profession. With this knowledge, we are reminded
that there will always be room for more ideas and skills in our practice and that there is
no other path for the nursing profession but the path towards improvement and mastery.
Nursing Theory
A nursing theory that I could relate to this study is the Stages of Clinical
Competence by Patricia Benner. As mentioned in the study, the advanced nurse
practitioners were given the training and in the stages of Patricia Benner, they are in
stage 5. They are experts in their fields, not necessarily having to follow certain sets of
rules, but instead they took the initiative to go beyond the expected scope of nursing
and further enhance their competency in their field. They were given the permission to
be trained and to perform the lumbar puncture procedure because they are understood
to have a great background experience in their profession and were able to identify the
problem faced by the institution.