Journal of Clinical Apheresis 30:32–37 (2015)
Brief Report Apheresis Training for Nurses and Physicians Around the World Marleen Neyrinck,1 Hans Vrielink,2*; on behalf of the Joint Task Force for Apheresis Education and Certification 1
2
Department of Hematology, AZ Delta, Roeselare, Belgium Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, The Netherlands
A training program for apheresis nurses in leukocyte collection and therapeutic apheresis was developed by the Joint Task Force for Apheresis Education and Certification. This is a modular program with theoretical and practical information and knowledge. On request of the Indonesian authorities, in the capital of Indonesia Jakarta, a certification course for apheresis nurses/operators based on the training program described above was organized in December 2013. The course existed of themes related to apheresis, such as hematology, anatomy, physiology, calculations, adverse events, basics of apheresis, nursing aspects, quality, collection of cells for cellular therapies, pediatrics, and therapeutic collections (cell reductions and exchange procedures). A pretest and post-test regarding the knowledge and judgment in the themes described was taken in Bahasa Indonesia or in English. In total, 38 apheresis nurses and 32 physicians participated in the course. In the post-test, the nurses scored in a mean 72/100 and the physicians 77/100 (nurses vs. physicians: P 5 0.005), which was significantly better than the results of the pretest (54/100 and 53/100, respectively (P < 0.0001 for both). In conclusion, with this course, 38 apheresis nurses/operators proved a significant increase of knowledge in the theory behind apheresis. This educational program provides an approach to educate and certificate apheresis nurses. It is also shown that also for physicians working in the field of apheresis, this course is of use increasing their knowledge regarding apheC 2014 Wiley Periodicals, Inc. resis. J. Clin. Apheresis 30:32–37, 2015. V Key words: training of apheresis nurses and physicians, Indonesia
INTRODUCTION
According to laws in many countries, workers in medical health care need to be qualified and competent for their job. To guarantee uniformity, quality, and efficiency in the training, a training program for apheresis nurses in leukocyte collection and therapeutic apheresis was developed by a group of experienced apheresis nurses and physicians from Europe and the United States (Joint Task Force for Apheresis Education). The curriculum is a modular program with theoretical and practical information and knowledge on apheresis. The theoretical part consists of identified themes including the basics of apheresis principles, basic hematology (e.g., the characteristics, kinetics, and function of blood cells), basic apheresis physiology, indications for apheresis procedures, difficulties, and risks of procedures, as well as the what to do in case of side effects. DEVELOPMENT AND COMPOSITION OF THE COURSE
In Europe, nurses and operators of apheresis equipment are usually solely trained by their experienced C 2014 Wiley Periodicals, Inc. V
colleagues and/or the manufacturing industry. Operators learn to operate the apheresis equipment and what to do when some problems with the machine appear during an apheresis procedure. However, the fundamental basic knowledge regarding the working of the apheresis machine and for instance why a procedure needs to be performed is usually lacking. Recognizing this gap, in 2012, two European apheresis physicians were discussing thoughts to build a course to educate the European apheresis nurses. These ideas were also discussed with American colleagues and it appeared that the situation in the United States equals to the situation in Europe. Because of that, a small group from the US apheresis representatives suggested to corporate with the European originators to build a course for *Correspondence to: Hans Vrielink, MD, PhD, Department of Transfusion Medicine, Sanquin Blood Supply, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands. E-mail: [email protected]. Received 20 June 2014; Accepted 30 June 2014 Published online 8 July 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jca.21345
Apheresis Training for Nurses and Physicians
33
Fig. 1. Concept for modular course for apheresis nurses/operators. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
apheresis nurses and operators. With this Trans Atlantic initiative we had an initiative to build a “Train-theTrainer” global course for apheresis nurses. To discuss the learning objectives for the course, in October 2012, a 2-day meeting was organized in Amsterdam in The Netherlands. Because of the motto of this course “Apheresis: For and By Nurses,” besides the Americans, experienced apheresis nurses from countries in Europe were invited. Approximately, 20 persons from Europe and the United States experienced in and working in the field of apheresis joined this meeting. The group consisted of nurses and physicians from Austria, Belgium, France, Italy, The Netherlands, Spain, Sweden, Switzerland, the United Kingdom, and the Unites States. To start discussions, composition of a course in a modular system was suggested. This system was based on a certification program for donor apheresis nurses in The Netherlands [1]. One basic module named “apheresis basics” was planned covering all basic knowledge in relation to apheresis with topics such as adverse events, anatomy, hematology, physiology, and so forth. To make a program fitting for each hospital and/or apheresis center, in subsequent modules cell collections for the benefit of cellular therapies, cell reductions [leukocytes, platelets, and/or red blood cells (RBCs)], and RBC and plasma exchange procedures were thought (see Fig. 1). In modules 5 until 10, education how to work with the various apheresis machines is covered. The latter modules are the existing program of the manufacturing industry to train the nurse/operator to work with a specific apheresis machine.
Based on the scheme as shown in Figure 1, the various modules were worked out, starting with the composition of module 1 “apheresis basics.” It was agreed by all participants that allied health care workers in the field of apheresis need to have a relevant knowledge in the various topics mentioned before. Specific relevant knowledge for the apheresis nurse within every topic was discussed in subgroups, and subsequently discussed in the plenary meeting. Based on these discussions, after 2 days, learning objectives for the content of modules 1–4, including a small adaptation of the scheme were worked out (see Table I and Fig. 2). Taking advantage of the opportunity that in 2013 the fourth edition of “Principles of Apheresis Technology” of the American Society for Apheresis was planned to be revised, the outcome of the meeting in Amsterdam was shared with editors and authors of the various chapters. All agreed to incorporate the learning objectives as suggested in the meeting as much as possible in the various chapters. Although not every part of the course is covered by the book, this fifth edition, released in April 2014 can be used as hand-out for the nurse course [2]. Also based on the learning objectives, a set of slides for each topic within the various modules was made. The basic setup for this course is a train the trainer course with per topic a set of slides. The intention is that the text on the slides is predetermined, but that presentation can be done in the local language by local trainers. The text on the slides is in English, including the concept text for the trainers. So by training the trainers, this course can be given in globally according to a program predetermined by a central group. In this way, rather standardized education can be given to new Journal of Clinical Apheresis DOI 10.1002/jca
34
Neyrinck et al.
apheresis health care workers, but the course can also be used to refresh the knowledge of the experienced apheresis nurses in the local language.
Besides the set of slides, also a set of questions based on the learning objectives for each topic of the course was composed. Of course, the participants do need pass the final test to achieve a certificate.
TABLE I. Topics Modules 1–4 Module 1: Apheresis basics Adverse events Anatomy Basics of apheresis Calculations in Apheresis Hematology Nursing and social aspects Pediatric apheresis Physiology Quality Module 2: Cell collections CD34 positive cells Lymphocytes Monocytes Granulocytes Pediatrics Module 3: Cell reductions Leukocytes Platelets Red blood cells Pediatrics
THE ASIAN EXPERIENCE Introduction Separation principles, disposables, general working of equipment
Pediatric aspects related to all topics in module Quality systems (FACT/JACIE), validations
Besides the United States and various European countries, also countries in Asia are interested in the course for apheresis nurses. The Indonesian Society of Haematology and Blood Transfusion and the Indonesian Society for Blood Transfusion Doctors requested to train and certify initially their apheresis nurses, but later also some physicians. Besides that, also the Malaysian blood transfusion service requested to train a group of apheresis nurses.
T-cells, NK-cells, phototherapy
Methods Pediatric aspects related to all topics in module
Pediatric aspects related to all topics in module
Module 4: Exchange procedures Plasma exchange Red blood cell exchange Pediatrics Pediatric aspects related to all topics in module
As mentioned, on request of the two Indonesian societies, a 3-day certification course for apheresis nurses/operators based on the training program described above was organized in December 2013 (see Fig. 3). Trying to learn the basic knowledge in the group of participants present prior to the start of the learning program and the effects of the course on the knowledge per participant, two tests were planned; (1) at the start of the course on the first day prior to all lessons and (2) a finishing test after all presentations. The questions in the pretest and post-test were exactly the
Fig. 2. Revised and final scheme for modular course for apheresis nurses. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Journal of Clinical Apheresis DOI 10.1002/jca
Apheresis Training for Nurses and Physicians
35
Fig. 3. Program Indonesia December 2013. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
same and given in Bahasa Indonesia or on request in English. The test existed of multiple choice, yes–no and open questions. All questions were composed to test knowledge and judgment as presented in the various topics as composed by “the Joint Task Force for Apheresis Education and Certification” meeting in Amsterdam. Each topic is covered by two or more questions. Because of that, also the knowledge of participants per topic could be evaluated. In total, maximally 100 points could be obtained. To satisfy the examiners, minimally 55 points should be scored. On request of the two Indonesian societies, the finishing exam was compulsory for all nurses. For physicians, the exam was on a voluntary basis. After the precourse test, the program (Fig. 3) started with presentations regarding subsequently basics of apheresis, hematology, anatomy, physiology, adverse events, calculations, and finally on day one the presentation of quality. On the second day, topics on nursing, platelet collections (on request of the organizers), pediatric procedures, collection of cells for cellular therapy, an introduction for therapeutic apheresis, cell reductions, and exchange procedures were discussed. On the third day, the final test was taken, followed by a refreshment course for working with the apheresis machine. Statistics
To compare the outcome of the results of the precourse and postcourse test per individual, the paired T-test was applied using GraphPad InStat version 3.06 (San Diego, CA). To compare the mean outcome of the tests of the nurses and physicians, the nonparametric Mann–Whitney test was used as no Gaussian distribution was seen (using the method Kolmogorov and
Smirnov). If P < 0.05, the differences were considered significant. Results Malaysia
Lessons were given at the second National Blood Apheresis Seminar entitled “Back to Basics” in Kuala Lumpur Malaysia organized by the Malaysian Blood transfusion organization. In consultation with the organizers, only a selection of themes of the complete program could be given since only 1 day was available. The ultimate topics were basics of apheresis, physiology, hematology, anatomy and side effects, collections for cellular therapies, and therapeutic apheresis. Besides these topics, on request a presentation on platelet collections in blood donors was given. A group of approximately 90 Malaysian apheresis nurses and physicians were participating in this seminar. Indonesia
In Indonesia, 39 experienced nurses/operators (35 from Indonesia, three from Singapore, and one from Cambodia) and 32 physicians [31 hematologists and donor doctors from Indonesia, and from Cambodia (n 5 1)] participated in the course. All nurses had minimally 2 years of experience in performing apheresis procedures in donors (mainly plateletapheresis) and patients (mainly cell reductions and plasma exchange procedures). As shown in Table II, on day one, 39 nurses performed the precourse test. With a mean score of 54 of 100 available points (range 34–63), 19 (48.7%) nurses scored less then 55 points and would have failed to satisfy the examiners when this would have been the final Journal of Clinical Apheresis DOI 10.1002/jca
36
Neyrinck et al.
TABLE II.
Results Precourse and Postcourse Tests of Nurses and Physicians
Apheresis nurses/operators
TABLE III.
Nurses: Total Score of Precourse and Postcourse Test per Topic
Physicians
Apheresis operators/nurses
December 5, December 7, December 5, December 7, 2013 (n 5 39) 2013 (n 5 38) 2013 (n 5 18) 2013 (n 5 16) Mean STD Median Min Max
a
54 6 54 34 63
b
72 5 73 57 83
c,d
53 8 53 35 64
e,f
77 5 76 67 85
a 19/39 (48.7%) nurses < 55/100 score and would not pass their exam. b December 5 versus December7: P < 0.0001 (t-test). c 8/18 (44.4%) physicians
Brief Report Apheresis Training for Nurses and Physicians Around the World Marleen Neyrinck,1 Hans Vrielink,2*; on behalf of the Joint Task Force for Apheresis Education and Certification 1
2
Department of Hematology, AZ Delta, Roeselare, Belgium Department of Transfusion Medicine, Sanquin Blood Supply, Amsterdam, The Netherlands
A training program for apheresis nurses in leukocyte collection and therapeutic apheresis was developed by the Joint Task Force for Apheresis Education and Certification. This is a modular program with theoretical and practical information and knowledge. On request of the Indonesian authorities, in the capital of Indonesia Jakarta, a certification course for apheresis nurses/operators based on the training program described above was organized in December 2013. The course existed of themes related to apheresis, such as hematology, anatomy, physiology, calculations, adverse events, basics of apheresis, nursing aspects, quality, collection of cells for cellular therapies, pediatrics, and therapeutic collections (cell reductions and exchange procedures). A pretest and post-test regarding the knowledge and judgment in the themes described was taken in Bahasa Indonesia or in English. In total, 38 apheresis nurses and 32 physicians participated in the course. In the post-test, the nurses scored in a mean 72/100 and the physicians 77/100 (nurses vs. physicians: P 5 0.005), which was significantly better than the results of the pretest (54/100 and 53/100, respectively (P < 0.0001 for both). In conclusion, with this course, 38 apheresis nurses/operators proved a significant increase of knowledge in the theory behind apheresis. This educational program provides an approach to educate and certificate apheresis nurses. It is also shown that also for physicians working in the field of apheresis, this course is of use increasing their knowledge regarding apheC 2014 Wiley Periodicals, Inc. resis. J. Clin. Apheresis 30:32–37, 2015. V Key words: training of apheresis nurses and physicians, Indonesia
INTRODUCTION
According to laws in many countries, workers in medical health care need to be qualified and competent for their job. To guarantee uniformity, quality, and efficiency in the training, a training program for apheresis nurses in leukocyte collection and therapeutic apheresis was developed by a group of experienced apheresis nurses and physicians from Europe and the United States (Joint Task Force for Apheresis Education). The curriculum is a modular program with theoretical and practical information and knowledge on apheresis. The theoretical part consists of identified themes including the basics of apheresis principles, basic hematology (e.g., the characteristics, kinetics, and function of blood cells), basic apheresis physiology, indications for apheresis procedures, difficulties, and risks of procedures, as well as the what to do in case of side effects. DEVELOPMENT AND COMPOSITION OF THE COURSE
In Europe, nurses and operators of apheresis equipment are usually solely trained by their experienced C 2014 Wiley Periodicals, Inc. V
colleagues and/or the manufacturing industry. Operators learn to operate the apheresis equipment and what to do when some problems with the machine appear during an apheresis procedure. However, the fundamental basic knowledge regarding the working of the apheresis machine and for instance why a procedure needs to be performed is usually lacking. Recognizing this gap, in 2012, two European apheresis physicians were discussing thoughts to build a course to educate the European apheresis nurses. These ideas were also discussed with American colleagues and it appeared that the situation in the United States equals to the situation in Europe. Because of that, a small group from the US apheresis representatives suggested to corporate with the European originators to build a course for *Correspondence to: Hans Vrielink, MD, PhD, Department of Transfusion Medicine, Sanquin Blood Supply, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands. E-mail: [email protected]. Received 20 June 2014; Accepted 30 June 2014 Published online 8 July 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jca.21345
Apheresis Training for Nurses and Physicians
33
Fig. 1. Concept for modular course for apheresis nurses/operators. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
apheresis nurses and operators. With this Trans Atlantic initiative we had an initiative to build a “Train-theTrainer” global course for apheresis nurses. To discuss the learning objectives for the course, in October 2012, a 2-day meeting was organized in Amsterdam in The Netherlands. Because of the motto of this course “Apheresis: For and By Nurses,” besides the Americans, experienced apheresis nurses from countries in Europe were invited. Approximately, 20 persons from Europe and the United States experienced in and working in the field of apheresis joined this meeting. The group consisted of nurses and physicians from Austria, Belgium, France, Italy, The Netherlands, Spain, Sweden, Switzerland, the United Kingdom, and the Unites States. To start discussions, composition of a course in a modular system was suggested. This system was based on a certification program for donor apheresis nurses in The Netherlands [1]. One basic module named “apheresis basics” was planned covering all basic knowledge in relation to apheresis with topics such as adverse events, anatomy, hematology, physiology, and so forth. To make a program fitting for each hospital and/or apheresis center, in subsequent modules cell collections for the benefit of cellular therapies, cell reductions [leukocytes, platelets, and/or red blood cells (RBCs)], and RBC and plasma exchange procedures were thought (see Fig. 1). In modules 5 until 10, education how to work with the various apheresis machines is covered. The latter modules are the existing program of the manufacturing industry to train the nurse/operator to work with a specific apheresis machine.
Based on the scheme as shown in Figure 1, the various modules were worked out, starting with the composition of module 1 “apheresis basics.” It was agreed by all participants that allied health care workers in the field of apheresis need to have a relevant knowledge in the various topics mentioned before. Specific relevant knowledge for the apheresis nurse within every topic was discussed in subgroups, and subsequently discussed in the plenary meeting. Based on these discussions, after 2 days, learning objectives for the content of modules 1–4, including a small adaptation of the scheme were worked out (see Table I and Fig. 2). Taking advantage of the opportunity that in 2013 the fourth edition of “Principles of Apheresis Technology” of the American Society for Apheresis was planned to be revised, the outcome of the meeting in Amsterdam was shared with editors and authors of the various chapters. All agreed to incorporate the learning objectives as suggested in the meeting as much as possible in the various chapters. Although not every part of the course is covered by the book, this fifth edition, released in April 2014 can be used as hand-out for the nurse course [2]. Also based on the learning objectives, a set of slides for each topic within the various modules was made. The basic setup for this course is a train the trainer course with per topic a set of slides. The intention is that the text on the slides is predetermined, but that presentation can be done in the local language by local trainers. The text on the slides is in English, including the concept text for the trainers. So by training the trainers, this course can be given in globally according to a program predetermined by a central group. In this way, rather standardized education can be given to new Journal of Clinical Apheresis DOI 10.1002/jca
34
Neyrinck et al.
apheresis health care workers, but the course can also be used to refresh the knowledge of the experienced apheresis nurses in the local language.
Besides the set of slides, also a set of questions based on the learning objectives for each topic of the course was composed. Of course, the participants do need pass the final test to achieve a certificate.
TABLE I. Topics Modules 1–4 Module 1: Apheresis basics Adverse events Anatomy Basics of apheresis Calculations in Apheresis Hematology Nursing and social aspects Pediatric apheresis Physiology Quality Module 2: Cell collections CD34 positive cells Lymphocytes Monocytes Granulocytes Pediatrics Module 3: Cell reductions Leukocytes Platelets Red blood cells Pediatrics
THE ASIAN EXPERIENCE Introduction Separation principles, disposables, general working of equipment
Pediatric aspects related to all topics in module Quality systems (FACT/JACIE), validations
Besides the United States and various European countries, also countries in Asia are interested in the course for apheresis nurses. The Indonesian Society of Haematology and Blood Transfusion and the Indonesian Society for Blood Transfusion Doctors requested to train and certify initially their apheresis nurses, but later also some physicians. Besides that, also the Malaysian blood transfusion service requested to train a group of apheresis nurses.
T-cells, NK-cells, phototherapy
Methods Pediatric aspects related to all topics in module
Pediatric aspects related to all topics in module
Module 4: Exchange procedures Plasma exchange Red blood cell exchange Pediatrics Pediatric aspects related to all topics in module
As mentioned, on request of the two Indonesian societies, a 3-day certification course for apheresis nurses/operators based on the training program described above was organized in December 2013 (see Fig. 3). Trying to learn the basic knowledge in the group of participants present prior to the start of the learning program and the effects of the course on the knowledge per participant, two tests were planned; (1) at the start of the course on the first day prior to all lessons and (2) a finishing test after all presentations. The questions in the pretest and post-test were exactly the
Fig. 2. Revised and final scheme for modular course for apheresis nurses. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] Journal of Clinical Apheresis DOI 10.1002/jca
Apheresis Training for Nurses and Physicians
35
Fig. 3. Program Indonesia December 2013. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
same and given in Bahasa Indonesia or on request in English. The test existed of multiple choice, yes–no and open questions. All questions were composed to test knowledge and judgment as presented in the various topics as composed by “the Joint Task Force for Apheresis Education and Certification” meeting in Amsterdam. Each topic is covered by two or more questions. Because of that, also the knowledge of participants per topic could be evaluated. In total, maximally 100 points could be obtained. To satisfy the examiners, minimally 55 points should be scored. On request of the two Indonesian societies, the finishing exam was compulsory for all nurses. For physicians, the exam was on a voluntary basis. After the precourse test, the program (Fig. 3) started with presentations regarding subsequently basics of apheresis, hematology, anatomy, physiology, adverse events, calculations, and finally on day one the presentation of quality. On the second day, topics on nursing, platelet collections (on request of the organizers), pediatric procedures, collection of cells for cellular therapy, an introduction for therapeutic apheresis, cell reductions, and exchange procedures were discussed. On the third day, the final test was taken, followed by a refreshment course for working with the apheresis machine. Statistics
To compare the outcome of the results of the precourse and postcourse test per individual, the paired T-test was applied using GraphPad InStat version 3.06 (San Diego, CA). To compare the mean outcome of the tests of the nurses and physicians, the nonparametric Mann–Whitney test was used as no Gaussian distribution was seen (using the method Kolmogorov and
Smirnov). If P < 0.05, the differences were considered significant. Results Malaysia
Lessons were given at the second National Blood Apheresis Seminar entitled “Back to Basics” in Kuala Lumpur Malaysia organized by the Malaysian Blood transfusion organization. In consultation with the organizers, only a selection of themes of the complete program could be given since only 1 day was available. The ultimate topics were basics of apheresis, physiology, hematology, anatomy and side effects, collections for cellular therapies, and therapeutic apheresis. Besides these topics, on request a presentation on platelet collections in blood donors was given. A group of approximately 90 Malaysian apheresis nurses and physicians were participating in this seminar. Indonesia
In Indonesia, 39 experienced nurses/operators (35 from Indonesia, three from Singapore, and one from Cambodia) and 32 physicians [31 hematologists and donor doctors from Indonesia, and from Cambodia (n 5 1)] participated in the course. All nurses had minimally 2 years of experience in performing apheresis procedures in donors (mainly plateletapheresis) and patients (mainly cell reductions and plasma exchange procedures). As shown in Table II, on day one, 39 nurses performed the precourse test. With a mean score of 54 of 100 available points (range 34–63), 19 (48.7%) nurses scored less then 55 points and would have failed to satisfy the examiners when this would have been the final Journal of Clinical Apheresis DOI 10.1002/jca
36
Neyrinck et al.
TABLE II.
Results Precourse and Postcourse Tests of Nurses and Physicians
Apheresis nurses/operators
TABLE III.
Nurses: Total Score of Precourse and Postcourse Test per Topic
Physicians
Apheresis operators/nurses
December 5, December 7, December 5, December 7, 2013 (n 5 39) 2013 (n 5 38) 2013 (n 5 18) 2013 (n 5 16) Mean STD Median Min Max
a
54 6 54 34 63
b
72 5 73 57 83
c,d
53 8 53 35 64
e,f
77 5 76 67 85
a 19/39 (48.7%) nurses < 55/100 score and would not pass their exam. b December 5 versus December7: P < 0.0001 (t-test). c 8/18 (44.4%) physicians
