Factors perceived to influence implementation of task shifting in highly specialised healthcare: a theory-based qualitative approach.

BACKGROUND: New approaches to control healthcare expenditures and increase access to quality care are required by decision-makers in high-income countries. One strategy is to reallocate tasks from doctors to nurses. Evidence suggests that quality, effectiveness and efficiency of task shifting are context sensitive and affected by implementation. However, little is known about implementability of task shifting in specialised healthcare. We aimed to identify factors perceived to influence implementation of doctor-to-nurse task shifting in a hospital setting and improve understanding of task shifting implementability by using theory-based frameworks for analysing behaviour. Nurse-led bone marrow examination exemplified task shifting from the medical to the nursing domain. METHODS: Doctors and nurses (n = 17) in a haematology department at a Norwegian university hospital were asked about factors perceived to influence implementation of nurse-led bone marrow aspirations and biopsies. Methods included in-depth semi-structured interviews (n = 11) and focus-group discussion (n = 6). Data were analysed using the Capability, Opportunity, and Motivation behaviour model and the Theoretical Domains Framework. RESULTS: Ten factors perceived to influence implementation were identified. Three factors were related to capability, including (1) knowledge and acceptability of task shifting rationale; (2) dynamic role boundaries; and (3) technical skills to perform biopsies and aspirations. Five factors were related to motivation, including (4) beliefs about task shifting consequences, such as efficiency, quality and patient satisfaction; (5) beliefs about capabilities, such as technical, communicative and emotional skills; (6) job satisfaction and esteem; (7) organisational culture, such as team optimism; and (8) emotions, such as fear of informal nurse hierarchy and envy. The last two factors were related to opportunity, including (9) project planning and leadership, and voluntariness; and (10) patient preferences. CONCLUSION: Task shifting from doctors to nurses in specialised healthcare requires not only development of technical skills but also complex changes in organisation, clinical routines and role identity. Educational and organisational interventions to build a team-oriented culture could potentially increase the possibility of successful task shifting and stimulate nurses to take on untraditional responsibilities. Environmental restructuring to support doctors using their time in activities only doctors can perform may be needed to realise potential efficiency gains.

Evaluation of bone marrow examinations performed by an advanced nurse practitioner: an extended role within a haematology service.

PURPOSE: Traditionally, medical personnel have undertaken bone marrow (BM) examination. However, specially trained nurses in advanced practice roles are increasingly undertaking this role. This paper presents the findings from an audit of BM examinations undertaken by an advanced nurse practitioner (ANP) at a regional haematology specialist centre. METHODS: The audit evaluated the quality of BM examinations performed by the ANP over the past two years (September 2007-September 2009). Over the two year period, 324 BM examinations were performed at the centre of which 156 (48.1%) were performed by the ANP. A random sample of 30 BM examinations undertaken by the ANP were analysed by the consultant haematologist. RESULTS: All 30 BM examinations undertaken by the ANP were sufficient for diagnosis. CONCLUSIONS: The ANP is capable and competent to obtain BM samples which are of a sufficient quality to permit diagnosis.

Use of buffered lidocaine in bone marrow biopsies: a randomized, controlled trial.

PURPOSE/OBJECTIVES: To determine whether a difference exists in perceived pain during preprocedure anesthetic injection for bone marrow biopsy between buffered and unbuffered lidocaine, to determine whether pain levels change over time, and to investigate relationships between perceived pain scores and other variables. DESIGN: A double-blind, randomized, experimental, crossover design. SETTING: A large hospital in the midwestern region of the United States. SAMPLE: 48 patients undergoing bone marrow biopsy. METHODS: The patients served as their own controls for the bilateral procedure. A 100 mm visual analog scale measured pain. A demographic questionnaire gathered the between-subjects exploratory variables. MAIN RESEARCH VARIABLES: Perceived pain scores and type of lidocaine anesthetic solution (buffered versus unbuffered). FINDINGS: Participants reported significantly lower pain scores on the side anesthetized with buffered lidocaine compared with the side anesthetized with unbuffered lidocaine. Higher pain scores were reported on the treatment side for participants who had received more than two surgical procedures. Patients who were members of a minority group had higher mean pain scores than Caucasians on the control side. CONCLUSIONS: Buffered lidocaine is superior to unbuffered lidocaine as an anesthetic for bone marrow biopsy procedures. IMPLICATIONS FOR NURSING: Advanced practice nurses perform a significant number of bone marrow biopsies and aim to improve patient comfort during invasive procedures. Use of unbuffered lidocaine should be questioned.

Bone marrow aspiration and biopsy: collection and interpretation.

PURPOSE/OBJECTIVES: To describe the role of the oncology nurse practitioner in the performance of bone marrow aspiration and biopsy and discuss the indications and diagnostic value of bone marrow examination. DATA SOURCES: Published articles, textbooks, personal experience. DATA SYNTHESIS: Bone marrow examination is useful in the diagnosis of many nonhematologic and hematologic conditions. Having a nurse practitioner perform bone marrow aspiration can improve patient care and comfort. CONCLUSIONS: Greater understanding of bone marrow aspiration procedure and diagnostic tests helps nurse practitioners and oncology nurses to provide better patient care. IMPLICATIONS FOR NURSING PRACTICE: Advanced practice nurses in the oncology setting must take an active role in the development and implementation of clinical practice protocols for bone marrow collection.

Utilidad de la tinción de la hemosiderina y la determinación de ferremia en el diagnóstico de las anemias / Utility of hemosiderin tinction and blood iron determination in Anaemia diagnosis

En este trabajo realizado con el material de 100 casos, se evalúa la relación entre la determinación de hierro sérico, la hemosiderina tisular y el conteo de sideroblastos. Los resultados permiten demostrar que cuando la CFFeS está elevada, el 91%de los casos tiene sideroblastos ausentes o bajos. El hierro en el eritroblasto se halla normalmente entre un 28 - 81%. Se puede así, conjungándolos, definir diagnósticos de deficiencia de hierro, anemia de enfermedad crónica, disponibilidad inadecuada del hierro para la eritropoyesis, bloqueo del paso de hierro tisular al glóbulo rojo y sobrecargas de hierro, encontrándose entre ellos dependencia estadística. Se proponen distintos patrones que pueden derivarse del análisis de estas determinaciones, cuando se realizan simultáneamente