Non-Medical Authorisation of Blood Components

Blood authorisation, as it is now termed, was primarily a medical role (Green and Pirie, 2009).  A prescription donates a legal requirement that the product is from the BNF, however there is agreement that in relation to blood products, a ‘written instruction’ or authorisation is the appropriate term (Blood Safety and Quality Regulations, 2005).  There is no specific legislation that requires a doctor to carry out the authorisation of blood components. A nurse is able to undertake this activity as long as it is within their scope of practice and they are appropriately trained and competent (Green and Pirie, 2009, Pirie 2013).

The Nursing and Midwifery Council (NMC) does not impose restrictions on a nurse’s practice and in fact encourages role development in view of changing patient needs.  The nurse remains accountable for their actions and must ensure they are competent before they accept the responsibility of the clinical decision making involved in clinical practice such as blood authorisation (Green and Pirie, 2009).

As with any healthcare professional involved in patient care, non-medical authorisers are all accountable to their respective professional bodies, to their patients and to the NHS as their employer to provide safe and appropriate care (Nursing and Midwifery Council 2015). 

Non-medical authorisers are required to complete all mandatory training relevant to safe transfusion practice. This can be accessed via NHS Learnpro.  It is the responsibility of the staff member to ensure training and education is updated every 2 years

In addition, non-medical authorisers must complete the Better Blood Transfusion Nurse Authorisation programme available on NHS Learnpro via local Transfusion Practitioner. All health care professionals are legally required to evidence training and care provided.  The non-medical authoriser must identify suitable clinical supervision from a mentor working in the field of practice.  A personal development plan must reflect competence and skill development relevant to an advance practice role, which includes the role of a non-medical authoriser. Non-medical authorisers will not authorise blood outwith their area of expertise/practice and competence.

Any adverse event should be reported via the on line adverse event reporting system, and investigated through the relevant line management structure.

The requesting and authorising of blood components is a shared responsibility with medical staff therefore in the event there is no non-medical  authoriser available to authorise a blood component this should be referred to a medical practitioner.

Role and Remit of Nurse Authoriser

A non-medical authoriser working at an advanced practice level must be approved to work within the relevant clinical area and speciality, and practice within the area of competence and clinical expertise only. Evidence of approval and competence will be demonstrated in the non-medical authoriser’s learning portfolio (appendix 1).

The non-medical authoriser will be responsible for making the decision to transfuse a patient with blood components, ordering the components from the Hospital Transfusion Laboratory (HTL), informing the patient of the decision to transfuse (obtaining verbal consent) and completing the appropriate documentation on the patient’s transfusion document. It is also considered appropriate for a non-medical authoriser to authorise blood components and be involved in the final bedside checking procedure (if appropriately trained in clinical bedside practice).

Level of Competence

To undertake the role of a non-medical authoriser, the following criteria must be met:

• Must be a registered nurse with a minimum of three years post registration experience
• At least a minimum of one year experience working within speciality and practising at level 6 (senior practitioner level) or above within the Careers Framework
• Manage a case load of patients
• Exercise a high level of knowledge, expertise, clinical reasoning and diagnostic skills
• Working interdependently within a healthcare team and be expected to utilise non-medical authorization of blood components on a regular basis
• Be responsible for maintaining and updating their knowledge and skills
• Participate in ongoing performance development and review
• Be aware of the boundaries of their role

A non-medical authoriser must have completed the 5 essential elements of assessment to be considered competent to authorise blood components within clinical practice:

• Completed LBT: Safe Transfusion Practice
• Completed LBT: Blood Components and indications for use
• Completed local training for the requesting and ordering of blood components
• Completed BBT Nurse Authorisation of Blood Components Programme available on Learnpro via Transfusion Practitioner
• All workshop presentations
• The self assessment / gap analysis (included in the Portfolio to Evidence Competence for non-medical authorizers of Blood Components) must be completed
• Provide evidence of having achieved all competencies as described in the Portfolio
• Complete a period of clinical supervision and assessment of competence by an approved mentor using a minimum of three case based discussions. Documents to record case based discussions / assessment and competence sign off are available in the Portfolio
• Maintain a portfolio providing details of blood components and special requirements they have been assessed on as competent in authorising and ensure competence is maintained. This portfolio is individual to the non-medical authoriser and will be updated as experience and competence is gained for new areas of authorisation.
• Competence and sign off of the authorisation of blood components will be verified by the identified prescriber mentor. Agreement must be reached with the responsible prescriber mentor if the non-medical authoriser is to initiate the first transfusion for a patient.

Mentor Responsibility

 A mentor, for the purposes of this policy, can be a senior medical or non medical personnel who is a competent blood component authoriser within their relevant clinical area.

The responsibilities of the mentor are to:

• Work in partnership to identify which patient groups are suitable for a nurse to authorise blood components
• Act as a mentor and supervisor of practice to the nurse. Mentor support is identified as a pre-requisite to successful clinical learning.

Appendix 2 is an additional guide for practice to support the non-medical authoriser with their clinical risk assessment and appropriateness of transfusion authorisation.

Management Responsibility

The responsibility of the line manager is to:

• Assist with identifying the financial and human resources necessary to ensure service development
• Agreeing who will undertake supervised practice and mentorship
• Ensuring robust risk assessments are undertaken to maintain patient safety
• Support practitioners to work within agreed boundaries
• Carry out regular performance review with the practitioner linked to their personal development plan.

The clinical specialty is responsible for ensuring that any service change would be in the best interest of the patients.  Local guidelines must be in place that considers:

• Which patient groups are suitable
• Under what circumstances blood component transfusion can be authorised by the registered nurse

Patients receiving a blood component transfusion should be made aware of the clinical need and consent to the administration of that blood component. Verbal consent is acceptable and this consent should be documented on the NHS Borders Transfusion record along with the indication for transfusion.

A thorough assessment of pre-specified clinical parameters is required before any blood component is requested or authorised. The non-medical authoriser is responsible for establishing the indication for transfusion and identifying and documenting any special requirements or instructions on the NHS Borders Transfusion Record.  The non-medical authoriser should refer clinical concerns to an appropriate doctor to support the safe authorisation and administration of blood components.

Non-medical authorisers will liaise with other members of the healthcare team e.g. HTL to carry out a snap­shot audit of their blood component authorisation within the first 6 months of starting practice. Audit will be undertaken as per NHS Borders Clinical Audit policy with results shared with healthcare team.

PORTFOLIO TO EVIDENCE COMPETENCE

FOR REGISTERED NURSE AUTHORISERS

OF BLOOD COMPONENTS

Contents

1. Introduction
2. Preparation for Practice
3. Assessment of Competence
4. Role of the Mentor
5. Knowledge – Gap Analysis
   • Competencies for Nurse Authorisers
   • Suggested education resources and further reading
6. Learning Plan
7. Case Based Discussion / Assessment Sheet
8. Competence ‘Sign off’ Sheet
9. References

Appendix 2

1. Introduction

Following a project to investigate the feasibility of registered practitioners other than doctors prescribing blood components, guidance was sought from the Royal College of Nursing (RCN) and the Medicines and Healthcare products Regulatory Agency (MHRA). The advice received is summarised below;

Following the introduction of Regulation 25 of the Blood Safety and Quality Regulations 2005 SI 2005 no 50) into UK law, Section 130, 1968 Medicines Act has been amended. The consequence of the amendment is that whole human blood and blood components are no longer considered a medicinal product and therefore cannot legally be prescribed by any practitioner.

In law the term prescription relates only to medicines listed in the British National Formulary (BNF), and not to blood components. For blood components it is a written authorisation to transfuse or administer. Therefore it was clarified that there are no legal barriers to other appropriately trained competent registered practitioners e.g. nurses ordering and authorising blood (Pirie and Green 2007). 

As good governance is essential to all role development following an extensive consultation a governance Framework was developed to support nurses and midwives to undertake this role safely (Pirie and Green 2009). The Framework suggests that the individual practitioner must:

• be a first level registered nurse or midwife
• have at least 3 years post registration experience
• have the ability to study at degree level
• have at least 1 year working within the relevant clinical specialty
• manage a caseload of patients or working as part of a clinical team managing the patients needs
• be deemed competent by their employer

have the relevant knowledge and skill requirements.

2. Preparation for Practice

This portfolio has been devised to aid your personal learning and to encourage reflective thinking. Using the competencies in section 5 you should undertake a knowledge gap analysis, identify your learning needs and develop an individual learning plan (Section 6). There is evidence from the development of other nurse roles that accessing the relevant learning by e.g. in-house lectures or attendance at a bespoke study workshop is an acceptable approach to addressing educational requirements (Boyden and Edwards 2007, Carberry 2006).

Suggestions for education and training and further reading to help you achieve competency are also included.

3. Assessment of Competence

Assessment of competence consists of 3 elements:

1. Completion of Module 1: Safe Transfusion Practice and Module 2: Blood Components and Indications for Use
   
   
2. Period of supervision and assessment of competence by approved mentor using a minimum of three case based discussions (A sheet to record case based discussions is included in section 7).

4. Role of the Mentor

Mentor support is identified as a pre-requisite to successful clinical learning (Barton 2006). The mentor should be an approved clinical practitioner with whom the nurse regularly works with e.g. medical consultant or authorised advanced nurse.

There is no single model for the mentorship, because some nurses will have more knowledge and experience than others. The model of clinical supervision should be agreed at local level, taking account of other staff support mechanisms and resources that are in place however, a minimum period of six months is recommended. The main aim of the relationship is to provide guidance, supervision and opportunities to develop competence in practice. The mentor also has a responsibility to confirm that the nurse has completed the agreed period of learning in practice, and met the required competencies. Learning in practice will be related to the medical conditions within the specialty in which the nurse is working.

It is suggested that the mentor should undertake the following:

• Meet with the practitioner to discuss their learning requirements and agree how to take forward their development activities
• Agree a period of supervision and practice
• Provide opportunities for the nurse to carry out consultations where in depth discussion and analysis of clinical management can occur
• Facilitate learning by encouraging critical thinking and reflection with the use of real cases from practice
• Using real cases from practice to enable decision making behaviour to be fully examined.

To assist the ‘sign off’ process the competencies required for this role have been summarised into three main aspects:

• Patient assessment/consultation
• Making the clinical decision to transfuse appropriately
• Authorising blood components within professional and organisational standards.

When the assigned mentor has witnessed practice and is satisfied with the evidence provided, the nurse can be ‘signed off’ as competent (Section 8 of Portfolio). Click here for Gap Analysis Tables

5. Knowledge – Gap Analysis

6. Learning Plan

7. Case Based Discussion/ Assessment Sheet

PHOTOCOPY THIS TEMPLATE PAGE AS REQUIRED

8. Competence ‘Sign off Sheet’

To assist the ‘sign off’ process the competencies required for this role have been summarised into three main aspects:

• Patient assessment/consultation
• Making the clinical decision to transfuse appropriately
• Authorising blood components within professional and organisational standards.

When the assigned mentor has witnessed practice and is satisfied with the evidence provided, the nurse can be ‘signed off’ as competent and a copy of the certificate can be kept in the practitioner’s professional portfolio as evidence.

References

Barton, T.D (2006) Clinical mentoring of nurse practitioners: the doctors' experience British Journal of Nursing 15, 15, 820 - 824

Boyden, J., Edwards, B. (2007) The advanced practitioner role in a community twilight service. Journal of Community Nursing 21 (1) 10-12

Carberry, M. (2006) Hospital Emergency Care Teams: our solution to out of hours emergency care. Nursing in Critical Care 11(4): 177-187.

Pirie, E., Green, J. (2007) Should nurses prescribe blood components Nursing Standard 21, 39, 35-41

Pirie, L. Green, J. (2009) A framework to support Nurses and Midwives making the clinical decision and providing the written instruction for blood component transfusion.

http://www.transfusionguidelines.org.uk/ (Accessed August 2011)