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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 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 apheresis nurses and operators. With this Trans Atlantic initiative we had an initiative to build a “Train-the-Trainer” 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 . 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 1 and Fig. 2).
Table 1. Topics Modules 1–4
Module 1: Apheresis basics
Basics of apheresis
Separation principles, disposables, general working of equipment
Calculations in Apheresis
Nursing and social aspects
Pediatric aspects related to all topics in module
Quality systems (FACT/JACIE), validations
Module 2: Cell collections
CD34 positive cells
T-cells, NK-cells, phototherapy
Pediatric aspects related to all topics in module
Module 3: Cell reductions
Red blood cells
Pediatric aspects related to all topics in module
Module 4: Exchange procedures
Red blood cell exchange
Pediatric aspects related to all topics in module
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 .
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 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.
THE ASIAN EXPERIENCE
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.
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 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.
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.
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.
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 = 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 2, 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 test. Thirty-eight nurses did the final exam postcourse. All 38 nurses performing the postcourse test scored significantly better (P < 0.0001, paired T-test) then before (see Fig. 4), and all scored more then 55 of 100 points (lowest score 57 points), with a mean score of 72 points.
Table 2. Results Precourse and Postcourse Tests of Nurses and Physicians
December 5, 2013 (n = 39)
December 7, 2013 (n = 38)
December 5, 2013 (n = 18)
December 7, 2013 (n = 16)
19/39 (48.7%) nurses < 55/100 score and would not pass their exam.
December 5 versus December7: P < 0.0001 (t-test).
8/18 (44.4%) physicians <55/100 score and would not pass their exam.
December 5: nurses versus physicians: no significant difference.
December 5 versus December 7: P < 0.0001 (t-test).
December 7: nurses versus physicians: P = 0.005 (Mann–Whitney test).
As mentioned before, the questions were regarding adverse events, basics of apheresis, calculations, cell collections for cellular therapies, exchange procedures, hematology, nursing, physiology, and cell reductions. In Table 3, the percentage of correct answers of the nurses per specific topic is given. As shown in Table 3, in the final exam there was a significant better score in the group of nurses regarding the topics adverse events (P = 0.004), basics of apheresis (P = 0.01), calculations (P = 0.004), hematology (P = 0.001), and physiology (P = 0.02). A better score was also seen in the reduction of cells, but as only two questions were given regarding this topic, a P-value could not be calculated.
Table 3. Nurses: Total Score of Precourse and Postcourse Test per Topic
For the physicians, 18 performed the precourse test on a voluntary basis. With a mean score of 53 of 100 available points (range 35–67), 8 (44.4%) physicians scored less then 55 points. Sixteen physicians did the final exam postcourse. All 16 physicians scored significantly better (P < 0.0001, paired t-test) then before (see Fig. 5), and all scored more than 55 of 100 points (lowest score 67 points), with a mean score of 76 points.
In Table 4, the percentage of correct answers of the physicians per specific topic is given. As shown in Table 4, there was a significant better score in the group of physicians in the final exam regarding the topics adverse events (P = 0.009), basics of apheresis (P = 0.01), calculations (P = 0.004), hematology (P = 0.003), and physiology (P = 0.01). A better score was also seen in the reduction of cells, but as only two questions were given regarding this topic, a P-value could not be calculated.
Table 4. Physicians: Total Score of Precourse and Postcourse Test per Topic
Comparing the scores of the nurses with those of the physicians, no difference was seen in the score at the precourse test (54 vs. 53 of 100 points), however, the physicians scored significantly better at the postcourse test (72 vs. 77 of 100 points, P = 0.005, Mann–Whitney test).
Conclusions Course in Indonesia
With this course composed by the Joint Task Force for Apheresis Education and Certification, as shown in the 3-day certification course in Jakarta Indonesia, 38 allied health care workers working in the field of apheresis showed an significant increase of their knowledge in apheresis. All 38 participants from Indonesia, Singapore and Malaysia could be certified on the requirements as resolved by this international group based on the outcome of the final test. To increase the knowledge on apheresis of physicians, this course is also of value for physicians.
This educational program composed by the “Joint Task Force for Apheresis Education and Certification” provides an approach to educate and test apheresis nurses en operators. The training program as made for and by nurses can lead to demonstrable presence of sufficient knowledge needed for a person who is qualified and capable doing his/her job. Besides this, the training provides also an important contribution to the apheresis nurses' motivation.
Second, it can be of help also to provide knowledge to physicians working in the field of apheresis. This can also be of help in GMP/ISO inspections and audits.