In 2021, almost 2 million blood products/components were supplied from the UK's NHS Blood and Transplant service (Narayan, 2022). When performed by skilled, knowledgeable and experienced staff, the risks associated with a transfusion are minimal. Ensuring the right patient receives the right blood is fundamental in limiting incidences of transfusion reaction (Soliman and Elhapashy, 2021). Transfusion error, which results in the patient receiving the wrong blood type, is one of the most frequently occurring errors relating to transfusion interventions in the UK and 81.9% of the errors are preventable according to the Serious Hazards of Transfusion (SHOT) report (Narayan, 2022).
The SHOT report (Narayan, 2022) examined transfusion data from 2020-2021 and reported 35 blood transfusion-related deaths in the UK, more than 50% of which were preventable. The Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee (JPAC) (2022) identified that most incompatible blood transfusions occur due to the misidentification of the patient. The final check between patient and blood component is the last step in preventing a potentially fatal mis-transfusion. Checking the right blood is available for the right patient, at the right time and in the right place is essential in preventing transfusion errors. JPAC also stated that the blood administration process must be underpinned by three key principles: positive patient identification, good documentation and excellent communication (JPAC, 2022). Patient safety rests on the competence of staff, but also rigour in compliance with processes and competence in being able to apply processes.
Registered nurses should work within their level of competence (Nursing and Midwifery Council (NMC), 2018a) and this applies to blood and blood product administration; nurses must also be proficient in monitoring for potential adverse reactions. Despite this, a lack of fundamental skill and knowledge relating to blood transfusion practice is putting patients at significant risk (Soliman and Elhapashy, 2021; Narayan, 2022). The majority of errors can be attributed to inadequate patient identification, blood being stored incorrectly (for example, a delay between collection and administration) and, lastly, the wrong blood group being transfused (inappropriate ABO).
There are four main blood groups: A, B, AB and O (NHS website, 2023). Patients who receive blood transfusions are matched based on their blood type and the donor's blood type. Checking that blood to be transfused is compatible is the most important step in the clinical transfusion procedure and errors are frequently human errors and are often fatal (JPAC, 2022). NHS Improvement (2021) has classified the accidental transfusion of incompatible blood as a ‘never event’ (JPAC, 2022). The 2021 SHOT report (Narayan, 2022: 21) identified that the wrong blood component was transfused to patients 266 times in 2021. Fortunately, no deaths occurred; however, major morbidity was apparent in three patients (Narayan, 2022: 79). The report also stated that data from 2016-2021 show that 1778 ABO-incompatible near miss events occurred and 19 ABO incompatible red cells were transfused to the wrong patients (Narayan, 2022: 25). Errors such as these occur worldwide, and appear to be related to insufficient training of nurses and lack of experience due to limited clinical exposure to transfusion practice in some hospitals (Yesilbalkan et al, 2019).
Ensuring that nurses are educated and prepared for their role as a registrant in contributing to patient safety in blood transfusion delivery is vital and relies on comprehensive and effective education incorporating simulation-based approaches (Flood and Higbie, 2016; Bayram and Caliskan, 2020). Knowledge and skill remain fundamental to optimise patient safety and ensuring high-quality education for all health professionals is paramount. Health Education England (2020) has pledged to ensure there is parity, guidance, and a strategic vision through key performance indicators for simulation-based education in the healthcare sector. This should incorporate the teaching of blood and blood product administration in the skills laboratories for nursing students. The aim is to improve patient safety and, in transfusion administration, should help to significantly reduce the risk to patients.
The impact of COVID-19 on nurse education
Education and training are essential in blood transfusion to reduce the risk of adverse events (Jimenez-Marco et al, 2012). Improving knowledge and understanding and addressing the issue of patient safety needs to begin before registration to ensure that new registrants are well prepared for their role in the safe administration of blood products. This challenge has been even greater when one considers the experiences of health educators and pre-registration students during the pandemic. Even pre-COVID-19, student nurses may never have managed a transfusion or witnessed an adverse reaction in the clinical setting. Over the years 2020 and 2021 we have seen major disruption to all health and social care education (Agu et al, 2021) and so many of the skills required have been undertaken in the simulated environment. Simulation has been used to capture placement hours in the past, but this has been quite limited whereas, over the course of the pandemic, there has been a greater reliance on simulation to support students progressing through the nursing curriculum, gaining skills and competencies to ensure they complete their education as close to the planned completion date as possible (Luctkar-Flude and Tyerman, 2021).
There has been a radical change in the use of simulation as a means of capturing vital placement hours as a result of the pandemic, with the NMC publishing emergency standards (2020). Internationally, the Society for Simulation in Healthcare in association with the International Nursing Association of Clinical Simulation and Learning released a position statement calling for the use of simulation as a means of capturing clinical hours (Foronda and Armstrong, 2020). Although this was essential to produce much-needed nurses to join the workforce, simulation has also increased students' confidence and competence.
What next for nurse education?
While we are in the ‘recovery phase’ of the pandemic and placement environments are opening their doors to students once again, we need to continue to invest in and use our simulation environments to broaden the exposure window and stretch and challenge students in blood and blood component transfusion practice. The environment needs to be as authentic as possible and high-fidelity simulation plays an important role in the education of novice student nurses by boosting their confidence levels, and helping them to recognise high-risk, low-incidence events (Prentice and O'rourke, 2013). Not only does high-fidelity simulation provide the knowledge and skills to recognise adverse reactions, it also provides a safe environment whereby competencies in the blood transfusion process can be assessed (Breymier and Rutherford-Hemming, 2017; Agu et al, 2021).
Low-fidelity simulation can also play a part in the preparation of student nurses for their role in the safe management of blood transfusion. Excellent communication between staff and thorough and accurate documentation have been highlighted as crucial in the process and poor practice in these areas contributes to preventable errors (Narayan, 2022). Having the opportunity to undertake case studies in the classroom and documentation exercises in low-fidelity simulations can be as important as responding to transfusion reactions in the high-fidelity simulated setting. This combination of classroom and simulation setting activity would enable students to follow guidelines, perform recommended checks to ensure the correct blood product is being administered, as well as effective patient identity checks, and the early identification of transfusion reactions with the employment of appropriate interventions (Flood and Higbie, 2016; Bayram and Caliskan, 2020).
Education and training challenges and solutions
It is widely recognised and reported that there are gaps in knowledge among health staff in this area (Jimenez-Marco et al, 2012; Smith et al, 2014; Flood and Higbie, 2016; Tan et al, 2017; Kavaklioglu et al, 2017; Sapkota et al, 2018).
According to Tan et al (2017), at the point of registration, all nurses should be competent to administer blood products safely and monitor for potential adverse reactions. However, in this study, students demonstrated little understanding, rarely witnessed transfusions or possible adverse reactions during their education programme and the participants were non-compliant with the national standards for blood transfusions, which included suboptimal vital sign monitoring and deficiencies in documentation. Practice such as this poses significant risks to blood transfusion safety. As this study took place in 2017, issues regarding a student's competence in undertaking the management and monitoring of blood and blood components transfusion should now be addressed through the Standards of Proficiency for Registered Nurses (NMC, 2018b). The NMC Code (2018a: 32) states that the student should be able to undertake all procedures using an ‘evidence-based’ and ‘best practice approach’. Challenges exist in that safe blood transfusion practice could be taught and simulated but access to clinical exposure may still be limited. It is imperative that new registrants understand their limitations and access support where they perceive deficits exist (NMC, 2018a).
Several studies show this is a problem in many countries. Studies analysing nurses' practices surrounding blood transfusion have revealed that knowledge and practices were inadequate (Sapkota et al, 2018; Majeed et al, 2020; Jogi et al, 2021). Results of the study conducted by Majeed et al (2020) found that more than half of nurses followed the guidance and standards prior to initiating the blood transfusion but less than half carried out safe evidence-based management and practice during the blood transfusion. Sapkota et al (2018) identified that at the initiation of blood transfusion, vital signs assessment was undertaken in only 2-4% of the cases. Khetan et al (2018) observed that only 28% of participants in their study gained patient consent before initiating a blood transfusion. Jogi et al (2021) called for urgent action to address significant deficits in both knowledge and skills relating to transfusion of blood and blood products. Khetan et al (2018) advocated for regular audits, whereas others recommended educational programmes for nurses to improve blood transfusion practices in clinical areas, especially where blood transfusions occur less regularly (Najafpour et al, 2017; Encan and Akin, 2019; Yesilbalkan et al, 2019).
Additional methods of enhancing patient safety may lie in patient education. If patients themselves are informed of transfusion reaction signs and symptoms they too may help reduce or prevent risks of morbidity and mortality (Najafpour et al, 2017). Although Tan et al (2017) found inadequate levels of knowledge and understanding in their student nurse sample, conversely, if student nurses experienced placements where blood transfusions were initiated on a regular basis, they found that the students were more inclined to develop the further knowledge and skills required to enhance their own practice.
Yesilbalkan et al (2019) undertook an intervention study with 60 qualified nurses in a haematology department. There was a statistically significant improvement in knowledge among the intervention group. Smith et al (2014) identified a safe level of knowledge among healthcare staff after completing an educational programme. However the retention of this knowledge can be poor and there was evidence of diminishing competence. Yesilbalkan et al (2019) suggested that ongoing in-service training would be required to continue to maintain and build on knowledge.
Examination of these studies shows that, despite pre-registration education, maintaining competence is a challenge and it may be that regular exposure in practice, with frequent short skills training courses to troubleshoot and promote excellence in practice may be the best route in promoting patient safety (Smith et al, 2014; Yesilbalkan et al, 2019).
Educational provision in pre-registration nursing is challenging, especially with the increasing skill requirements of the NMC. Making the transition from classroom to practice may present challenges and nursing students may lack the confidence and experience when faced with patients in the clinical environment (Guimond et al, 2011). Bayram and Caliskan (2020). Flood and Higbie (2016) stated that virtual reality simulations during student nurses' training enables them to develop skills, build confidence and prepare for clinical practice, particularly following a didactic lecture as this appears to strengthen cognitive learning and aid knowledge retention.
The classic concept ‘from novice to expert’ developed by Benner (1982) suggested that nurses develop skills and an understanding of patient care over time and that it takes a strong educational foundation plus personal experience to become an expert. This model could be applied to a nurse's level of knowledge and competence surrounding blood transfusion practice. Benner (1982) argued that to become an expert in a clinical field usually takes between 2 and 3 years. A ‘novice’ nursing student who has had no experience in monitoring patients for blood transfusion reactions would, according to Benner's (1982) theory, not be able to predict possible adverse reactions, for example. Therefore they would not be competent upon qualifying even though they had an understanding through theoretical learning and simulation. It would take experience to become an ‘advanced beginner’ and, later, ‘competent’ through nursing patients who have had similar symptoms.
Jimenez-Marco et al (2012) stated that nurses who had education and training and frequently transfused blood had the best practice outcomes, which supports Benner's (1982) hypothesis. Tan et al (2017), however, stated that nursing students should have the knowledge and skills to transfuse upon qualifying as this is crucial when entering clinical practice. Optimised learning by using a blend of theory and simulation could enhance transfusion practice (Tan et al, 2017). However, assessment of the newly qualified nurse by a registered nurse who is deemed competent in blood transfusion practice, in addition to the newly qualified nurse's own accountability and awareness of their limitations, may be a more preferred method of maintaining patient safety.
Box 1 presents some recommendations for educators and managers.
Box 1.Recommendations
- Training is recommended on the potential hazards of blood transfusions, the prevention of errors, patient safety, and the importance of compliance with guidelines. An awareness that human factors can contribute to errors is essential
- To ensure patient safety, pre-registration and post-registration nursing programmes need to maximise clinical competence through clinical simulation and didactic taught elements
- A key recommendation of the 2019 annual SHOT report (Narayan, 2020) echoes the blood transfusion guidance from the National Institute for Health and Care Excellence (2015), advising that clinical and laboratory staff should be trained in the fundamentals of transfusion, human factors, cognitive biases, investigating incidents and patient safety principles. Such a holistic approach will ensure safe, high-quality, patient-centred care and help embed an organisation-wide culture of learning from patient safety incidents
Conclusion
Education and training are fundamental to ensuring health professionals have the knowledge and skills to provide high-quality, safe and effective patient care. To ensure up-to-date knowledge and skills, staff must have regular training to maintain and develop evidence-based practice and competence to reduce the risk of errors and improve patient outcomes.
Smith et al (2014) highlighted a reduction in participants' recognition of the importance they placed on safe practice and adherence to guidelines over time and supported the need for frequent refresher courses to ensure best practice.
Providing student nurses with the opportunity to witness blood transfusions, along with lecture and simulation exercises (Flood and Higbie, 2016) should help to increase their ability to safely administer blood and blood products and follow the pre- and post-transfusion checks, while also monitoring patients for adverse reactions. Ensuring personal accountability, awareness of limitations and assessment of the skill attainment of newly qualified or newly appointed qualified staff is imperative before delegation of this potentially harmful intervention.
Limitations inherent in this discussion paper include an appreciation that there is no standardised approach to nurse education worldwide, therefore comparisons across geographical areas may be challenging. However, key and consistent messages emerged from the research. Preventable transfusion errors remain a major cause of morbidity and mortality and more focus should be given to educating future nurses and those already qualified no matter the grade or level of experience. With the NHS's ambition to become the safest healthcare system in the world (NHS England/NHS Improvement, 2019) addressing deficits in nurses' knowledge is essential so that the public can be assured that those caring for patients who are undergoing transfusions of blood and blood products are skilled, up-to-date and competent practitioners.
KEY POINTS
- Education is vital in ensuring blood transfusion safety for patients
- To maintain competence, staff should engage in regular updates and maintain their transfusion practice
- Clinical simulation can support competence and confidence in transfusion practice
- Pre-registration nurse education in the management of blood transfusions is crucial as it can lay a strong educational foundation for safe practice by the newly qualified nurse
CPD reflective questions
- As a newly qualified nurse how did you ensure your competence in the management of blood transfusions?
- How can you support a newly qualified nurse in the management of blood transfusion practice in your clinical area?
- What strategies could you instigate in your area to enhance safe blood transfusion practice?