VOL: 103, ISSUE: 8, PAGE NO: 44
Sarah Dodds, BSc, RGN, is matron, respiratory medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter; Graham Williamson, PhD, MA, BA, PGDiPEd, is senior lecturer, University of PlymouthFollowing the introduction of new guidelines in February 2006, assessments for long-term oxygen therapy are now being undertaken by respiratory nurse specialists. The key skill required is arterial blood gas sampling. This has traditionally been the role of the doctor, however by using an education and training package along with a competency-based assessment, nurses can now perform this extended role. Sarah Dodds and Graham Williamson describe a competency-based education and training programme for nurses to carry out this procedure.
Following the introduction of new guidelines in February 2006, assessments for long-term oxygen therapy are now being undertaken by respiratory nurse specialists. The key skill required is arterial blood gas sampling. This has traditionally been the role of the doctor, however by using an education and training package along with a competency-based assessment, nurses can now perform this extended role. Sarah Dodds and Graham Williamson describe a competency-based education and training programme for nurses to carry out this procedure.
Arterial blood gas (ABG) sampling is an essential component of the assessment of patients who may require long-term oxygen therapy (Royal College of Physicians, 1999). It is also used to assess any patient with respiratory failure following assessment if physical abnormalities - for example, changes in respiratory rate, breathing pattern and cyanosis - are present. Arterial blood is sampled for subsequent blood gas analysis by an analyser.
Traditionally, doctors carry out ABG sampling, however with the development of new ways of working, respiratory specialist nurses at Royal Devon and Exeter NHS Foundation Trust have set up a programme of education and competency-based assessment so they can undertake this extended role. The initiative also provides training for nurses who are monitoring patients receiving ventilatory support in the respiratory HDU. The British Thoracic Society (2002) guidelines recommend that staff providing non-invasive pressure ventilation should be able to carry out ABG measurement, rather than relying on the on-call doctor.
Developing training that is competency-based
A pilot group of respiratory specialist nurses and senior nurses on the respiratory HDU at Royal Devon and Exeter NHS Foundation Trust attended a half-day teaching session by the respiratory consultant. This covered the theoretical and practical procedures, including the Allen test (Box 1), and the relevant anatomy, contraindications and possible complications of the procedure. Procedural guidelines were produced for the training.
Education and training competencies
The education and training competencies aimed to enable registered nurses to perform ABG sampling safely, without causing the patient unnecessary trauma and discomfort. It was decided that nurses conducting this procedure must meet the following criteria:
- Have their name entered in the NMC register;
- Be willing to be involved in the procedure;
- Be confident in their own level of competence;
- Keep themselves updated with developments and changes related to the procedure of ABG sampling.
This training programme comprises a self-directed learning package, a demonstration by medical staff and supervised clinical practice.
Nurses must complete a learning package and be supervised and assessed by a competent senior house officer for at least a month, or the final competency assessment nurses must perform three arterial samples under the supervision of a specialist registrar or consultant (Box 2). They are only able to perform this procedure on the radial artery and are limited to two attempts on any one patient; they must also maintain their expertise by performing at least three arterial samples a month. The practical assessment included preparing the patient for the procedure as well as assessingthe nurse's approach to the patient and the care of the patient during and following the procedure. Within two months of the teaching programme participants had to complete the theoretical component of the course and demonstrate in writing that they could:
- Describe the anatomy and physiology of the artery and surrounding tissues, including veins and nerves;
- List four hazards associated with ABG sampling, specifically related to blood-borne diseases;
- List four complications of ABG sampling and outline measures to prevent them;
- List six contraindications for performing ABG sampling.
Evaluation and conclusion
The respiratory nurse specialists involved in the pilot soon became competent in ABG sampling and use it regularly. However, due to a high turnover of senior nurses on the respiratory HDU, it had limited success in this area. To compensate for this, there are plans to teach a larger group of nurses.
This is a useful example of how a doctor-led service is now nurse led; ABG sampling is now a core skill for respiratory nurses and is also used on acute medical assessment units and respiratory wards. In response to changes in the assessment of patients needing long-term oxygen therapy, this competency framework could help respiratory assessment centres equip respiratory nurses with appropriate training to undertake the oxygen assessments.
British Thoracic Society Standards of Care Committee (2002) Guidelines on non- invasive ventilation in acute respiratory failure. Thorax; 57: 3,192-211.
Girling, K.J., Hobbs, G.J. (1997) Arterial Blood Sampling and Peripheral Arterial Cannulation in Essential Medical Procedures.London: Arnold
Royal College of Physicians (1999) Domiciliary Oxygen Therapy Services: Clinical Guidelines for Prescribers.London:RoyalCollege of Physicians.
Thomas, A.N. (1994) Arterial Puncture in Procedures in Practice, 3rd edition. London: BMJ Publishing Group.
The authors are developing this work as an elearning resource and have become Fellows of the Centre of Excellence in Professional Placement Learning at the University of Plymouth. Anyone wishing to take part in piloting this resource, free of charge, should email email@example.com