Introduction to Transplant Nursing
Solid organ transplantation offers the best treatment option for improved quality of life for people of all ages with end-stage solid organ disease (Galbraith & Hathaway, 2004
). Since the first successful kidney transplant was performed in 1954, solid organ transplantation has continued to advance as a treatment for end-stage organ diseases of the kidney, pancreas, liver, heart, lung, and small bowel.
The number of transplants worldwide continues to grow. The number of transplants completed in the United States in 1988 was 12,623. By 2007, the number had risen to 28,357. The number of individuals needing an organ continues to increase dramatically with the growing number of individuals with diseases such as diabetes and cardiovascular disease resulting in organ failure. The demand for solid organs for transplantation is greater than the number of donor organs available (UNOS, 2008
). Though living donation has expanded over the last 50 years to include other organs (e.g., liver and lung), the need for solid organs from both living and deceased donors continues to escalate.
The recent 50-year anniversary of the first successful transplant has drawn attention to the contribution of nursing to the success of transplantation. Multiple factors influence the provision of transplant nursing care. Transplant patients require specialized care based upon expert knowledge and skills from experienced transplant nurses. As the acuity of transplant patients increases and the length of hospitalization after
transplantation decreases, transplant nurses are required to provide high-level, expanded care to patients and their families outside the traditional hospital setting.
Advancing technology and treatments require transplant nurses to make a lifelong commitment to learning. Organ shortages require that transplant nurses help educate the community about the need to donate. Providing collaborative care as members of interprofessional teams of specialists is just one of the roles of transplant nurses. The global shortage of nurses in general, and transplant nurses in particular, continues to grow, and the transplant nurse will be challenged to provide the best care to transplant patients with limited resources. The population continues to live longer both with and without a transplant. Consequently, individuals must live many years with multiple chronic illnesses.
In the midst of these circumstances and changes, the transplant nurse continues to provide specialized care to patients, their families, and communities, blending the science and art of nursing. The nurse’s role and function is differentiated according to education, position description, and practice setting, with these factors further defining practice. Nursing education varies widely throughout the world; nursing practice varies dramatically as well. Because each country, state, and province has its own laws regulating nursing, the limits, functions, and titles for nurses may differ from state to state and country to country, particularly at the advanced practice level. Nurses must ensure that their practice remains within the boundaries defined by their governmental agencies. However, transplant nurses must continually examine their practice, looking for ways to improve the practice of nursing throughout the world.
This document addresses the role, scope, and standards of nursing practice for the specialty of transplant nursing. The scope of practice addresses the definition of transplant nursing, its various levels of practice based on educational preparation recognizing its worldwide variations, current clinical practice activities and sites, and current evidence-based practice relevant to transplant nursing. The standards of transplant nursing practice are objective, measurable statements of the responsibilities for which transplant nurses are accountable.
Solid organ transplantation is distinct from bone marrow transplantation, which treats diseases of the blood. Nursing care provided to bone marrow transplant recipients is covered in such publications as Statement on the Scope and Standards of Advanced Practice Nursing in Oncology (3rd Edition) from the Oncology Nursing Society (ONS) and Pediatric Oncology Nursing: Scope and Standards of Practice from the Association of Pediatric Hematology/Oncology Nurses (APHON).
Description of Transplant Nursing
Transplant nursing is specialized nursing care focused on protection, promotion, and optimization of the health and abilities of both the transplant recipient and the living donor across the life span. This care includes prevention, detection, and treatment of illness and injury related to diseases treated by solid organ transplantation, and diseases that may result from living donor donation in individuals, families, communities, and populations of all ages.
Transplant nursing is also specialized nursing care focused on protection, promotion, and optimization of the deceased organ donor and the living organ donor during the process of organ donation. This care includes prevention, detection, and treatment of illness and injury that may occur during the process of organ donation and recovery in individuals and families of all ages.
Transplant nursing encompasses care and support of the ill organ recipient or potential recipient who may have multi-organ and multisystem disease processes, the deceased donor, and the healthy person who desires to donate or has donated an organ. Transplant nursing requires knowledge of immunology, transplant pharmacology, infectious diseases, and psychological implications of caring for the morbidity and mortality faced by the potential transplant recipient, the organ donor, and their families and communities. In communities, transplant nurses provide organ donation support and education. Transplant nursing is the application of evidence-based care to individuals, families, and communities through all phases of the transplant process to optimize health, functional ability, and quality of life. This care includes assisting individuals of all ages, and their families and communities, with the transplant processes that may affect their lives.
Key elements of transplant nursing include:
Interventions that maintain or improve physiologic, psychological, and social health;
Interventions that facilitate and optimize behavioral change and treatment adherence with complex, lifelong therapies;
Advocacy to support patients and families in the planning, implementation, and evaluation of their care; and
System improvements to support optimal transplant outcomes.
Once a transplant or living donation occurs, transplant nurses continue to promote optimal health, disease and injury prevention, symptom recognition, disease management, and alleviation of suffering in individuals, families, and communities.
Transplant nursing also encompasses the optimization of the system in which transplant care is delivered. These aspects of care center on quality monitoring, collaboration, education, research, and administration. Other key elements of nursing care provided by transplant nurses include development, initiation, and maintenance of systems and processes that promote teamwork, collaboration, efficiency, and patient satisfaction. Transplant nursing is based on health provider education, patient safety, and care efficacy.
The relatively new area of transplant nursing research broadens the knowledge base of transplant nursing care. The dimensions of practice described above are just now beginning to be systematically tested through transplant nursing research. The International Transplant Nurses Society (ITNS) promotes transplant research and evidence-based practice by providing several research grants each year. The recipients disseminate their findings through the ITNS annual symposium and publications. There are many opportunities for research because transplant care is diverse and often specific to a given institution in which transplant care is provided.
Practice Settings and Roles
The transplant nurse works in a variety of settings, which may include the wards or units, intensive care units, and operating rooms of hospitals, ambulatory care clinics, other clinical facilities, and the community. The transplant nurse may concentrate on:
Clinical care (as a clinical nurse),
Coordination of care (as a transplant nurses coordinator):
for the transplant recipient (as a recipient nurse coordinator),
for the deceased donor (as a procurement nurse coordinator),
for the living donor (as a living donor nurse coordinator), or
Advanced clinical care (as an advanced practice transplant nurse).
The clinical nurse works in patient care wards or units, operating rooms, and clinics. The transplant nurse coordinator and advanced practice transplant nurse also work in a multitude of settings such as inpatient units, and outpatient clinics, providing direct patient care, coordinating all aspects of care, and providing support through education and research.
The procurement nurse coordinator often works in the intensive care environment and operating rooms, but may also travel to distant centers to provide patient and staff education and to assist with procurement of organs. Following donation efforts, the procurement nurse coordinator has a significant role in providing follow-up support and advocacy for donor families, often by phone or other electronic communications.
The living donor nurse coordinator works predominantly in clinics to prepare and educate donors about donating their organs. Following donation, the living donor nurse coordinator will follow patients for varying lengths of time to enhance recovery and continued health.
The transplant nurse coordinator, regardless of practice setting or concentration, is an ambassador for organ donation and transplantation and as such also has a role in education at public events, hospitals, and schools.
The table on the following page summarizes the nursing care focus of each of these roles. A more detailed discussion of the transplant nurse
coordinator begins on page 10
, and of the advanced practice transplant nurse begins on page 13
Transplant Nursing Roles and Foci of Nursing Care
Types of transplant nursing roles
Focus of nursing care
Transplant clinical care for the transplant plant patient, organ donor, and/or family
Recipient nurse coordinator
Coordination of care for transplant recipient
Procurement nurse coordinator
Pre-donation care, organ procurement, support for deceased donor family
Living donor nurse coordinator
Pre- and post-donation care of living donor
Advance practice transplant nurse
Leadership and advanced transplant clinical care
Development of Transplant Nursing Practice
Growth of Transplant Care and Transplant Nursing
Since the first kidney transplant over 50 years ago, transplant nursing practice has continued to evolve. Advances in transplantation care include improvements in transplant pharmacology, development of new transplant technology, and new surgical procedures to transplant other solid organs. The scope of nursing practice initially involved providing hospital- and community-based transplant care to individuals and families experiencing acute, chronic, and critical illnesses requiring transplantation, and deceased and living donors. The scope of practice has expanded to include people awaiting transplant in the hospital or community with life-supporting technology bridging them to transplantation, those living with a transplanted organ for many years, patients who are re-transplanted, and living donors after they have donated organs.
The current practice of transplant nursing requires extensive clinical knowledge and expertise to provide highly specialized acute, critical, or end-of-life care to hospitalized patients. The practice has also
expanded to include increased emphasis on organ donation through the education of individuals, families, communities, and other healthcare providers. Transplant nurses collaborate with individuals, families, communities, and other healthcare professionals to encourage patient self-care using symptom and disease management in order to improve patient outcomes.
Significant advances in transplant care for people who donate a solid organ or who receive a transplant create a need for many roles, such as caregivers, coordinators, educators, administrators, care managers, and quality specialists who optimize transplant outcomes. Transplant nurses manage and provide unique, complex treatments to donor and transplant patients. For example, the person receiving a heart and kidney transplant because of complications from diabetes mellitus will require patient education related to physiology, pathophysiology, self-monitoring, follow-up appointments, testing and lab results, medications, role changes, and safety. The transplant nurse must be knowledgeable to teach individuals and families about complex topics (physiology, pathophysiology, signs and symptoms to monitor, when to contact the transplant team, diet, exercise, role changes, and medications). The transplant nurse must also educate and support the patient’s caregiver. As transplant technology expands, caregivers are frequently required to provide home-based support and advanced care for someone who is awaiting or has received a transplant.
The transplant nurse seeks to go beyond the general nursing role of one who cares for a patient who happens to have a transplant. Instead, the transplant nurse demonstrates a strong interest in caring for individuals who have had a transplant or for those who are donating an organ, a desire to improve care for this unique population, and a love for lifelong learning related to transplant nursing. To be a transplant nurse requires a level of transplant nursing knowledge (basic or advanced) and transplant care nursing skills that are setting-specific and that include assessment, diagnosis, planning, implementation, and evaluation of transplant care that attains, maintains, or restores health or leads to a peaceful death. Transplant nursing roles have expanded to include more autonomous actions, including the development of advanced practice nursing roles such as the clinical nurse specialist and nurse practitioner.
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