Transplant Nursing SS v9.0doc (1)

CONTENTS

AcknowledgmentsScope and Standards of Transplant Nursing Practice

Function of the Scope of Practice StatementFunction of Standards

Scope of Transplant Nursing PracticeIntroduction to Transplant NursingDescription of Transplant Nursing

Key ElementsResearchPractice Settings and Roles

Development of Transplant Nursing PracticeGrowth of Transplant Care and Transplant Nursing International Transplant Nurses Society (ITNS)

Practice Characteristics: Collaboration and Role DifferentiationClinical Transplant Nurse/Transplant Nurse GeneralistTransplant Nurse Coordinator Advanced Practice Transplant Nurse

Specialty Certification for Transplant NursesEducational Requirements for Transplant NursesKnowledge and Skills Base of Transplant NursingGlobalization of Transplant NursingPalliative Care and Transplant NursingEthics and Informed Decisions Future Considerations

Standards of Transplant Nursing PracticeFunction of Standards

Standards of Practice for Transplant Nursing Standard 1. Assessment

Standard 2. Diagnosis

Standard 3. Outcomes Identification

Standard 4. Planning

Standard 5. Implementation

Transplant Nursing: Scope and Standards of Practice 12014 July Revision

Standard 5a. Coordination of Care

Standard 5b. Health Teaching and Health Promotion

Standard 5c. Consultation

Standard 5d. Prescriptive Authority and Treatment

Standard 6. Evaluation

Standards of Professional Performance Standard 7. Quality of Practice

Standard 8. Education

Standard 9. Professional Practice Evaluation

Standard 10. Collegiality

Standard 11.Collaboration

Standard 12. Ethics

Standard 13. Research

Standard 14. Resource Utilization

Standard 15. Leadership

Glossary

References

Index


SCOPE AND STANDARDS OF TRANSPLANT NURSING PRACTICE

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.

Function of the Scope of Practice StatementThe scope of practice statement (pages xx–yy) describes the “who,” “what,” “where,” “when,” “why,” and “how” of a particular nursing practice. Each of these questions must be sufficiently answered to provide a complete picture of the practice, its boundaries, and membership. The depth and breadth in which individual registered nurses engage in the total scope of nursing practice is dependent upon that individual’s education, experience, role, and the population being served.

Function of StandardsThese Standards are comprised of standards of practice (pages zz–aa) and standards of professional performance (pages bb–cc). These are authoritative statements that describe the duties of nurses practicing within the roles, population, and specialties governed by this document (Transplant Nursing: Scope and Standards of Practice) and those they are expected to competently perform. The Standards published herein may be utilized as evidence of the legal standard of care that govern nurses practicing within the roles, population, and specialties governed by this document. The Standards are subject to change with the dynamics of the nursing profession and as new patterns of professional practice are developed and accepted by the nursing profession and the public. In addition, specific conditions and clinical circumstances may also affect the application of the Standards at a given time; e.g., during a natural disaster. The Standards are subject to formal periodic review and revision.

The measurement criteria that appear below each standard are not all-inclusive and do not establish the legal standard of care. Rather, the measurement criteria are specific, measurable elements that can be used by nursing professionals to measure professional performance at the basic level of practice for each particular role. Nurses practicing within a particular role, population, and specialty can identify opportunities for development and improvement by evaluating performance on these elements.


SCOPE OF TRANSPLANT NURSING PRACTICE

Introduction to Transplant Nursing Solid organ transplantation remains the best treatment option for improved quality of life for people of all ages with end-stage solid organ disease. 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; and has expanded as a treatment option to countries across the globe.

The number of transplants worldwide continues to grow with 114,690 reported in 2012 (http://www.transplant-observatory.org). As an example of this rapid growth in 1988 the number of transplants performed in the United States was 12,623 and by 2013 the number had risen to 28,954 (http://optn.transplant.hrsa.gov). The number of individuals needing an organ also continues to increase dramatically as people live longer with chronic conditions such as diabetes and cardiovascular disease which result in organ failure. The resulting demand for solid organs for transplantation has for many years outpaced the number of donor organs available for transplantation in the United States and world-wide. Though living donation has expanded over the last 60 years to include organs other than kidneys (e.g., liver and lung), the need for solid organs from both living and deceased donors continues to escalate.

Throughout the history of organ transplantation, nursing has played a major role in the provision and advancement of the care of organ recipients and donors as well as their families. Multiple factors influence the provision of transplant nursing care that requires specialized care based upon expert knowledge and skills from experienced transplant nurses. The acuity of transplant recipients and complexity of deceased and living donor care, tied with the movement to minimize the length of hospitalization after transplantation requires the provision of high-level, expanded care inside and outside the traditional hospital setting.

The field of organ transplantation has advanced rapidly since its inception and continues to make major strides as new technology, procedures, and treatments emerge. This changing landscape requires that transplant nurses make a lifelong commitment to learning and assume roles outside traditional patient care. Providing collaborative care as members of an interprofessional team of specialists is just one of the roles of transplant nurses. Because of the shortage of organs for transplantation, transplant nurses play an essential role in donor awareness. Other transplant nurses may become involved in research to help improve transplant recipient outcomes or the care of organ donors.

A global shortage of nurses exists which presents particular challenges for transplant nurses who must provide the best care possible to transplant patients in a multifaceted and dynamic field at a time of limited resources. Moreover, as the


http://optn.transplant.hrsa.gov/

http://www.transplant-observatory.org/

population continues to age and experience multiple chronic conditions, the care required by transplant recipients both in the hospital and community is becoming increasingly complex. Transplant nurses practicing in this changing environment continue to provide specialized care to organ recipients and donors, their families, and communities incorporating both the science and the art of nursing.

The roles and functions of transplant nurses are differentiated according to education, position description, and practice setting, with these factors further defining practice. As an international specialty, transplant nursing is further influenced by differences in nursing education, nursing practice, nursing research, and systems of health care delivery across national boundaries. Because each country, state, and province has its own laws regulating nursing practice, the limits, functions, and titles for nurses may differ by state and country, particularly at the advanced practice level. Nurses must ensure that their practice remains within the boundaries defined by their respective governmental agencies. However, regardless of where they live and work, transplant nurses must continually be in search of methods and strategies to improve and enhance nursing practice and science.

Solid organ transplantation is distinct from bone marrow transplantation which is used to treat hematologic disorders. Nursing care of bone marrow transplant recipients is described by the Oncology Nursing Society in the Statement on the Scope and Standards of Oncology Nursing Practice: Generalist and Advanced Practice (2014)and also by the Hematology/Oncology Nurses in the Pediatric Oncology Nursing: Scope and Standards of Practice(2009).

Description of Transplant NursingTransplant nursing is the delivery of 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. Throughout this document, the term ‘patient’ denotes both transplant candidates/recipients and living donors. Care of these patients 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. Such care may be delivered at the level of the individual, their family and support system, community, and to populations of all ages. In addition, transplant nursing includes the prevention of further disease and promotion of optimal health and well-being of organ recipients and donors. Transplant nurses not only care for the patient but also have a commitment to the care of their families.

Transplant nursing encompasses care and support of the patient awaiting transplantation or an organ recipient who may have multi-organ and multi-system disease processes, the deceased donor, and the healthy person who desires to donate or has donated an organ. To accomplish this, transplant nurses must have a knowledge base in immunology, transplant pharmacology, and infectious diseases.


Transplant nurses must also understand the psychological implications of caring for transplant recipients in regard to the risks of subsequent morbidities and the possibility of death. In communities, transplant nurses provide education and support for organ donation. These activities are accomplished through the application of evidence-based care to individuals, families, and communities through all phases of the transplant process with the goal of optimizing health, functional ability, and quality of life.

Transplant nursing also encompasses the optimization of the health care 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.

Key Elements

Key elements of transplant nursing include:

Education of the patient, their family and support system, and the community

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, their families and support systems, in the planning, implementation, and evaluation of their care

System improvements to support optimal transplant outcomes

Research to broaden and enrich the knowledge base of transplant nursing, provide evidence for practice, and bridge practice and theory

Practice Settings and Roles

The transplant nurse works in a variety of inpatient, outpatient, and community settings, including wards or clinical units, intensive care units, operating rooms of hospitals, ambulatory care clinics and other clinical facilities in the community. Regardless of role or setting, all transplant nurses serve as ambassadors for organ donation and transplantation.

The roles transplant nurses in these settings focus on:

Clinical care (Clinical Transplant Nurse or Transplant Nurse Generalist)

Coordination of care (Transplant Nurse Coordinator)

o for transplant recipients (Recipient Nurse Coordinator),

o for deceased donors (Procurement Nurse Coordinator),


o for living donors (Living Donor Nurse Coordinator)

Advanced clinical care (Advanced Practice Transplant Nurse)

The Clinical Transplant Nurse, also known as the Transplant Nurse Generalist in some countries, provides patient care primarily at the bedside, in inpatient wards or units and operating rooms, and may practice in outpatient clinics in the community. Regardless of the setting, or type of transplant, clinical transplant nurse generalists focus on the delivery of direct care and education to recipients, donors, and/or their families.

The Transplant Nurse Coordinator provides both direct and indirect patient care. Transplant coordinators are responsible for synchronizing all aspects of transplant care across settings ensuring high quality, efficacious, safe care. Transplant coordinators further their efforts for optimal patient and family outcomes through education and research for patients and families, as well as the transplant healthcare team. Transplant Nurse Coordinators often focus on provision of care for recipients or organ donors as described below.

The Transplant Recipient Coordinator usually practices in an outpatient or clinic environment with responsibilities that often extend into the community. Transplant Recipient Coordinators are responsible for guiding candidates for organ transplantation through the pre-transplant evaluation. This involves coordinating all aspects of care including assuring all necessary pre-transplant tests and procedures are performed, providing educational information and emotional support, and following patients for varying lengths of time post-transplant.

The Procurement Nurse Coordinator may practice in the intensive care environment, emergency and trauma units, and operating rooms, but may also travel to distant centers to provide patient and staff education and to assist in organ procurement. Following donation efforts, the procurement nurse coordinator has a significant role in providing follow-up support and advocacy for donor families.

The Living Donor Nurse Coordinator works predominantly in clinics or outpatient settings to prepare and educate potential donors about organ donation. Following donation, the living donor nurse coordinator will follow patients for varying lengths of time to help promote full recovery of both physical and mental health.

The Advanced Practice Transplant Nurse works in a multitude of settings such as inpatient units, outpatient clinics, and the community. In the United States, there are four categories of Advanced Practice Registered Nurses (APRN); Nurse Practitioners, Clinical Nurse Specialists, Nurse Anesthetists, and Nurse Midwives.


However, these categories, related titles, role responsibilities, and educational requirements vary across national boundaries. Regardless, Advanced Practice Nurses are generally the most experienced nurses who serve in a variety of roles delivering an advanced level of patient care. Advanced practice transplant nurse roles have evolved from general APRN roles to those that are specialty-based within transplant.

New Roles continue to emerge as health care systems around the world and will continue to evolve as the field of transplantation expands and becomes more complex. As these new roles develop and are integrated into the practice environment it should be anticipated that many will have overlapping functions or alternate names for existing or similar roles. Over time, as these roles are incorporated in the health care system, roles that are sustainable will become more well-defined and consequently the nomenclature will become more consistent.

A more detailed discussion of the roles of transplant nurses roles begins on page xx.

Development of Transplant Nursing PracticeGrowth of Transplant Care and Transplant Nursing

Since the first kidney transplant was performed over 60 years ago transplant nursing has continued to evolve as solid organ transplantation became the treatment of choice for many end-stage organ diseases. Major advances in the field are primarily the result of progress in transplant pharmacology, state-of-the-art technologies, and advanced surgical techniques. More recently, advances that are impacting practice include the development of an innovative system of “transplant chains” to generate a series of linked living-donor transplants which has increased the donor pool and progress in the areas of genetics, immunology, ventricular assist, sustainable organ perfusion pumping, stem cell, and composite transplantation.

As we look toward the future we can anticipate further innovations in the areas of total artificial heart implantations; immunosuppression-free tolerance, and xeno-transplantation; further development and use of electronic health records, telemedicine, direct consumer use of self-monitoring devices, artificial intelligence, bioinformatics, and application of nanotechnology. As the field of transplantation has developed, so has the role and scope of transplant nursing practice. Initially, transplant nursing practice involved providing hospital- and community-based care to individuals and families experiencing acute, chronic, and critical illnesses requiring transplantation, and to deceased and living donors. The scope of practice has expanded to include transplant candidates in the hospital or community on life-supporting bridge technology,


long-term survivors of solid organ transplantation, and the post-operative living donor.

Today, care delivered by transplant nurses goes beyond the basic care of transplant candidates, recipients, donors, and their families. The complex healthcare needs of today’s patients require a high degree of proficiency among transplant nurses. Being a proficient transplant nurse, at any level or in any role, requires a thorough knowledge of transplant nursing knowledge and skills that is appropriate for the nurse’s level of practice, is setting-specific, and includes assessment, diagnosis, planning, implementation, and evaluation of transplant care that attains, maintains, or restores health or supports palliative care. To accomplish this, transplant nurses must demonstrate a keen interest in improving the care of this population and seek new knowledge and specialty-enhancing interests through education, mentoring, professional organizations, and clinical experiences.

International Transplant Nurses Society (ITNS)

There are several transplant organizations that provide continuing education and professional growth opportunities for transplant professionals. Among these, the International Transplant Nurses Society (ITNS) was founded in 1992 as an organization specifically committed to the promotion of excellence in transplant clinical nursing through the provision of educational and professional growth opportunities, interprofessional networking, collaborative activities, and nursing research. ITNS serves the educational and professional needs of over 1,900 transplant nurses and is composed of 32 national and international local chapters that promote transplant nursing throughout their geographical region and transplant centers..

The goals of ITNS are to:

Provide a network for communication among professional nurses with a focus and commitment to transplantation.

Provide a means of continuing education for professional nurses with a focus in transplant nursing.

Examine new trends in transplantation affecting patient care and the role of the transplant nurse.

Promote and support research in transplant nursing. Distribute the results of scientific investigations among professionals

interested in transplantation. Foster an awareness of ongoing ethical considerations in procurement,

donation, and recipient awareness. Ensure the accomplishment of the proper and lawful purposes and

objectives of the Society. Ensure the accomplishment of the proper and lawful purposes and

objectives of the society.


Through the Board of Directors, ITNS is committed to the field of transplantation and strives to maintain the mission and integrity of the society through its activities and educational collaborations. ITNS promotes transplant research and evidence-based practice by providing several research grants each year. The grant recipients disseminate their findings through the ITNS annual symposium and publication. ITNS promotes adherence and patient self management through the publication of educational brochures in a variety of languages that address post-transplant problems (diabetes, skin cancer, gingival hyperplasia, gastrointestinal complications, etc.) as well as strategies for maintaining a healthy lifestyle following transplantation.

Practice Characteristics: Role Differentiation and CollaborationGiven the complexity of care required by a diverse transplant population, the need exists for a variety of roles within transplant nursing to optimize patient outcomes. These roles include caregivers, coordinators, educators, administrators, care managers, quality specialists, and others. Within these roles, transplant nurses manage and provide complex and often unique care to donors and transplant recipients. For example, transplant recipients typically have multiple co-morbidities that require comprehensive care and patient education that addresses the multiple disease processes, self-monitoring and management of each condition, and the psychosocial aspects of transplantation including role change, the potential for family stressors, financial concerns and mood disorders. The transplant nurse must have a thorough understanding of these complex topics in order to provide the appropriate care and teach individuals and families how to care for their health and when to contact the transplant team.

Due to the complexity and growing body of knowledge related to the care of transplant recipients, transplant nurses commonly specialize their practice in either donor or recipient care. Such role differentiation also serves to enhance donor and recipient advocacy and confidentiality, reduce conflict of interest, and facilitate the acquisition of more in depth knowledge and skills.

The various roles fulfilled by transplant nurses may include, but are not limited to the clinical or transplant nurse generalist, transplant nurse coordinator, educator, case manager, counselor, patient advocate, consultant, research nurse, nurse scientist, leader, administrator, and advanced practice registered nurse. Some emerging roles transplant nurse are assuming are in the areas of quality improvement, regulatory education and oversight, and patient safety. Regardless of their role, the transplant nurse serves as an advocate for organ donation and transplantation, working to increase awareness among healthcare professionals and the community.

Role differentiation provides a cadre of highly skilled expert professionals within nursing and across the health professions, all focused on providing the best possible care of their patients. However, the interplay of multiple co-


morbidities, patient care requirements, and overlapping areas of practice require close collaboration among all health care providers. Such collaboration often takes place in team meetings where patient needs and care is discussed, as well as on a daily basis as patient care is undertaken and problems unfold.

Regardless of the setting or circumstances where collaboration among health professions occurs, the goal is always to provide comprehensive, ethical, and evidence-based care. The accomplishment of this goal requires mutual respect among professional colleagues for the unique knowledge and skills each possess. It is these unique talents possessed by individual team members that enable the group as a whole to address the vast array of problems transplant patients encounter.

Clinical Transplant Nurse/Transplant Nurse Generalist

The transplant nurse working at the generalist level, most commonly a clinical nurse, delivers specific services on a routine basis to patients and their families. A registered nurse license or international equivalent is required. At a minimum, the transplant nurse practicing at this level must obtain pre-licensure education, clinical experience, and ongoing continuing education as recommended for all nurses. Preparatory courses are offered to the nurse who wants to specialize in transplantation, or the nurse may receive formal or informal institution-specific training under the supervision of an experienced transplant nurse. Transplant nursing practice at the generalist level includes, but is not limited to, assessment, diagnosis, outcome identification, plan of care, interventions, and evaluation of care.

Transplant Nurse Coordinator

While the general role of transplant nurse coordinator is unique to transplantation, it is similar to a case manager in its role diversity. Most transplant coordinators are registered nurses however, they may be licensed as other healthcare providers such as social workers or paramedics. Transplant coordinators often have population-specific roles as described below; however, all transplant nurse coordinators have some common role characteristics. The transplant nurse coordinator:

Has experience in nursing and transplantation

Has a global transplant nursing perspective with a focus on long-term outcomes

Learns from experience what to expect in a given situation and alters plans accordingly

Has an intuitive grasp of situations and operates from a deep understanding of the situation


Recognizes when situations are outside the expected and uses analytical skills and abilities to investigate alternative perspectives

Conducts comprehensive assessments

Promotes health and the prevention of injury and disease

Serves as an advocate and educator

Mentors, delegates, and provides feedback to their support team,

Participates in quality assurance process improvement (QAPI) to improve transplant nursing practice, patient outcomes, and processes

Provides consultation and education to healthcare providers and the community regarding transplant issues

Possesses an understanding of regulatory requirements and incorporates these into their practice

Participates in research to improve transplant nursing practice

The procurement nurse coordinator ensures compassionate and confidential care for all deceased donors and their support system, allowing them to fulfill their wish to donate the gift of life. The role of this coordinator varies internationally. In addition to the care delivered by the general transplant nurse coordinator, the procurement nurse coordinator’s care includes, but is not limited to:

Assessment and management of physiological processes of the deceased donor

Teaching team members, community partners, and/or deceased donor families and others about the donation process

Coordinating the process of organ removal

Facilitating allocation to the recipient

The living donor nurse coordinator works with people who wish to donate an organ to ensure potential donors are fully prepared for this experience, are competently evaluated from both physical and psychological perspectives, and followed closely long-term to optimize outcomes. In some cases, this coordinator is also designated as a “donor advocate”. In addition to the general transplant nurse role, the living donor nurse coordinator’s care may also include:

Education of the potential donor regarding the donor and recipient process

Assessment and management of the living donor’s emotional response to donation during all phases of the process

Management of the living donor’s goals and outcomes of donation


Recognition of the financial impact on the living donor

Follow-up of the long-term health of the donor

The recipient nurse coordinator provides care to the potential transplant recipient both before and after transplantation. It may be a role with combined pre- and post-transplant care responsibilities or focused on a specific time period within the continuum of transplant care.

Pre-transplant care – The recipient nurse coordinator focuses on managing issues related to organ failure to ensure the patient remains in optimal health, enabling the patient to proceed with transplantation when a suitable organ is available. In addition to the general transplant nurse role, the recipient nurse coordinator’s pre-transplant care includes, but is not limited to:

Managing the potential recipient’s evaluation to determine candidacy status

Assessing and managing the candidate’s health throughout the process and while on the waiting list so that the candidate is in optimal physiological, psychological, and psychosocial health at the time of transplant

Supporting the transplant candidate during the potentially long wait for transplant by developing and enhancing their coping skills

Providing anticipatory teaching about post-transplant issues including: medications, signs and symptoms of infection and rejection, chronic care needs, post-transplant follow-up routines, and potential psychosocial issues

Post-transplant care – The recipient transplant nurse coordinator helps the patient achieve the highest level of wellness possible. In addition to the general transplant nurse role, the nurse’s post-transplant care includes:

Providing emotional support

Patient education including: medications and adherence; signs, symptoms, diagnosis, treatment and outcome of rejection and infection; chronic care needs and potential post-transplant complications; psychosocial needs and complications; follow-up schedule with the transplant team; routine labs, procedures and tests; and healthy living issues post-transplant.

Advanced Practice Transplant Nurse


The Advanced Practice Registered Nurse (APRN) is “a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master’s degree is recommended for entry level” (http://international.aanp.org/Practice/APNRoles).

In transplant nursing, the APRN functions in the position of nurse practitioner or clinical nurse specialist. Most countries require graduation from an approved school of nursing for advanced practice but may or may not require a registered nursing license. The advanced practice roles include, but are not limited to:

Specialized and expanded knowledge and skills

Advanced assessment and ability to synthesize data and interventions

Significant role autonomy, with the integration and application of a broad range of theoretical and evidence-based knowledge.

The overall role of the APRN in transplant nursing is to provide leadership and advanced clinical expertise to promote optimal patient outcomes and promote the growth of transplant nursing at the institutional, national and international level.

The nurse practitioner (NP ) specializing in transplant care is a nurse who has completed advanced nursing preparation at the master's or doctoral level. The role requires expanded knowledge and skills for providing expert care to individuals or populations who require solid organ transplantation for end stage organ disease. The NP is skilled in formulating a differential diagnosis. The NP combines patient assessment findings with scientific and clinical knowledge, behavioral science, health and illness experience, pathophysiology, psychopathology, epidemiology and infectious disease. The NP assesses clinical manifestations of acute illness, chronic disease, emergency health needs, and normal health events; using these skills and their knowledge to diagnose illness and disease.

Collaboration and consultation with other disciplines helps provide targeted health services that meet individual patient’s needs according to evidence-based practice, scientific rationale, and evidence-based guidelines. From the differential diagnosis through the physical exam and diagnostic and laboratory investigations, the NP provides pharmacologic and non-pharmacologic treatments for the management and treatment of acute and chronic illness and disease. The NP’s practice demonstrates effective health promotion and prevention of illness and complications in the transplant recipient’s care. The NP practices in primary, acute, and long-term settings and performs both autonomously and in collaboration with other healthcare professionals to treat and manage health problems related to


transplantation. The NP serves as a patient advocate for individuals, families, groups and communities, and may also practice as a researcher and a consultant.

The clinical nurse specialist (CNS ) in transplant care is a nurse who has completed advanced nursing preparation at the master's or doctoral level as a CNS. The CNS is a clinical expert who works with patients and their families, the healthcare team and the organization (AACN 2011). As an expert in evidence-based transplant nursing practice, the CNS promotes prevention strategies as well as treats and manages the health problems of transplant patients and populations. The CNS practices autonomously, integrating knowledge of disease and medical conditions into the prevention, assessment, diagnosis and treatment of patients' illnesses. The CNS works collaboratively with other members of the healthcare team. The CNS designs, implements, and evaluates both patient-specific and population-based programs of care. The CNS in transplantation acts as a leader by advancing the practice of transplant nursing to achieve quality and cost-effective patient outcomes and by guiding interprofessional groups to design and implement innovative solutions to systems and patient care problems. As a direct care provider, the CNS in transplantation performs comprehensive health assessments, forms differential diagnoses, and in some states and countries, may have prescriptive authority to prescribe pharmacologic and non-pharmacologic treatments for the direct management and treatment of acute and chronic illness and disease. The CNS in transplantation serves as a patient advocate, consultant and educator, and conducts and interprets quality improvement projects and research to improve practice.

Specialty Certification for Transplant NursesThe transplant nurse can further demonstrate commitment to improving the quality of nursing care by pursuing certification in the field of transplantation. Certification is available through transplant organizations in North American and Europe with various eligibility requirements. The transplant nurse who has the necessary knowledge and skills to care for transplant donors and/or recipients may validate this competency by taking a certification examination. The following certifications are available through The American Board for Transplant Coordination (ABTC) and the European Society for Transplantation (ESOT):

Certified Clinical Transplant Nurse

Certified Clinical Transplant Coordinator

Certified Procurement Transplant Coordinator

Certified Transplant Preservationist

Certificate of European Transplant Coordination

With certification, the transplant nurse must actively maintain his or her knowledge and competence at the levels defined by certification. The nurse is


responsible for assessing daily practice to identify knowledge deficits or areas for improvement. The nurse must work within the identified scopes of practice of his or her role with daily practice guided by the standards of practice for the nursing profession and the specialty area of transplant.

Educational Requirements for Transplant NursesA state, commonwealth, territory, government or other regulatory body provides an established mechanism for recognition and authorization of adequately educated and prepared individuals to practice nursing, including the specialty of transplant nursing. The associated registration or licensing processes vary by country. In the United States, a nurse is licensed by a state and is called a registered nurse. The individual is educationally prepared for competent practice at the beginning level upon graduation from an approved U.S. school of nursing and then becomes qualified by examination for registered nurse licensure. Outside of the United States, countries require graduation from an approved school of nursing but may or may not require a registered nursing license. Other countries, such as Germany, require a state examination after three years of education for those pursuing a nursing degree.

Entry level nurses may begin their profession through a variety of educational degrees and levels which vary internationally. Experienced nurses become proficient in one or more practice areas or roles and may chose to focus on patient care in clinical nursing practice specialties, such as transplant nursing. As discussed previously, specialized transplant nursing knowledge and experience may be acknowledged through an identified certification process, in which specific nursing educational requirements and demonstration of knowledge in transplant nursing practice have been delineated and validated.

Transplant nurses may choose to pursue advanced degrees to prepare for transplant nursing practice specialization. Educational requirements vary by specialty, role, educational institution and country. Upon graduation from an advanced level academic program, transplant nurses may pursue additional certification in direct and indirect care roles, such as a clinical nurse specialist or nurse practitioner, based on educational preparation. In response to the changing healthcare environment, educational programs, and requirements and regulatory environments, new models for educational preparation continue to evolve. An advanced certification examination in transplant nursing is a future goal.

Knowledge and Skills Base of Transplant NursingGeneral transplant nursing care requires a broad knowledge base in anatomy, physiology, immunology, pharmacology, pharmacogenomics, pharmacotherapeutics, nutrition, psychology, sociology and developmental theory. Clinical competencies beyond fundamental nursing preparation include assessment and management of the deceased transplant donor, assessment


and management of the transplant candidate and recipient, assessment and management of the potential or living donor and education and counseling for the transplant recipient and living donor. An understanding of the patient’s self-care management skills and healthy living and chronic health care complications and needs is essential.

Competencies in serving the physiological, pathophysiological and psychosocial needs of transplant patients, families and communities are critical. Transplant nurses must possess the skills to support aging patients, and when necessary assist them as they transition and prepare for death. Transplant nurses must be knowledgeable of the principles of ethical practice and have resources available to evaluate the merits, risks and social concerns of transplantation. As transplantation becomes a treatment option for both older and younger patients, transplant nurses must support and advocate for the more vulnerable patient and family

The core of transplant nursing practice is the provision of care based on theory, current evidence, best practices and consideration of patient preferences using good clinical judgment and decision-making. In providing comprehensive transplant nursing care across the age continuum, the transplant nurse uses the nursing process to assess individual and group needs, formulate an appropriate nursing diagnosis, design a mutually agreed upon plan of care, coordinate and provide therapeutic interventions, document care, and evaluate the action plan using an interprofessional case management approach.

Transplant nurses must possess a global perspective on patient and donor long-term goals, understand the expected clinical course and outcomes in a given transplant situation and alter plans accordingly. By conducting comprehensive assessments and using analytical abilities the transplant nurse operates from an in-depth understanding of transplant nursing, recognizes when situations are outside the expected and investigates alternative transplant perspectives. The transplant nurse promotes health and the prevention of injury and disease; serves as an advocate and educator for the patient, their family and support system; provides consultation and education to healthcare providers and the community; and participates in research and quality improvement processes to improve practice.

Sound assessment skills are the foundation of transplant nursing practice with the assessment of rejection and infection being paramount. Further assessment varies based on the organ that is transplanted. For example, if the patient has received a kidney transplant, the transplant nurse will also assess signs and symptoms of decreased urine output and a potential knowledge deficit related to dietary and medication modifications post-transplant.

Advances in transplantation include new technologies to assist in evaluating and monitoring end-stage organ disease and then extending treatment by


transplantation. For example, as fetal echocardiography becomes more accurate, earlier diagnosis of high-risk cardiac lesions will be possible with earlier listing for cardiac transplantation (i.e., 36 weeks gestation). Implantable artificial hearts are available to prolong life for those waiting for a heart transplant and transplantation across ABO blood groups is now possible. Transplant nurses will need to acquire new knowledge and skills in order to successfully navigate the technological advance on the horizon.

Transplant nurses acquire advanced knowledge and skills from technology that is used to monitor data, plan care and improve patient outcome; for example, becoming skilled in caring for patients with implantable artificial hearts or utilizing gene expression profiling blood tests to monitor and assess for rejection. Transplant nurses use expertise with advanced technologies to assess the patient’s response to treatment; diagnose the patient, family, and support systems response to new technology; provide education and support to assist the patient their family and support system as they to adapt to the new technology; and to monitor quality and safety and outcomes. A solid knowledge base in transplantation is essential for transplant nurses, administrators, researchers, case managers, transplant coordinators, advanced practice nurses, quality specialists and educators to ensure optimal care for the transplant recipient and donor and their families within a dynamic healthcare delivery system.

Globalization of Transplant NursingTransplant nursing is an international specialization. The transplant nurse delivers culturally sensitive care when caring for donors, transplant candidates, recipients, families, and communities. These issues are many and varied and also may involve providing transplant nursing care in collaboration with nurses with varied levels of nursing educational preparation. Cultural influences impact transplantation policies and procedures, availability, and transplant care practices. Providing transplant nursing care in countries with limited financial resources or those involved in organ trafficking or marketing will present challenging social and ethical issues for the transplant nurse.

Palliative Care and Transplant NursingPalliative care is both a philosophy of care and a system or model for providing care. The goal of palliative care is to prevent or relieve suffering and to focus on helping patients achieve the best possible quality of life throughout their life-limiting or life-threatening illness (National Consensus Project for Quality Palliative Care 2009). The eight recognized domains of palliative care are:

Structure and process of care

Physical aspects of care

Psychological aspects of care

Social aspects of care


Spiritual aspects of care

Cultural aspects of care

Care of the imminently dying

Ethical or legal aspects of care

Transplant nursing naturally encompasses many of the palliative care domains, which are reflected in these standards.

Ideally, palliative care is implemented at diagnosis and is provided in conjunction with curative efforts. By incorporating a palliative care philosophy, the goals and preferences of the patient, their family and support system are clarified; aggressive pain and symptom management is provided, psychosocial and spiritual support is offered, and ethical issues are addressed.

Transplant nurses are uniquely qualified to care for transplant candidates and recipients within the palliative care philosophy, integrating palliative care domains with the management of patients pre- or post-transplant. If transplantation is not a viable option of care or if post-transplant complications become life-threatening, palliative care measure can be actively implemented. Palliative care will ensure that patients are physically comfortable, their desired goals are being met, and that end-of-life wishes will be fulfilled

Ethics and Informed Decisions The transplant nurse is concerned about the availability and accessibility of the specialized care required for donors, transplant candidates, recipients, families, and communities. Transplant nursing is based on the belief that patients and families have the right and responsibility to make informed decisions about their care. The transplant nurse may be faced with caring for patients whose quality of life can be compromised by unanticipated consequences of technological advances in health care. Even as transplant procedures and technologies mature and become more reliable, the potential remains for serious and enduring unanticipated side-effects. Patients, their families, and their communities need to know of such issues.

Ethical issues unique to the conflicts inherent in transplant nursing often arise. Transplant candidates and their families face life-threatening illnesses, where survival is dependent on the availability of viable, healthy organs. Conflicts may arise between the rights of the individual, the rights of families, available accepted scientific and technological treatments, and economic realities. The rights and needs of the potential transplant recipient must be balanced with the rights and needs of the potential donors and their families, whether the donor is living or deceased.

Because the need for organs greatly exceeds availability, it is imperative that ethical principles be followed to help ensure the fair and equitable distribution of organs. The transplant nurse should be aware of unethical activities such as


payment for organs and organ trafficking. When caring for transplant recipients, donors, and families, the transplant nurse should always consider the principles of autonomy, beneficence, confidentiality, equality, and justice. The transplant nurse may participate in discussions and the decision-making processes with other support staff, such as Social Workers, psychiatrists, patient advocates, and members of ethics boards and hospital committees to resolve such dilemmas.

The transplant nurse recognizes that each patient is a unique human being, and must protect the individual’s basic rights during every phase of the transplant process. The transplant nurse is responsible for reporting incidents of abuse of patients’ rights and practices that are incompetent, unethical, or illegal. In the United States, the transplant nurse should approach ethical decisions as guided by Code of Ethics for Nurses with Interpretive Statements (ANA, 2005). This resource may be helpful for transplant nurses in countries where a code of ethics has not yet been established.

Future Considerations

The specialty of transplant nursing will continue to develop and expand as new technologies and transplant procedures are created to provide healthy tissue and organs. Efforts to increase the numbers of transplantable organs will remain at the forefront in transplantation. Xenotransplantation, the organ transplantation across species, continues to be explored as a way to expand the organ donor pool. Stem cell research will continue to advance the science of creating organs from cells. Composite transplantation, the transplantation of hand or face tissue from one individual to another, has been successful in early trials. The emergence of 3-D printing of strips of cells harvested from biopsies or stem cells provides an exciting glimpse into the future where entire organs may be able to be created using a framework that allows cells to adhere to the appropriate structure.

Using genomics, including pharmocogenomics, to identify patients who would most benefit from transplantation and associated therapies may contribute to improved transplant outcomes in the future. Advances in computer technology will provide readily accessible information to help the transplant process progress more effectively and efficiently. Advances in technology allow for changes in assessment, monitoring and patient support and includes the use of mobile applications and remote monitoring via online programs. As solid organ transplantation has become more successful, recipient age criteria have already expanded and with an increasing emphasis on long-term graft survival recipients can be expected to live longer with their transplanted organs. A growing interest in gero-transplantation is emerging and the National Institutes of Health already actively supports research focused on older transplant recipients (NIH, 2012).

The need for transplant nurses is expanding across the world. The aging nursing workforce, coupled with the aging world population, complicates the issue. As the


number of specialty nursing areas increases and demand for transplant services escalates, transplant administrators are finding it more difficult to attract and retain qualified transplant nurses. Experienced and competent transplant nurses are critical to maintaining and improving transplant patient outcomes. As the acuity of transplant patients intensifies, the skills, knowledge, and abilities of transplant nurses must meet the corresponding care and education demands of the patients, family, community, and institution. In addition to educational programs provided by local institutions, several organizations host conferences and provide workshops which provide opportunities for transplant professionals to remain current with advances in the field. In addition, certification programs are available for transplant nurses and coordinators which attest to the individuals’ achievement of a defined set of competencies.

Transplant nurses must be active participants in developing, implementing, and evaluating innovative patient care systems and models of care to improve transplant patient care delivery and outcomes. Nursing education curricula should continue to develop qualified undergraduate and graduate nurses who can specialize in transplantation. As healthcare undergraduate curricula move toward integrated education across professions, transplantation provides a unique opportunity for students and faculty alike to experience integrated teams providing care to patients, families, and communities. Appropriate funding for undergraduate and graduate education must be provided.

The worldwide shortage of physicians provides an opportunity for advanced practice registered nurses to meet the needs of those most vulnerable and in need of care. Advanced practice registered nurses in transplantation can provide the knowledge, experience, and skills to efficiently and effectively fill these healthcare gaps. These nurses are particularly well positioned to provide chronic illness care to transplant patients, families, and communities and promote effective, preventive self-care and positive outcomes.

Healthcare delivery systems have been designed to support acute episodes of care rather than improved long-term patient outcomes. Refocusing the healthcare system on transitional care, chronic illness, and patient self-management is likely to enhance long-term outcomes. Transplant nurses, across educational levels, are well positioned to lead the movement in expanding chronic illness management which includes patient self-management and preventative care. Advanced practice registered nurses must continue to educate transplant professionals regarding the positive patient outcomes associated with transplant care. They must also work with transplant administrators and regulators to integrate advanced practice registered nurse services into routine transplant health care. With these changes in health care comes a continued need to emphasize patient safety.

Transplant nurses are charged to remain current through lifelong learning and provide evidenced-based care in a dynamic global healthcare environment. Transplant nurses must promote patient, family, and community safety through


evidence-based practice and quality improvement efforts. Only through a continuous quest for new knowledge and excellence will transplant nursing excel as a nursing specialty.


STANDARDS OF TRANSPLANT NURSING PRACTICE

Function of the StandardsThe standards of transplant nursing, which are comprised of the standards of practice and the standards of professional performance, are authoritative statements by which nurses practicing within the role, population, and specialty governed by this document (Nursing: Scope and Standards of Practice) that describe the duties transplant nurses are expected to competently perform. These standards may be utilized as evidence of the legal standard of care governing nurses practicing within the role, population, and specialty governed by this document. The standards are subject to change with the dynamics of the nursing profession and as new patterns of professional practice are developed and accepted by the nursing profession and the community. In addition, specific conditions and clinical circumstances may also affect the application of the standards at a given time such as during a natural disaster. The standards are subject to formal periodic review and revision.

The measurement criteria that discussed within each standard (pages xxxx) are not all-inclusive and do not establish the legal standard of care. Measurement criteria are specific, assessable elements that can be used by transplant nursing professionals to measure professional performance. Nurses practicing within the specialty of transplant nursing should identify opportunities for development and improvement based on performance as outlined by these standards.


STANDARDS OF PRACTICE

STANDARD 1. ASSESSMENTThe transplant nurse collects comprehensive data pertinent to the patient’s health status or situation.

Measurement Criteria:The Transplant Nurse:

Collects clinical data in a systematic and ongoing process

Includes the patient, their family and support system, and interprofessional healthcare team members in holistic data collection

Involves assessment of patients of all ages across the continuum of care from acute to community care to end of life care

Prioritizes data collection based on the patient’s immediate condition or anticipated needs

Uses developmentally appropriate evidence-based assessment techniques and instruments in data collection

Uses analytical models and problem-solving tools

Documents relevant data in a comprehensive and retrievable format

Additional Measurement Criteria for the Transplant Nurse Coordinator: The Transplant Nurse Coordinator:

Initiates diagnostic tests and procedures relative to the transplant patient’s current status based on established protocols and procedures

Additional Measurement Criteria for the Advanced Practice Registered Nurse: The Advanced Practice Registered Nurse:

Initiates and interprets diagnostic tests and procedures relative to the transplant patient’s current status

Assists staff and the interprofessional team in developing and maintaining competency in transplant assessment

Synthesizes data, information, and knowledge relevant to the situation to identify patterns and variances


STANDARD 2. DIAGNOSISThe transplant nurse analyzes assessment data to determine nursing diagnoses or health-related problems or needs.


Derives diagnoses, problems, or needs based on assessment data that reflect the patient’s current clinical condition.

Derives diagnoses encompassing:o Identified or potential age-related physical, psychological, social, or

developmental problemso Need for rehabilitation care post-transplant based on comorbidities,

developmental level and psychosocial statuso Support and educational needs of care giverso Any present, or potential, physical or psychosocial environmental

problem Discusses diagnoses, problem, or needs with the patient, their family

and support system, members of the interprofessional team, and other healthcare providers when possible and appropriate

Documents diagnoses or issues in a manner that facilitates the determination of the expected outcomes and plan

Additional Measurement Criteria for the Transplant Nurse Coordinator:The Transplant Nurse Coordinator:

Refines and revises diagnoses based on ongoing assessment data Systematically compares clinical findings with normal variations

Additional Measurement Criteria for the Advanced Practice Registered Nurse:The Advanced Practice Registered Nurse:

Systematically compares clinical findings with normal in formulating a differential diagnosis

Utilizes complex data and information obtained during interview, examination, and diagnostic procedures in identifying diagnoses


STANDARD 3. OUTCOMES IDENTIFICATIONThe transplant nurse identifies expected outcomes for a plan individualized to the patient or the situation.

Measurement Criteria: The Transplant Nurse:

Identifies expected outcomes mutually with the patient, family and support system, and other healthcare providers. Expected outcomes are patient-oriented, developmentally appropriate, evidence-based, attainable, and realistic in relation to the patient’s, caregiver’s, and their support system’s present and potential abilities

Derives culturally and age-appropriate expected outcomes from the diagnoses

Considers associated risks, benefits, costs, current scientific evidence, and clinical expertise when formulating expected outcomes

Defines expected outcomes in terms of the patient, patient values, ethical considerations, environment or situation with consideration of associated risks, benefits and costs, and current scientific evidence

Includes a time estimate for attainment of expected outcomes

Develops expected outcomes that provide direction for continuity of care

Documents expected outcomes as measurable goals

Implements consensus-driven clinical guidelines


Identifies expected outcomes that incorporate scientific evidence and are achievable through evidence-based practices

Modifies expected outcomes based on patient changes and evaluation of the situation.

Supports the use of clinical guidelines linked to positive patient outcomes


Identifies expected outcomes that incorporate cost and clinical effectiveness, patient satisfaction, and continuity and consistency among providers

Develops clinical guidelines that are linked to optimal patient outcomes Provides leadership in the coordination of the interprofessional healthcare

services to identify patient outcomes.


Synthesizes data and information to facilitate necessary system and community support measures, including environmental modifications that will affect patient outcomes.

Leads the multidisciplinary team at a systems level to identify outcomes


STANDARD 4. PLANNINGThe transplant nurse develops a plan of care that prescribes strategies and alternatives to attain expected outcomes.


Develops an individualized plan of care that considers patient characteristics and developmental level, and is culturally appropriate and environmentally sensitive

Participates in the design and development of interprofessional processes to address the situation or issue

Contributes to the development and continuous improvement of organizational systems that support the planning process.

Supports the integration of clinical, human, and financial resources to enhance and complete the decision-making process

Develops a plan of care with the patient, their family and support system, and others, with an understanding and appreciation of the patient’s values and beliefs, developmental level, and coping style

Includes strategies in the plan that addresses each of the identified diagnoses or issues, which may include strategies for promotion and restoration of health and prevention of illness, injury, and disease.

Provides for continuity in the plan of care Incorporates a clinical pathway or timeline in the plan. Establishes priorities with the patient and their support system to meet

the goals of the plan of care Has an awareness of current trends and research affecting care in

planning Considers the economic impact of the plan on the patient, their family

and support system Uses standardized language or recognized terminology to document

the plan


Collaborates with interprofessionals to carry out the plan Identifies assessment, diagnostic strategies, and therapeutic

interventions in the plan that reflect current evidence, including data, research, and literature

Reviews the plan to make sure it reflects current statues, rules, and regulations, and standards of transplant nursing practice



Utilizes the plan to provide direction to other members of the healthcare team

Modifies the plan to reflect current evidence, including data, research, literature, and expert clinical knowledge

Selects and designs strategies that meet the multifaceted needs of complex transplant patients

Includes the synthesis of the patient’s values and beliefs regarding nursing and medical therapies in the plan


STANDARD 5. IMPLEMENTATIONThe transplant nurse implements the identified plan.

Measurement criteria: The Transplant Nurse:

Implements the plan in a safe and timely manner. Implements the plan using the fundamentals of project or systems

management Documents implementation and modifications of the identified plan. Utilizes knowledge of evidence-based practices specific to the

diagnosis or problem Assists the multidisciplinary team in working with community resources

that are consulted to help implement the plan of care Collaborates with nursing colleagues, the multidisciplinary team and

other disciplines to implement the plan

Additional measurement criteria for the Transplant Nurse Coordinator: The Transplant Nurse Coordinator:

Facilitates utilization of systems and community resources to implement the plan

Supports collaboration with nurses and the interprofessional team to implement the plan

Incorporates new knowledge and strategies to initiate change in nursing care practices to achieve the desired outcomes

Additional measurement criteria for the Advanced Practice Registered Nurse:The Advanced Practice Registered Nurse:

Appraises initiates and facilitates the utilization of systems and community resources to implement the plan

Leads collaboration with organizational systems that support the implementation of the plan

Facilitates and monitors implementation of the plan, adjusting strategies as needed based on the desired outcome


STANDARD 5A. COORDINATION OF CAREThe transplant nurse coordinates care delivery.

Measurement criteria: The Transplant Nurse:

Provides direct care that implements the plan Documents implementation of care. Documents and reports any unexpected outcomes in implementing

care. Assists in developing modifications in care delivery.

Additional measurement criteria for the Transplant Nurse Coordinator:The Transplant Nurse Coordinator:

Coordinates system and community resources that enhance delivery of care across the continuum

Monitors the coordination of care delivery to achieve the desired outcomes


Provides leadership in the coordination of the interprofessional healthcare services for the integrated delivery of patient care

Synthesizes data and information to facilitate necessary system and community support measures, including environmental modifications.

Leads the multidisciplinary team at a systems level to monitor care delivery and assess outcomes


STANDARD 5B. HEALTH TEACHING AND HEALTH PROMOTIONThe transplant nurse employs strategies to promote health and a safe environment.

Measurement criteria:The Transplant Nurse:

Provides health teaching that addresses patient self-monitoring, developmental needs, healthy behaviors, activities of daily living and preventive self-care

Uses health promotion and teaching methods appropriate to the situation and the patient’s developmental level, learning needs, readiness, ability to learn, literacy level, language preference and culture

Seeks opportunities for feedback and evaluation of the effectiveness of the strategies used


Designs transplant patient education appropriate to the patient’s developmental level, learning needs, readiness to learn, cultural values and beliefs

Designs community education programs about organ donation, transplantation and the treatment of end-stage organ diseases


Synthesizes empirical evidence regarding risk behaviors, learning theories, behavioral change and motivational theories, epidemiology and other related theories when designing health information and patient education

Designs transplant education resources that are appropriate to the patient’s developmental level, learning needs, readiness to learn, cultural values and beliefs

Evaluates health information resources in the field of transplantation for accuracy, readability and comprehensibility to help patients access quality health care information


STANDARD 5C. CONSULTATIONThe transplant nurse coordinator or advanced practice registered nurse provides consultation to influence the plan of care, enhance the abilities of others and effect change.

Measurement criteria:The Transplant Nurse Coordinator:

Facilitates the effectiveness of consultation by involving the patient in decision-making and negotiating role responsibilities

Communicates consultation recommendations to facilitate change

Additional measurement criteria for the Advanced Practice Registered Nurse:

The Advanced Practice Registered Nurse:

Synthesizes clinical data, theoretical frameworks and evidence when providing consultation

Facilitates the effectiveness of a consultation by conducting research and disseminating research findings to enhance psychosocial and clinical outcomes


STANDARD 5D. PRESCRIPTIVE AUTHORITY AND TREATMENTThe Advanced Practice Registered nurse uses prescriptive authority, procedures, referrals, treatments and therapies in accordance with state and national laws and regulations.

Measurement criteria for the Advanced Practice Registered Nurse: Prescribes evidence-based treatments, therapies and procedures

considering the patient’s comprehensive healthcare needs

Prescribes pharmacologic agents based on a current knowledge of pharmacology and physiology

Prescribes specific pharmacological agents and treatments based on clinical indicators, the patient’s status and needs and the results of diagnostic and laboratory tests

Evaluates therapeutic effects of pharmacological and non-pharmacological treatments, monitors outcomes and adjusts care as needed to obtain the desired outcomes

Evaluates potential adverse effects of pharmacological and non-pharmacological treatments and adjusts treatment to achieve the desired results

Provides patients with information about intended effects and potential adverse effects of proposed prescriptive therapies

Provides information about costs, the use of brand vs generic medications and alternative treatments and procedures as appropriate


STANDARD 6. EVALUATIONThe transplant nurse evaluates progress toward attainment of outcomes.

Measurement criteria:The Transplant Nurse:

Includes the patient and others involved in patient care during the evaluation process

Documents results of the evaluation

Uses ongoing assessment data to revise the nursing diagnoses, the plan of care, implementation and outcomes


Evaluates the accuracy of the diagnosis and effectiveness of the interventions in relation to the patient’s attainment of expected outcomes.

Uses the results of the evaluation to recommend process or structure changes, including policy, procedure or protocol documentation as appropriate.


Leads a systematic, ongoing and criterion-based evaluation of the outcomes in relation to the structure and processes prescribed by the plan and the indicated timeline.

Synthesizes the results of the evaluation to determine the impact of the plan on the affected patients, families, groups, communities, institutions, networks and organizations.

Disseminates the results to the patient and others involved in the care or situation, as appropriate, in accordance with country and state laws and regulations.

Uses the results of the evaluation to make or recommend process or structure changes, including policy, procedure, or protocol documentation, as appropriate


STANDARD 7. QUALITY OF PRACTICEThe transplant nurse systematically enhances the quality and effectiveness of nursing practice.


Obtains and maintains professional certification

Functions in accordance with legislative and common law affecting nursing practice

Protects the rights of individuals and groups

Provides age- and developmentally appropriate care in a manner that demonstrates an understanding of cultural norms and influence

Documents the application of the nursing process in a responsible, accountable and ethical manner

Understands the role of consultants and other referrals that contribute to continuity of care and is aware of their recommendations

Documents plan-of-care communications, rationales for plan-of-care changes, and collaborative discussions to support and advance patient care and the well-being of their family and support system.

Uses the results of quality improvement activities to initiate change, and monitor effectiveness in nursing practice and the healthcare delivery system

Uses creativity and innovation in nursing practice to improve care delivery

Evaluates the practice environment in relation to existing evidence, identifying opportunities for the generation and use of research

Incorporates new knowledge and evidenced based findings to initiate changes in nursing practice to achieve desired outcomes

Supports efforts of transitional care modalities for patients and families, e.g., acute nursing care is one link in the chain of all healthcare components which can include hospitalizations, home and community, to ensure optimal care delivery

Participates in quality improvement activities. Such activities may include:

o Collecting data to monitor quality and effectiveness of nursing practice

o Integrating technological advances to support, maximize, and ensure safe nursing care delivery modalities

o Participating in efforts to minimize costs and unnecessary duplication


Additional Measurement Criteria for the Transplant Nurse Coordinator: The Transplant Nurse Coordinator:

Designs quality improvement initiatives.

Develops, implements, and evaluates policies, procedures and guidelines to improve the quality of practice. .

Participates in interprofessional transplant team-based care to evaluate clinical care or healthcare delivery services. (AACN, 2011)

Implements processes to remove or decrease barriers within organizational systems


Applies quality improvement processes in designing, implementing, evaluating, and recommending change to improve healthcare outcomes

Provides leadership in the coordination of the interprofessional healthcare services to attain quality in nursing practice

Synthesizes data and information to facilitate necessary system and community support measures, including environmental modifications to attain quality in nursing practice

Analyzes organizational systems for barriers, facilitators and potential strategies for change

Analyzes outcomes related to safety, satisfaction, effectiveness and cost to design program innovations that promote quality

Integrates technological advances to optimize quality in nursing care delivery systems


STANDARD 8. EDUCATION: The transplant nurse attains knowledge and competency that reflects current nursing practice.


Participates in ongoing educational activities related to the appropriate knowledge base and professional issues in transplant nursing

Demonstrates a commitment to lifelong learning through self-reflection and inquiry to identify learning needs

Seeks experiences that reflect current practice in order to maintain skills and competence in clinical practice or role performance

Acquires knowledge and skills appropriate to the specialty area, practice setting, role, or situation

Seeks formal and independent learning experiences and activities to maintain and develop proficient clinical skills and knowledge.

Uses current healthcare research findings and other evidence to expand clinical knowledge, enhance role performance, and increase knowledge of professional issues.

Participates in ongoing interprofessional educational activities to ensure high quality interprofessional collaborative practice and interprofessional team-based care

Is aware of and may consider additional professional and educational advancement through graduate level education


Promotes a climate of research and inquiry through collaboration with nurse-scientists and mentoring transplant nurses in evaluating and basing practice on evidence generated through research

Provides leadership in the design, implementation, and dissemination of quality assessment studies to promote evidence based nursing practice

Assesses and analyzes the educational needs of the transplant nursing team and formulates a plan for ongoing education and assessment


STANDARD 9. PROFESSIONAL PRACTICE EVALUATIONThe transplant nurse evaluates self-practice in regard to professional practice standards and guidelines, relevant statutes, rules, and regulations.


Applies knowledge of current practice standards, guidelines, statutes, rules, and regulations into practice.

Engages in self-evaluation of practice on a regular basis, identifying areas of strength as well as areas in which professional development would be beneficial.

Obtains informal feedback regarding self-practice from patients, peers, professional colleagues, and others.

Participates in systematic peer review as appropriate.

Takes action to achieve goals identified during the evaluation process.

Provides rationales for practice beliefs, decisions, and actions as part of the informal and formal evaluation processes.

Engage in a formal process seeking feedback regarding role performance from individuals, professional colleagues, representatives, administrators of corporate entities, and others.


Advocates for health policy, financing, regulation, healthcare delivery systems and political processes that advance the safe and effective care of patients, families, and caregivers.

Evaluate and interpret the effectiveness of evidenced base health promotion and risk reduction strategies to patient, families and support systems.


STANDARD 10. COLLEGIALITYThe transplant nurse interacts with, and contributes to the professional development of the interprofessional team


Actively participates on interprofessional teams that contribute to role development and advances the practice of nursing

Shares knowledge and skills with peers and colleagues as evidenced by such activities as patient care conferences or presentations at formal or informal meetings.

Provides peers with feedback regarding their practice or role performance.

Interacts with peers and colleagues to enhance one’s own professional nursing practice and role performance.

Supports and facilitates education of students in healthcare professions.

Contributes to a supportive and healthy work environment. Mentors novice nurses and other allied health professionals as

appropriate. Models proficient practice within the interprofessional team and with

healthcare consumers.


Engage other healthcare professionals appropriate to specific care situations in understanding the unique contributions, scope of practice and educational preparation of all members of the health care team.


STANDARD 11.COLLABORATION AND COMMUNICATIONThe transplant nurse collaborates with patients, their family and support system, and others in the conduct of nursing practice.


Communicates with the patient, their family and support system, and healthcare providers regarding patient care and the nurse’s role in providing that care.

Collaborates in creating a documented plan focused on outcomes and decisions related to care and delivery of services that indicates communication with patients, families, and others.

Uses communication practices that minimize risks associated with handoffs among providers and across transitions of care

Communicates with the patient and their support system to ensure access and optimize adherence to necessary follow-up care

Participates with other disciplines to optimize patient care and care delivery through interprofessional activities such as education, management, technological development, or research opportunities

Partners with others to effect change and generate positive outcomes through knowledge of the patient or situation

Documents plan-of-care communications, rationales for plan-of-care changes, and collaborative discussions to support and advance patient care and the well-being of their family and support system


Facilitates communication among the interprofessional

Partners with other disciplines to enhance patient care through interprofessional education, consultation, management, technology development, or research activities.

Assesses the effectiveness of the collaborative and communicative processes across systems that are involved in the overall care of the patient, their family and support system.


Provides leadership within the transplant interprofessional team to improve patient care through education, consultation, management, technology development, and research


Engage other healthcare professionals appropriate to the specific care situation in shared patient and family centered problem solving

Analyzes the outcomes of collaborative and communicative processes of the interprofessional teams in regard to patient outcomes.

Based on this analysis, strategizes and develops programs to optimize the effectiveness of interprofessional collaboration and communication.


STANDARD 12. ETHICSThe transplant nurse integrates ethical principles in all areas of practice.


Uses Code of Ethics for Nurses with Interpretive Statements (ANA, 2001) to guide practice.

Delivers care in a manner that preserves and protects patient autonomy, dignity, rights, values, beliefs and diversity

Recognizes the patient, their family and support system as core members of the healthcare team

Maintains appropriate therapeutic and professional patient nurse relationship with appropriate boundaries

Maintains patient confidentiality within legal and regulatory parameters

Serves as a patient advocate by promoting patient self-advocacy

Demonstrates a commitment to practicing self-car and stress management

Understands that ethical dilemmas may arise within the transplant specialty related to organ allocation, transplant candidacy, and available technologies

Participates in committees or in care conferences with the interprofessional team to help resolve ethical issues involving patients, the healthcare tem, or healthcare system

Takes appropriate action at the transplant nurse level to report illegal, incompetent, or impaired practices.

Demonstrates an understanding of diversity awareness and cultural humility in working with patients, families and the interprofessional team.


Provides leadership within the interprofessional team to address ethical issues that impact the patient, family and healthcare team.

Synthesizes data and information to facilitate strategies to operationalize ethical principles in nursing practice


Uses the results of an evaluation to make or recommend process or structure changes, including policy, procedure, or protocol documentation, as appropriate to optimize ethical practice.


STANDARD 13. EVIDENCED BASED PRACTICE AND RESEARCHThe transplant nurse integrates evidence and research findings to inform best practice.

Measurement Criteria: Evidence-Based PracticeThe Transplant Nurse:

Utilizes findings from evidence-based research to implement best nursing practice and guide clinical judgment

Participates in research activities as a transplant nurse by: Identifying practice issues that are problematic

o Assessing current evidence about specific topicso Implementing evidence-based practice guidelines to influence or

change current practiceo Participating in data collection for research purposeso Participating in an institution-based research committee or program o Incorporating research as a basis for learning.

Ensures the protection of human subjects, understanding that patients and families who are involved in research studies should experience minimal risk and potential for harm.

Additional Measurement Criteria for the Advanced Practice Registered Nurse: ResearchThe Advanced Practice Registered Nurse:

Provides leadership within the interprofessional team to promote evidence based practices that impact the patient, family and healthcare team.

Uses scholarly evidence to improve healthcare outcomes and advance nursing practice.

Conducts or synthesizing research that discovers, examines, and evaluates knowledge, theories, criteria, and creative approaches to improve health care.

Formally disseminates research findings through presentations and publications

Promotes a climate of research and inquiry through mentoring transplant nurses, reviewing the literature, participating in research activities, and evaluating research findings

Uses research findings in the development of policies, procedures, and standards of practice in patient care

STANDARD 14. RESOURCE UTILIZATION


The transplant nurse considers factors related to regulation, legislation, safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing services.


Uses organizational and community resources to formulate interprofessional plans of care.

Evaluates factors such as safety, effectiveness, availability, cost–benefits, efficiencies, patient preference and impact on practice, when choosing practice options with similar expected outcome.

Assists the patient their family and support system in identifying and securing appropriate and available services to address health-related needs.

Assigns or delegates tasks, based on the needs and condition of the patient, potential for harm, stability of the patient’s condition, complexity of the task, and predictability of the outcome.

Assists the patient their family and support system in becoming informed consumers about the options, costs, risks, and benefits of treatment and care.

Recognizes the importance of effective communication with the patient, their family and their support system in achieving and ensuring optimal care pre- and post-transplant.


Develops solutions for patient care problems that address effective resource utilization and maintenance of quality.

Promotes interventions that assist others in becoming informed about the goals of care, the strategies to achieve those goals, the risks and benefits of care, and costs.


Develops evaluation strategies and programs to demonstrate cost effectiveness, cost benefit, and efficiency factors associated with nursing practice.

Provides leadership within the interprofessional team to address effective resource utilization.


STANDARD 15. LEADERSHIPThe transplant nurse provides leadership in the professional practice setting and the profession of transplant nursing.


Engages positively with others on the transplant team as a team player and in team-building strategies.

Demonstrates effective communication and conflict resolution skills.

Participates with the team in helping to maintain a healthy work environment

Demonstrates the ability to set achievable goals through realistic interventions that are measureable

Demonstrates an interest in continuing education

Promotes success through role modeling

Exhibits flexibility through times of change

Demonstrates leadership skills by contributing to a culture where safe design principles are developed and implemented

Disseminates information and promotes the advancement of transplant nursing through publications and presentations

Participates on committees, councils, and administrative teams within the institution

Participates in professional nursing and transplant organizations to promote the profession of transplant nursing

Additional Measurement Criteria for the Transplant Nurse Coordinator The Transplant Nurse Coordinator:

Directs the coordination of care across settings and among caregivers or providers, including oversight of licensed and unlicensed personnel in any assigned or delegated tasks.

Provides direction to enhance the effectiveness of the healthcare team.

Describe strategies to integrate patients/families as primary members of the health care team.

Reviews and revises protocols or guidelines to reflect evidence-based practice, incorporates accepted changes in care management, and solves emerging problems.


Initiates and revises protocols or guidelines to reflect evidence-based practice, incorporates accepted changes in care management, or solves emerging problems.

Promotes advancement of the profession of nursing through attaining leadership roles in professional organizations.

Advocates for the value and role of the professional nurse as a member of, and leader within, the interdisciplinary healthcare team for the provision of high quality and safe care to individuals and families


Creates a culture of innovation

Advances nursing’s autonomy and accountability through involvement in healthcare policy making related to nursing roles.

Provides leadership to influence decision-making bodies to improve patient care

Applies quality improvement processes in designing, implementing and evaluating change to improve healthcare outcomes.


REFERENCES

American Nurses Association (ANA). (2005). Code of Ethics for Nurses with Interpretive Statements.

Association of Pediatric Hematology/Oncology Nurses (APHON). (2009). Pediatric Oncology Nursing: Scope and Standards of Practice.

Global Observatory on Donation & Transplantation (GODT). (2012). Retrieved August 18, 2014 from http://www.transplant-observatory.org

Organ Procurement and Transplantation Network (OPTN) (2014) Retrieved August 18, 2014 from http://optn.transplant.hrsa.gov

International Council of Nurses. Nurse Practitioner/Advanced Practice Nursing Network. Definitions of the Role. Retrieved August 18, 2014 from http://international.aanp.org/Practice/APNRoles

National Institutes of Health (NIH). (2012). Solid Organ Transplantation: Older Donors and Recipients, PA 13-030, 13-037, and 13-038.

National Consensus Project for Quality Palliative Care. Clinical practice guidelines for quality palliative care. 2nd ed. Pittsburgh (PA): National Consensus Project for Quality Palliative Care; 2009.

J. Brant and R. Wickham (Eds.) Statement on the Scope and Standards of Oncology Nursing Practice: Generalist and Advanced Practice. Pittsburg, PA: Oncology Nursing Society (ONS). (2014).

.


http://international.aanp.org/Practice/APNRoles

http://optn.transplant.hrsa.gov/

http://www.transplant-observatory.org/

GLOSSARY

Assessment. A systematic, dynamic process by which the nurse, through interaction with the patient, family and support systems, and interprofessional team, collects and analyzes data about the patient. Data may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional, developmental, economic, and lifestyle.

Caregiver. A person who provides direct care for another, such as a child, dependent adult, the disabled, or the chronically ill.

Code of ethics. A list of provisions that makes explicit the primary goals, values, and obligations of the profession.

Continuity of care. An interprofessional process that includes patients and family and support systems in the development of a coordinated plan of care. This process facilitates the patient’s transition between settings, based on changing needs and available resources.

Criteria. Relevant, measurable indicators of the standards of clinical nursing practice.

Data. Discrete entities that are described objectively without interpretation.

Diagnosis. A clinical judgment about the patient’s response to actual or potential health conditions or needs. The diagnosis provides the basis for determination of a plan of care to achieve expected outcomes. Transplant nurses utilize nursing or medical diagnoses depending upon educational and clinical preparation and legal authority.

Disease. A biological or psychosocial disorder of structure or function in a patient, especially one that produces specific signs or symptoms or that affects a specific part of the body, mind, or spirit.

Environment. The atmosphere, milieu, or conditions in which an individual lives, works, or plays.

Evaluation. The process of determining both the patient’s progress toward the attainment of expected outcomes and the effectiveness of nursing care.

Evidence-based practice. A process founded on the collection, interpretation, and integration of valid, important, and applicable patient-reported, clinician-observed, or research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments.


Expected outcomes. End results that are measurable, desirable, and observable, and that translate into observable behaviors.

Family. Family of origin or significant others as identified by the patient.

Guidelines. Systematic statements, based on available scientific evidence and expert opinion, that describe a process of patient care management which has the potential to improve the quality of clinical and consumer decision-making.

Health. “The state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (World Health Organization. Retrieved August 18, 2014 from http://www.who.int

Healthcare provider. A person with special expertise who provides healthcare services or assistance to patients. This may include nurses, physicians, psychologists, social workers, nutritionist/dietitians, and various therapists.

Holistic. Based on an understanding that the patient is an interconnected unity, a whole system that is greater than the sum of its parts, and that physical, mental, social, and spiritual factors need to be included in any interventions.

Illness. An unhealthy condition due to an abnormal process in which aspects of the social, physical, emotional, or intellectual condition and function of a person are diminished or impaired compared with that person's previous condition. (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier).

Implementation. Activities such as teaching, monitoring, providing, counseling, delegating, and coordinating. The patient, significant others, or healthcare providers may be designated to implement interventions within the plan of care.

Information. Data that are interpreted, organized, or structured.

Interprofessional. Reliant on the overlapping knowledge, skills, and abilities of each professional team member, resulting in synergistic effects where outcomes are enhanced and more comprehensive than the simple aggregation of the team members’ individual efforts.

Knowledge. Information that is synthesized so that relationships are identified and formalized.

Registered Nurse. An adequately educated and prepared individual registered or licensed by a state, commonwealth, territory, government, or other regulatory body to practice as a registered nurse.


Nursing. the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. (American Association of Nursing. Retrieved August 18, 2014 from http://www.nursingworld.org.)

Outcomes. Measurable, expected, patient-focused goals that translate into observable behaviors.

Palliative care. Patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice. (National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care, Third Edition. 2013.)

Patient. The recipient of transplant nursing care, whether a potential donor, transplant candidate, organ donor, or transplant recipient. When the patient is an individual, the focus is on his or her health state, problems, or needs. When the recipient of care is a family or group, the focus is on their health state as a whole, and/or on the reciprocal effects on the health states group members. When the patient is considered to be a community or population, the focus of care is on the collective personal and environmental health and the health risks.

Peer review. A collegial, systematic, and periodic process by which registered nurses are held accountable for practice and which fosters the refinement of knowledge, skills, and decision-making at all levels and in all areas of practice.

Plan. A comprehensive outline of the steps that need to be undertaken to attain expected outcomes.

Quality of life. An individual’s general perception of happiness and satisfaction with life; domains include health, physical, psychological, financial, social, family, economic, and spiritual areas. The transplant patient’ perception may focus on health-related quality of life issues, and the impact on his or her normal functioning by disease or illness.

Recipients of nursing care. See Patient

Self-care maintenance. Self-monitoring adherence behaviors used by patients to maintain health.

Self-care management. The decision-making process that patients use when conducting self-care maintenance.

Situation. A set of circumstances, conditions, or events that affect someone or something at a particular time and in a particular place.


Standard. An authoritative statement enunciated and publicized by the profession, by which the quality of practice, service or education can be judged.

Standards of nursing care. Authoritative statements that describe a competent level of clinical nursing practice demonstrated through assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.

Standards of practice. Authoritative statements that describe a level of care or performance common to the profession of nursing by which the quality of nursing practice can be judged. Standards of clinical nursing practice include both standards of care and standards of professional performance.

Standards of professional performance. Authoritative statements that describe a competent level of behavior in the professional role, including quality of care, professional practice evaluation, education, collegiality, ethics, collaboration, research, resource utilization, and leadership.

Strategy. A plan of action to achieve a major overall goal.

Transplant nursing. Specialized nursing care of the transplant recipient and donor with these focuses:

Protection, promotion, and optimization of health and abilities of the transplant recipient and living donor across the life span. Includes prevention, detection, and treatment of illness and injury related to diseases treated by solid organ transplantation, and diseases that may occur due to living donor donation in individuals, families, communities, and populations of all ages.

Protection, promotion, and optimization of the deceased donor organ during the process of organ donation. 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.
