NHS Blood and Transplant (NHSBT) Tissue and Eye Services (TES) save and improve the lives of thousands of patients every year. Tissue such as corneas, skin, bone, heart valves and tendons can be donated after death. Corneas enable the gift of sight, skin is donated for life-saving treatment for victims of severe burns, bone is used in a variety of orthopaedic surgeries, tendons for sports injuries and heart valves for life-saving cardiac procedures.
Unlike solid organ donation, the supply of tissue for donation is directly linked to recipient demand. TES monitors and predicts the requirements for transplantation and retrieves tissue in order to meet recipient need. For example, in order to meet known tissue requirements, TES may be required to gain consent, retrieve and process tissue from 10 deceased donors every day.
There are specific clinical selection criteria associated with tissue donation and very different clinical risk assessments are made in terms of suitability compared with our organ donation colleagues. Organ donation is lifesaving, while tissue donation can both save and improve lives and so the concept of organ and tissue donation after death are both similar yet different.
Most people can donate tissue after their death. However, whereas organ donation is currently restricted to deaths inside critical care or emergency departments, tissue donation is possible for a much wider range of potential donors. Many donations can be facilitated up to 48 hours after death and the opportunity for tissue donation can be a positive act for many bereaved donor families at a very difficult time.
Some tissues can also be donated by living donors. These types of tissue donation involve instances in which patients decide to donate their femoral head bone following an elective hip replacement or a pregnant woman decides to donate her placenta after a planned caesarean section. Amniotic membrane is used as a graft or dressing in ophthalmic reconstruction surgery.
Nurses working in tissue donation
The roles and responsibilities of the nurses working in TES are diverse. Across the TES supply chain nursing roles are pivotal. They range from raising awareness of tissue donation and creating robust referral systems through to skilled communication with recently bereaved families over the telephone, as well as advanced nursing practice in clinical decision-making regarding suitability for transplantation and research.
Nursing roles include:
Hospital development nurse practitioners
In the UK, around 25 million people have registered to donate organs and tissues. However, there is poor understanding around the tissue-donation process.
Hospital development nurse practitioners (HDNPs) provide a professional link between service providers/users and TES so that effective working partnerships can be developed. HDNPs ensure that there is a professional link from TES to support, educate and advise a wide range of health professionals about tissue donation. They are a visible and respected presence in the trusts within which they work and continuously build on these successful working partnerships and contractual agreements to increase donor referrals.
Consistent findings from a global body of research for organs and tissues over the past 15 years shows that there are key factors that influence family decision making (Sque et al, 2008; Siminoff et al, 2010; Long-Sutehall et al, 2012; Sque et al, 2018).
Evidence suggests that key factors include:
The role of the HDNP aims to overcome some of these barriers and work towards increasing the number of referrals of potential tissue donors. This includes creating robust referral systems, raising awareness, educating, and sharing information about tissue donation so that patients and their families can make an informed choice about donating tissue for transplant and/or research. HDNPs work closely with selected NHS trusts at strategic levels to implement referral systems. This includes working alongside senior colleagues such as chief executives, directors of nursing, end-of-life-care specialists and coroners. HDNPs also work closely with nursing colleagues in NHSBT Organ Donation.
In recent years HDNPs have supported several trusts in developing automatic referral systems whereby 100% of adult deaths are referred to the TES National Referral Centre (NRC) in Liverpool so the nurses are able to reach many more families to discuss the option of donating tissue. Not all suitable families who are approached will agree to donation, yet most respond positively to having been given the opportunity to make a decision that is right for them.
Specialist nurses in tissue donation
Referrals of potential donors are made to the specialist nurses in tissue donation (SNTDs) in the TES NRC. These nurses are responsible for the clinical assessment of all potential tissue donors and their role involves facilitating tissue donation, often within very specific timeframes. For example, cornea donation must be facilitated within 24 hours of death.
In 2019, the NRC received around 20 000 referrals. Despite a busy and fast-paced environment, the SNTDs are required to be adaptable and to meet the needs of each family.
The team is responsible for facilitating tissue donation after death throughout the four countries within the different legislation frameworks of the UK. The role is unique, complex and fast paced. While based within a heavily regulated environment governed by the Human Tissue Authority (HTA), the role is tempered by the extremely rewarding aspect of communicating with and supporting acutely bereaved families.
When any potential donors are referred to the NRC, an SNTD will assess their clinical suitability to donate in accordance with national and international donor selection guidelines. This is the first step in ensuring that donated tissue is safe and there is minimal risk to any potential recipients of transplant. If a deceased person is suitable to donate, the SNTD will, through advanced communication skills, guide the family through the donation process. If the family agree that donation may proceed, the SNTD will obtain appropriate consent.
All contacts with health professionals and family members are conducted over the telephone. Conversations are audio recorded as a record of consent, which may also include consent for research and education. Conversations facilitated over the phone require specific skills. The focus is very much on non-verbal cues. Tone of voice, language used and pauses within a conversation are key to adjusting to the needs of the family and is a very different skill set to face-to-face communication. Every case and every donor family are different, which means that every conversation has to be different. The SNTDs must be adaptable and be able to quickly develop rapport and trust with the bereaved families, who they have never met. In a unique way these conversations enable nurses to conduct peer review, research, clinical supervision and reflective practice.
Clinical support nurse team
The clinical support nurse team (CSNT) within TES is an example of registered nurses working at an advanced level, making professionally autonomous decisions for which they are accountable. As the Royal College of Nursing has noted:
‘With an ever-increasing demand for health care and financially constrained budgets it has never been more important to have the right staff who are educated and competent, delivering the best care possible at the right time. Registered nurses are increasingly extending and expanding their scope of practice in all healthcare settings developing skills, competence and confidence.’
The CSNT comprises two band 7 nurses and a band 8a manager who work together to safely assess and authorise the precious donated tissue for transplant. The CSNT works collaboratively with TES medical consultants to ensure the clinical safety of transplantable tissue to hospitals across the whole of the UK.
In order to achieve this, the team is required to use complex reasoning, critical thinking, reflection and analysis to inform their assessment and clinical judgement. CSNT practice is guided by the Donor Selection Guidelines set by the Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee (2013). These guidelines stipulate contraindications to tissue donation on which the CSNT bases clinical decisions to ensure the safety of the recipients of any donated tissue by ruling out the chances of contracting any transmissible illness or transplanting tissue of compromised quality.
Although a large component of the TES CSNT workload is to authorise donor files from those patients who have died and generously donated to help others after their death, there are also living donation programmes such as surgical bone and amnion that the CSNT must also assess. The CSNT must ensure that a donor's previous past medical history and current health deem them to be a suitable and safe tissue donor.
The final responsibility of the CSNT is to oversee the Autologous/Allogeneic Serum Eye Drop Programme (ASE/AlloSE). This involves reviewing clinical requests made by ophthalmologists for serum eye drop options. Whether it be autologous serum, where patients themselves donate their own blood to produce their own eye drops, or AlloSE, where a blood donor donates their blood altruistically for serum for another patient's eye drop treatment, the CSNT must ensure that the patient is medically suitable to undergo a blood donation session for ASE. If they are not well enough to go through this process, they can be considered for the AlloSE option.
This is just a brief snapshot of how CSNT nurses apply their expert knowledge and skills to a broad range of clinically challenging and complex situations. It demonstrates how nursing practice has evolved to encompass responsibilities that only 2 years ago were held solely by the medical consultants. This shows how advanced nursing practice is not a doctor substitute but a hybrid approach between nursing and medicine that has resulted in an improved, cost-effective service while ensuring that the key values that underpin the organisation—caring, expertise and quality care—are at the core of the team.
Conclusion
The nursing roles within TES are challenging and diverse. It is crucial that nurses continue to develop and thrive within this very niche area of healthcare provision and continue with their unique skillset of caring for our donor families. They are at the forefront of compassionate care and communication, while fulfilling clinical commitments to recipient patients.