ISBT Science Series (2011) 6, 270–276

ª 2011 The Author(s).

STATE OF THE ART 2B-E1.6 ISBT Science Series ª 2011 International Society of Blood Transfusion

The role of the transfusion nurse in the hospital and blood

centre
L. Bielby, L. Stevenson & E. Wood
Australian Red Cross Blood Service, Melbourne; and Blood Matters Program, Department of Health, Victoria, Australia

The transfusion process is complex, involving many interlinking chains of events,

and a multidisciplinary group of health professionals with different levels of aware-
ness and understanding of transfusion practice. In recent years, many measures
have been implemented to increase blood component safety and the clinical trans-
fusion process. Haemovigilance programs report the greatest risks to patients from
transfusion in many countries now relate to hospital-based steps in the process.
The role of the Transfusion Nurse (TN) is evolving as an integral part of efforts to
optimise appropriate use of blood components, reduce procedural risks and improve
transfusion practice generally. The TN position is a relatively recent specialist role
within hospitals and blood services, and continues to develop with growing experi-
ence of areas requiring intervention in the clinical setting, and increasing expecta-
tions for improvements in transfusion clinical governance.
The role typically includes activities to improve clinician and patient awareness
of transfusion issues and practical knowledge of blood product use, and therefore to
improve clinical decision-making and enhance blood administration processes,
along with responsibilities for education/training, auditing and adverse event fol-
low-up. Within the Blood Service in Australia the role also covers approval and
provision of specialised blood products along with many of the hospital-based TN
functions.
The TN serves as an expert resource and has been fundamental in development of
tools, resources and skills in the following areas:
- Patient blood management:
- Education
- Governance
- Professional development
- Research
Benchmarking across organizations has demonstrated that availability and
review of comparative data can be a powerful motivator of change. Reviews of the
TN role/programmes highlighted their effectiveness and resulted in ongoing sup-
port/funding. Skills and attributes such as confidence, persistence, energy, excellent
communication/ technical knowledge and clinical experience are key requirements
for the roles success.
Conclusion The specialist transfusion practitioner/Transfusion Nurse is an integral
part of a multidisciplinary team, supporting efforts at institutional and national
levels to reduce transfusion risks and improve practice.
Key words: transfusion practice, transfusion nurse, transfusion practitioner.

Correspondence: Linley Bielby, Blood Matters Program Manager, Australian Red Cross Blood Service ⁄ Department of Health, 50 Lonsdale Street,
Melbourne, Victoria, Australia
E-mail: linley.bielby@health.vic.gov.au

270

Introduction
The transfusion process is complex, involving many inter-
linking chains of events, and a multidisciplinary group of
health professionals with different levels of awareness and
understanding of transfusion practice. In recent years,
numerous measures have been implemented to increase
both the safety of blood components and the transfusion
process itself. However, haemovigilance programmes con-
tinue to report that the greatest risks to patients from trans-
fusion in many countries relate to hospital-based steps in
the process, particularly transfusion of the wrong blood
component.
Over the last decade, many countries have introduced
clinical transfusion practice improvement programmes to
optimize appropriate use of precious blood components,
reduce the procedural risks of transfusion administration
processes and improve transfusion practice generally. These
improvement activities typically involve a multidisciplin-
ary team, and the role of the Transfusion Nurse (TN) is
evolving as an integral part of these programmes and con-
tinues to develop with growing understanding of areas
requiring intervention in the clinical setting, and increasing
requirements for improvements in transfusion clinical gov-
ernance. The TN is (generally) a relatively recent specialist
position within hospitals and blood services. The role is
multifunctional, requiring diverse skills and attributes, and
incorporates a range of clinical, quality, risk management
and educational activities.
Drivers underpinning clinical transfusion
practice improvement programmes
A number of factors have prompted the development of
practice improvement programmes:
(1) Clinical governance: Many countries now have
requirements from healthcare quality accreditation
bodies that include standards for transfusion gover-
nance, and considerable resources may be required
to demonstrate compliance. For example in Australia,
both the Australian Commission for Safety and Qual-
ity in Healthcare (a national, standard-setting body)
and the Australian Council on Health Care Standards
(a hospital assessment and accreditation body) now
have detailed requirements for transfusion practice.
(2) Risk management: International haemovigilance data
indicate significant hazards associated with the trans-
fusion of incorrect or inappropriate blood components,
plus a substantial number of near misses with the
potential for harm.
(3) Demand: The demands for blood and blood products are
increasing each year in many countries for a variety of
 2011 The Author(s).
ISBT Science Series  2011 International Society of Blood Transfusion, ISBT Science Series (2011) 6, 270–276
Role of the transfusion nurse 271
reasons, such as ageing populations, changes in treat-
ment options, introduction of new technologies, and
improvements in supportive therapy. With increased
demands come associated costs, including costs associ-
ated with production, management and administration
of blood components and fractionated blood products.
(4) Patient expectations: Patients are now much more
informed about treatments, including transfusion, and
their potential risks, and have expectations for more
information to make informed decisions about their
therapy.
(5) Availability of new clinical practice guidelines and
research findings, for example, in the areas of blood
conservation, including intra- and post-operative cell
salvage techniques and the development of pre-opera-
tive anaemia management clinics [such as from the UK
Better Blood Transfusion (BBT), and Canadian onTrac
programs].
Many governments and health agencies have considered
these factors and now place increased emphasis on appro-
priate use and management of blood, and as a consequence
some have provided direction and resources, including
financial support, to establish clinical transfusion practice
improvement initiatives.
What do these programmes look like?
Established clinical transfusion practice improvement
programmes and the activities within them vary signifi-
cantly both between and within countries; and are
strongly influenced by the local health care system
needs and government expectations. Programmes gener-
ally involve a multidisciplinary team raising awareness
around transfusion to improve practical knowledge of
blood product use, and provide a basis to improve clini-
cal decision-making and enhance blood administration
processes and patient care. Data generated from audits
and other programme activities can be powerful motiva-
tors of change and tools for benchmarking within and
across organizations.
The individuals undertaking these roles have various
titles, such as TN, TN specialist or consultant, transfusion
safety officer, haemovigilance officer and specialist practi-
tioner of transfusion. In Australia, New Zealand and the UK
these specialist transfusion practitioner positions are now
well established and are predominantly nursing roles, while
in other settings, personnel with scientific ⁄ technical (e.g.
Canada) or medical (e.g. France) backgrounds may perform
some or all of these activities. In all cases, they work very
closely with other healthcare professionals in transfusion
support, patient blood management and blood conserva-
tion. Links to some established programmes and groups are
provided at the end of this article.
272 L. Bielby et al.

Table 1 Examples of activities of some practice improvement programmes and the role of the TN in achieving results

Activities and achievements Key elements ⁄ skills of TN

Promote and participate in Patient Blood Management (PBM) programs:

• Support PBM including blood conservation practices (e.g. UK Better Blood Transfusion including Knowledge, preparation, implementation,
e-learning programme for cell salvage, see http://www.learncellsalvage.org.uk) support and education,
• Provide tools and materials, such as patient information brochures (e.g. for management of iron Clinical input, real-time education to
deficiency anaemia), fact sheets and other materials which are age and culturally appropriate. patients ⁄ staff and clinical intervention
(see BloodSafe and Blood Matters websites)
• Manage nurse-led clinics for anaemia management (see OnTrac website)
• Promote multidisciplinary team approach – e.g. involvement in clinical ward rounds enabling
real-time education or clinical intervention
Education
• Develop and implement programmes within health services and blood services, including: Online Knowledge, development and implementation,
e-learning ⁄ paper-based training ⁄ competency packages e.g.: support and education,
• BloodSafe (South Australia): see https://www.bloodsafelearning.org.au Understanding and working with technology,
• Bloody Easy (Transfusion Ontario): see http://www.transfusionontario.org Being a change agent,
• Scottish National Blood Transfusion Service (SNBTS): see Project management,
http://www.learnbloodtransfusion.org.uk Communication with and across disciplines
• Develop templates to provide consistent transfusion information and assist new TNs
• Educational posters on indications, special requirements, identification, blood
sampling, transfusion reactions, etc. (see Better Blood transfusion tools).
Newsletters to highlight important messages
Governance
• Develop and implement policies and procedures, manuals, clinical guidelines, charts and forms to Knowledge,
support safe and appropriate transfusion practice. For example: Change agent,
• Policies and procedures to support new clinical practice guidelines and ⁄ or requirements, e.g. Auditing and monitoring,
for massive transfusion, or for specialised products such as intravenous immunoglobulin and Recording, analysing and maintaining data,
recombinant factor VIIa Literature review,
• Institutional activities to support blood supply contingency planning strategies Education and training,
• Patient identification – conduct audits and make recommendations for change, develop Communication with and across disciplines,
policy, conduct trials and participate in implementation of technology, i.e. Working with multidisciplinary teams
radiofrequency identification system (RFID) for patient ID – e.g.‘Blood Track’
• Informed consent – develop and implement policy and procedures, patient
information (age appropriate and culturally sensitive) and forms to support increased
patient knowledge and understanding of risks. Establish and support hospital
transfusion committees, to provide authority and action change improvement
processes. Transfusion reaction follow-up and incident reporting internally and
externally, including to Haemovigilance programs
• Prepare reports to national and local governments, local institutions ⁄
organisations ⁄ departments and clinicians
Professional development
• Develop resources for new TNs e.g. UK BBT tools – ‘A drop of knowledge,‘A Wealth of Knowledge Knowledge, development and implementation,
and Blood Matters ‘Handbook for Transfusion Practitioners 2010’ support and education,
• Clinical support networks to facilitate information and resource sharing and provide support to Communication with and across disciplines and
TNs (e.g. Australia ⁄ NZ ‘AUSPOTS’ and UK SPOT networks organisations,
• Participate in post-graduate specialist qualifications: e.g. Blood Matters ⁄ University of Project management,
Melbourne Graduate Certificate in Transfusion Practice. TNs have played a major part in Contract management,
designing and delivering this course Multimedia presentation skills,
• Participate in local, national and international professional meetings and conferences Facilitating change
to share knowledge
Audit and research
• Plan and conduct audits of clinical practice (e.g. administration practice, overnight transfusion, Auditing, monitoring maintaining and
sample collection and compliance, appropriateness of transfusion against guidelines, patient interpreting data,
identification and storage and handling). Implementing change,
• Use audit data to support practice change and benchmarking. Participate in research, including Understanding and working with technology,
clinical trials Communication with and across disciplines,
Working with multidisciplinary and
international teams

 2011 The Author(s).

ISBT Science Series  2011 International Society of Blood Transfusion, ISBT Science Series (2011) 6, 270–276

Skills and attributes of the TN
The skills and attributes of TNs ⁄ practitioners are impor-
tant factors in the success of the role and their contribu-
tion to clinical transfusion practice improvement
programmes.
Transfusion nurses are vital connections between the dif-
ferent health professionals engaged in the transfusion
chain, in particular, those beyond the transfusion labora-
tory. They act as educators, trainers, co-ordinators, data
collectors, project managers and change agents. They are
critical components of hospital transfusion teams, and pro-
vide invaluable support for the efforts of the hospital trans-
fusion committee (or equivalent).
The TN skills should include comprehensive and current
knowledge of transfusion practice, excellent communica-
tion skills, an ability to interact with a broad range of peo-
ple from hospital executives, quality co-ordinators, senior
and junior medical officers, scientists and nurses, to
patients and relatives. The ability to understand and work
with the local hospital ⁄ health service ‘politics’ is a definite
advantage when implementing change. Skills such as effec-
tive project management and coordination, and attributes
such as confidence, energy and persistence are necessary to
see ideas through implementation and to fruition. As prac-
tice change is often achieved slowly, a coordinated and per-
sistent approach is required for truly ‘embedded’ long term
changes.
Achievements
The TN has been fundamental in the development and
implementation of many improvements; however, it
must be noted that while the TN is the driver and agent
of many of these changes, strong local leadership and
support from management is also essential to the pro-
cess, and especially required to ensure there is a contin-
uous cycle of improvement. Depending on the role and
the organization, this support could be provided by a
number of sources including hospital clinical champions,
transfusion team and transfusion committee, the blood
service transfusion medicine team, and professional TN
networks and specialty societies.
Where practice improvement programmes are well estab-
lished and have been evaluated they have demonstrated
increased awareness and knowledge to support decision-
making and appropriateness of transfusion, ultimately
resulting in improved outcomes in patients [1].
Table 1 demonstrates the complexity and diversity of
some of the achievements that have been possible within
these programmes and also outlines key elements and skills
of the TN required to achieve these results.
 2011 The Author(s).
ISBT Science Series  2011 International Society of Blood Transfusion, ISBT Science Series (2011) 6, 270–276
Role of the transfusion nurse 273
The Australian experience
A number of transfusion practice improvement pro-
grammes have been established over the past decade in
Australia, generally constructed as formal collaborations
between state ⁄ territory health departments and the Austra-
lian Red Cross Blood Service and in partnership with local
hospitals. Their activities, and those of the TNs employed
within them, reflect both national and local state or terri-
tory government priorities, resulting in variation in activity
and responsibility depending on the context and location
of their work. For example, some TNs oversee activities in a
large area health service (either metropolitan or regional)
covering many hospitals and health services, whereas oth-
ers are based at one hospital, such as a large metropolitan
university teaching hospital. At the time of publication,
there were approximately 75 specialist nurse positions
across Australia. A review of the TN role and the Blood
Matters program conducted in 2007 highlighted the effec-
tiveness and resulted in ongoing support ⁄ funding.
A Graduate Certificate in Transfusion Practice was devel-
oped by the Blood Matters program and is now offered
entirely on line for Blood Matters by the University of Mel-
bourne. This specialist qualification is recommended for
TNs undertaking this role in Victoria. Since 2003, a total of
70 students across Australia have successfully completed
the course, including a number of international and non-
nursing background participants.
In some Australian states, funding has been secured to
introduce additional resources in the form of non-specialist
nurse transfusion trainers (TT) and ‘link’ nurses to imple-
ment quality activities at regional and rural hospitals. These
roles are typically undertaken on a part-time basis, 1 day ⁄
week or fortnight, depending on the number of transfusion
episodes in their hospital.
The TN role is also an integral part of the Transfusion
Medicine Services (TMS) team at the Australian Red Cross
Blood Service. The TMS team provide clinical and technical
transfusion advice and support to clinicians, hospitals and
laboratories nationally.
Currently, 14 TNs are employed within the Blood Service
across Australia to cover each state and territory. The Blood
Service TN role includes approval and provision of specia-
lised blood products with particular reference to intrave-
nous immunoglobulin (IVIG) and specialised platelet
support, along with assistance with clinical advice, educa-
tion and support. In Australia, IVIG is an intensively man-
aged blood product, with the Blood Service designated as
one of the key authorized approvers; as such the Blood Ser-
vice TNs are key facilitators of these approvals, along with
other members of the TMS team. The Blood Service TNs
have assisted governments with the implementation and
274 L. Bielby et al.
ongoing education and support of the ‘Criteria for clinical
use of IVIG in Australia’ (Commonwealth of Australia
2007) and provided input to the recent review of this docu-
ment. The Blood Service TN role also incorporates the co-
ordination and provision of specialised platelet support (i.e.
HLA-matched and directed products). The Blood Service
TNs work closely with the hospital-based TNs and the role
also includes clinical audit and research (see below).
The TNs in Australia are actively involved in all aspects
of transfusion practice improvement as outlined in Table 1.
Some additional interesting aspects of the TN role in Aus-
tralia include participation in a range of clinical research
projects, such as:
(1) Data linkage activities, where hospital admission data
are linked with laboratory data to help understand
usage patterns at institutional and regional levels.
(2) A study of hospital intern knowledge of blood and
blood transfusion, which has been helpful in planning
further educational interventions.
(3) Collecting patient data for a number of clinical regis-
tries such as the Australian and New Zealand Haemo-
stasis Registry (to capture non-haemophilia-related use
of recombinant factor FVIIa), and the new national reg-
istries for neonatal alloimmune thrombocytopenia and
thrombotic thrombocytopenic purpura.
(4) National coordinator role for the Australian arm of the
international ‘TOPPS’ study (a randomized controlled
trial examining the use prophylactic platelet transfu-
sions in patients with haematological malignancies).
(5) Mapping and costing studies of red cells and platelets.
Within Australia, each clinical transfusion practice
improvement programme regularly uses an email network
or online forum at regional (e.g. Blood Matters – Transfu-
sion Interest Group) or national (Australian Specialist Prac-
titioners of Transfusion – AUSPOTS) level to interact, and
share resources or information from colleagues, including
through national networks in other countries such as the
UK Specialist Practitioner of Transfusion (SPOT) group.
Challenges for the TN role
(1) Facilitating change and maintaining the drive and
enthusiasm to continue to promote and support change
where in some settings there is little evidence and con-
flicting clinical and other priorities.
(2) The complexity of the transfusion chain and the num-
ber of staff involved, with frequent turnover, which
creates sustained pressure on the number and fre-
quency of education requirements.
(3) Maintaining funding to support and maintain pro-
grammes in the setting of tight healthcare budgets is a
constant challenge and requires proactive managers
and the use of data to demonstrate the value and need
ISBT Science Series  2011 International Society of Blood Transfusion, ISBT Science Series (2011) 6, 270–276
for such programmes. In Australia, support and funding
has generally been focused at hospitals in the public
sector to date but it is hoped to expand this further to
the private sector and rural areas in the future.
Where to from here?
In the current healthcare climate, and with imperatives to
reduce costs and risks, it is important that the outcomes
and achievements from these clinical transfusion practice
improvement programmes continue to be circulated and
published, to share results, celebrate achievements, identify
problems, minimize duplication of effort and assist with
benchmarking. Collaboration between programmes can
both maximize results and reduce workloads, generating
cost efficiencies and serving to provide a variety of addi-
tional skills and experiences for TNs, including opportuni-
ties for exploration of new technologies and their
implementation. Where institutions, regions or countries
are exploring or establishing new programmes, established
programmes could provide valuable support and direction
by sharing knowledge and experiences.
Summary ⁄ conclusion
Specialist transfusion practitioners ⁄ TNs have played sig-
nificant roles in delivering the many achievements of
the transfusion practice improvement programmes estab-
lished to date, working as part of multidisciplinary teams
at institutional and national levels in hospitals and
blood services to reduce transfusion risks and improve
practice. Sustaining improvements in transfusion practice
requires the continued support and co-ordination of
these efforts.
Disclosures
The authors declare that there are no potential conflicts of
interest.
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