Evidence Review

A literature review was conducted to identify references related to a minimum number of bone marrow or surgical procedures required to determine trainee competency. Various references from nursing and physician literature were identified. The Accreditation Council for Graduate Medical Education (ACGME) Review Committee provides established minimum numbers of procedures for residents to perform in emergency medicine (EM) rotations.4 Wen and colleagues conducted a cross-sectional descriptive study of EM trainees’ self-reported procedural competency for performing core procedures and resuscitation based on the ACGME guidelines. Residents in the EM program were to complete intubations, chest tube insertions, central venous access, internal cardiac pacing, procedural sedation, cricothyrotomy, lumbar puncture, and vaginal delivery; and to assess perceived competency.5 Each EM trainee was to complete each procedure at least 10 times; however, they exceeded the minimum volume required for all but 3 of the procedures and endorsed their competency for performing those procedures. The investigators found that competency was reported to be lower for procedures in which the minimum requirement of 10 was not achieved: cricothyrotomy, pericardiocentesis, and internal cardiac pacing.5

Kyser and colleagues were concerned about the limited experience physician trainees were receiving in forceps deliveries, a complex but low-frequency procedure. Some hospitals determine the minimum requirement to obtain competency for some procedures as a percentage of that facility’s volume.6 The authors explored 2008 state inpatient data for childbirths in nine states — Arizona, California, Florida, Iowa, Maryland, New Jersey, North Carolina, Washington, and Wisconsin — and found a significantly low volume of forceps delivery.6 Of 835 hospitals in the 9 states, an analysis of 624,000 operative deliveries demonstrated that nearly 40% of hospitals did not perform forceps deliveries and 50% performed 5 or fewer.6 The conclusion and concern were that training physicians and assuring competency is difficult with low volumes of procedures.6 Recommendations from Kyser’s team were to consider, develop, and test new training methods for technically complex procedures that occur in low volumes.


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In a different assessment of proficiency in procedures, Hernigou and colleagues conducted a study to explore the anatomy of the ilium for performing bone marrow aspirations and to identify risks of breaching the ilium on cadavers.7 The researchers identified that surgeons who performed fewer than 10 BM harvests had more breaches than those who performed more than 10 harvests (75 [31%] vs 19 [8%]) among 240 entry points each.7 Of these 3 studies, volume of procedures is reported to contribute to competency, and 10 is a common acceptable minimum.

The nursing literature was also explored to identify standards for training NPs in performing BM procedures. In an early study, BMX performed by NPs was compared with those by physicians.8 Although the length and quality of BMX were not significantly different, quality of BM aspirates were poorer (lack of spicules) in the procedures by NPs. The authors stated that NPs had difficulty obtaining the skill for making smears of the marrow. The BMX samples were found to be of equal quality, and the authors subsequently concluded that properly trained NPs can perform marrow procedures as effectively as physicians.8

More recently, Jackson and colleagues outlined competencies NPs must meet to perform BM procedures.3 They recommend that NPs perform 10 procedures under supervision to demonstrate competency.

Kelly and colleagues reviewed BM procedures performed by NPs in Ireland, and found the quality of BM specimens obtained by NPs were comparable to those obtained by physicians.9 Once again, 10 was determined to be the required minimum number of procedures to document competency.9 This recommended minimum volume of procedures to demonstrate competency identified in the literature is commensurate with the required minimum in the pediatric cancer center.

Principles of Training and Learning

Exploring the evidence and validating the recommended minimum volume of procedures to incur competency is only one component of training APPs. Jackson and colleagues outline the basic elements of a training program to establish procedural competency for performing bone marrow aspiration procedures.3 First, the training plan must provide standardized “written, verbal, and video instructions … on rationale, risks and benefits of the procedure, anatomy and physiology of biopsy sites and anatomic markings, equipment used to obtain a sample, the procedure itself, and the treatment implications of the findings.”3 The next steps are for the trainee to observe 10 procedures then begin hands-on training, performing 10 procedures under direct supervision. Lastly, all trainees must review the pathology reports for sample quality and adequacy.3 These steps illustrate basic elements of training, yet highlight constructs that deserve further discussion and appreciation.

Ford and Meyer discuss the development of competency-based education for procedures performed in the actual work setting.10 The value of supervised training of APPs in the cancer center over a period of weeks to months provides the trainee the opportunity to develop the knowledge, skills, and attitudes for success in performing procedures. The trainer can provide immediate feedback, support, guidance, and insight, and help the learner develop confidence. Ford and Meyer discuss the Four Component Instructional Design (4C-ID) model that includes 4 components and 10 steps. The 4 components include learning tasks, supportive information, procedural information, and part-task practice. Integrated into these 4 components are steps that analyze cognitive strategies and rules, mental models, utilize prerequisite knowledge, and design procedural models and part-task practice. Cognitive steps of learning are applied to each component of the task as the task increases in complexity.10

APPs in the cancer center receive the didactic information regarding policies and procedures and are trained under supervision over a period of time. Supervised training during which one performs the minimum required number of procedures provides time for mentorship and learning strategies for performing procedures on various types of patients and in various challenging scenarios. Ford and Meyer discuss the development of competency based on Merrill’s 5 principles of instruction:

  • Learners are engaged in solving real-world problems;
  • Existing knowledge is activated as a foundation for new knowledge;
  • New knowledge is demonstrated to the learner;
  • New knowledge is applied by the learner;
  • New knowledge is integrated into the learner’s world.11

Literature on establishing procedural competency and principles of training provides evidence to support required volumes but also provides the theoretical background to improve and support the training process.