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Issue 5 | June 2023

Welcome from Vicky, Annette and Jo

Welcome to the June 2023 edition of the East Genomic Medical Service Alliance (GMSA) Nursing and Midwifery Genomics Newsletter. Below we focus on:

  • a paediatric genomic practitioners’ pilot project.
  • some practical issues in genomics like consent and confidentiality and how children’s clinical nurse specialists deal with these in their practice.

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Vicky Carr 

East GMSA Nurse Lead
Cambridge University Hospitals

Annette Breen

East GMSA Nurse Lead

Nottingham University Hospitals

Joanne Hargrave

East GMSA Midwife Lead

Norfolk and Norwich University Hopsitals

Consent and confidentiality

Consent involves a process of shared decision making between the patient and healthcare professional, which allows the patient to make an informed choice. Consent for genomic testing builds on existing healthcare practice for consent.  However, in genomics there are some additional complexities to consider:


Addressing the needs of the wider family

Although genetic information is personal, family members may be affected by genomic results because they share genetic information, and/or because they are involved in the care of their relatives. Genomic testing can reveal unexpected social information, such as non-paternity, as well as medical information; ideally, this possibility should be made clear during the consent process, although this will not necessarily help to determine whether, when or how such a finding should be disclosed.  The majority of patients are willing to share their genomic test results with their families, but some are not.  


The large scope of genomic information

There are a large number of possible outcomes from a genomic test, which it might not be practical to cover in depth during a consultation. It is important to discuss the types of information that genomic testing might find in a way that the patient can understand.


Uncertainty of genomic information

Genomic testing does not always provide an answer for the patient’s presenting condition and can give uncertain or unexpected results. Knowledge about genomics may change over time as new information emerges.

 

The potential predictive nature of genomic tests

Some genomic tests aim to confirm a diagnosis that is already present in an individual. However, a genomic test may also reveal the potential for an individual to develop additional problems in the future.  Predictive testing can also be done in individuals who have a family history of a condition who are currently healthy and well, to find out whether they have a chance of developing it in the future.

 

Data storage and sharing protocols 

Genomic testing may generate a large amount of data, and it can be helpful to compare this with an individual’s other tests to interpret any results more accurately and informatively.

Record of discussion form

When ordering or undertaking any genomic test, it is vital to discuss the test, its implications and its possible outcomes with the patient or, where appropriate, their parent or guardian. 


This discussion, and the patient’s decisions, should be recorded.

 

Further information can be found here. 


Embedding paediatric genomic practitioners in NICU, PICU and paediatric neurology

15% of all newborn babies are admitted to NICU. Their initial clinical presentation may not accurately predict their outcomes.  Many investigations are invasive and sequential leading to delays in diagnosis and treatment. 


Whole exome and genome sequencing is available for acutely ill children with a likely monogenic condition in NICU, PICU and other paediatric settings to give a more timely diagnosis to inform care and treatment pathways more accurately. 

Consent for genomic testing is complex and should include that the results may predict future health as well as diagnosis, the scope and limitations, the possibility of additional, unexpected or incidental findings and that outcomes may be uncertain or unclear.

 

To embed and evaluate workforce transformation in genomics in acute paediatrics, two pilot projects are taking place; one in Nottingham and one in Cambridge. The aim is to develop a new role of ‘link’ genetic counsellor/genomic nurse practitioner who will form part of the paediatric team and clinical genetics service/MDT and is able to directly meet with parents when they are attending the ward, explain genomic testing in detail and go through the Record of Discussion process.

Meet Caroline and Shelby, Paediatric Genomic Specialist Nurses

Could you introduce yourselves and your role?

We are Caroline Hoad (left) and Shelby Mathlin (right) and we are both paediatric genomic specialist nurses at Cambridge University Hospitals. 

We are working on a pilot workforce transformation in paediatrics to embed paediatric genomic practitioners in neonatal and paediatric intensive care units and paediatric neurology. 


We get referrals mainly from NICU, but PICU as well, where babies and children are acutely ill and are likely to have a monogenic condition.  We arrange to meet the family on the unit to discuss genomic testing with them to ensure that they understand what testing is, and also the possibility that they might get a rare disease diagnosis that could have serious future implications for them and their child.  If the family consent, we coordinate sample taking for the parents, usually in outpatients, and the child.  


We are working on our involvement in the results giving process, as we are aiming to develop a full end-to-end care pathway.


We also get referrals from neurology clinics where genomic testing has been discussed with families who have a child with a serious neurological condition, like severe hypotonia. We contact the family after clinic to make an appointment, usually by phone or over ‘Attend Anywhere’, a secure NHS video call service for people with pre-arranged appointments, as the neurology clinicians see patients from a wide area including parts of Essex, Norfolk and Suffolk as well as Cambridgeshire. 


How did you become paediatric genomic specialist nurses?

We are both registered children’s nurses. I [Shelby] have worked in NICU for most of my career. I was interested in a specialist role and had heard of genomics as my friend’s baby was diagnosed with cancer, just after his first birthday and was offered whole genome sequencing.


I [Caroline] have worked in paediatric A&E for most of my career. Neonatal care has always been an interest of mine, having had a link role in A&E, so to be more involved with this group of patients really appealed. I also think it’s great that this project is building on strong findings from previous genomic research studies at Addenbrookes, and for the benefit of patients.


When we first started in post, we observed and shadowed the Clinical Genetics Team at CUH and completed the Health Education England Genomics 101 series of modules.  We went on to complete the PG Certificate in Genomics and Counselling Skills module at University of West England; this was very good and we were able to apply the learning directly to our clinical practice. 


What is the most challenging thing about your job?

Having a complete blank canvas to start with and creating the service overall, as the process was very ad hoc before.   


What is the most rewarding thing about your job?

We have definitely improved the care pathway, which means that that some babies and children have had their results sooner than they would have done which has informed decisions about their care.


We have had very positive feedback from consultants about how helpful and beneficial it is that families have a point of contact. We liaise with laboratories to find out how far sample testing has progressed, and when the results are likely to be available and feedback to consultants and the families.

 

Find out more

Genomics Education Programme / Health Education England online courses:

Genomic BITEs: Lunch and learn sessions for busy nurses and midwives

Our next Genomics BITE session will focus on Paediatric Genomic Practitioners in NICU, PICU and neurology and takes place on Wednesday 14 June, 12.45pm - 1.30pm via MS Teams. You can register your free place here.


Our previous Nursing and Midwifery Genomics BITE sessions are now available to watch on our YouTube channel:

Topics for future sessions include the national Newborn Genomes Programme. To suggest a session that would be of interest to you please contact Annette Breen.

Meet the East GMSA Nursing and Midwifery Team

Contact: Melissa Cambell-Kelly, Annette Breen, Vicky Carr, Jo Hargrave or Katy Blakely. We also have a network of LINK Nurses across our 29 Partner Trusts. If would like to know who your local Genomic LINK Nurse is, contact us here.

Education, Training and Resources

The Genomics Education Programme has a wide range of free to access learning and education resources for nurses, midwives and health visitors.  No matter where you are in your leaning journey about genomics, there is something for you to build your knowledge and support your NMC revalidation including:

  • Bite size genomics a series of 10 minute animations and films
  • Genomics 101 a series of 9 short introductory courses, each lasting about 30 minutes for those with a little bit or no knowledge about genomics
  • Taught courses up to Masters level
  • GeNotes help healthcare professionals make the right genomics decisions at each stage of a clinical pathway. GeNotes are in development to provide:
    • In The Clinic information focussed at the point of patient care with clinical scenarios, when to consider genomic testing, what you need to do and the results stage
    • Knowledge Hub accessed via links within ‘In The Clinic’ to external sources and resources and signpost to relevant guidelines, including NICE.

GeNotes are organised into clinical specialities and will be released in a phased manner.  There are currently some Oncology and Fetal and Women’s Health clinical presentations and summaries available to support you in your practice.


Midwives, Obstetricians and others working in the maternity care pathway 

We are looking for volunteers to join our working group for Fetal and Women’s Health GeNotes. Please contact us to register your interest.

     

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