Supportive Care in Cancer

, Volume 19, Issue 2, pp 203–210 | Cite as

An exploration of the influences on clinical decision making and the culture of blood transfusion practise in cancer-related anaemia using an ethnographic methodology

  • Liz Bishop
  • Sara Faithfull
  • Helen Allan
Original Article



This study seeks to explore the cultural practises, which shape the culture of transfusion, and to identify the key elements, which influence clinical decision making in blood transfusion in haemato-oncology and lung cancer patients.


The assessment and decision making processes for blood transfusion were explored using fieldwork observation, six patient and nine clinician interviews based on ethnographic methodology. Data were analysed using thematic analysis.


First, the findings suggested that despite anaemia and transfusion being ubiquitous in this cancer setting, it sits low in the hierarchy of clinical concerns (The unimportance of anaemia). Second, there is a great deal of uncertainty surrounding the diagnosis and management of this clinical problem; but this uncertainty was acknowledged by both patients and clinicians (Acknowledging uncertainty). Third, clinicians and to some extent patients, are socialised into the practise of the sub-discipline (Socialisation in practise). Fourth, the haemoglobin level was used as a distinct fragment of information on which to assess for the presence of anaemia and base the decision to treat with blood transfusion (Disaggregation of the body).


The management of anaemia is not a priority in this setting; however, by understanding the complexity of factors for variation in practise in the clinical context, new models for learning transfusion skills can be developed. Furthermore, different collaborative groups could be organised to develop optimal transfusion practises, for example to include nurse-prescribing of blood components or by developing patient-centred decision making systems.


Anaemia Blood transfusion Cancer, neoplasms Culture Decision making 



The authors would like to thank Guy’s and St Thomas’ NHS Foundation Trust for funding the research and Professor Sara Faithfull and Dr. Helen Allan of Surrey University for their supervision of this study. This study was undertaken as part of a Doctorate in Clinical Practice.


  1. 1.
    Ludwig H, Van Belle S, Barrett-Lee P, Birgegard G, Bokemeyer C, Gascon P, Kosmidis P, Krazkowski M, Nortier J, Olmi P, Shneider M, Schrijvers D (2004) The European Cancer Anaemia Survey (ECAS): a large multinational, prospective survey defining the prevalence, incidence and treatment of anaemia in cancer patients. Eur J Cancer 40:2293–2306PubMedCrossRefGoogle Scholar
  2. 2.
    Bokemeyer C (2005) Therapy related causes of anaemia in cancer patients. In: Bokemeyer C, Ludwig H (eds) anaemia in cancer, 2nd edn. Elsevier Ltd, London, pp 45–83Google Scholar
  3. 3.
    Estrin JT, Schocket L, Kregenow R, Henry DH (1999) A retrospective view of blood transfusions in cancer patients with anaemia. The Oncologist 4:318–324PubMedGoogle Scholar
  4. 4.
    Barrett-Lee PJ, Bailey NP, O’Brien MER, Wager E (2000) Large scale audit of blood transfusion requirements and anaemia in patients receiving cytotoxic chemotherapy. Br J Cancer 82:93–97PubMedCrossRefGoogle Scholar
  5. 5.
    Demetri GD (2001) Anaemia and its functional consequences in cancer patients: current challenges in management and prospects for improving therapy. Br J Cancer 84(suppl 1):17–23PubMedGoogle Scholar
  6. 6.
    Glaspy J (2001) Anaemia and fatigue in cancer patients. Cancer 92(suppl 1):1719–1724PubMedCrossRefGoogle Scholar
  7. 7.
    Ludwig H, Strasser K (2001) Symptomatology of anemia. Semin Oncol 28(suppl 8):7–14PubMedCrossRefGoogle Scholar
  8. 8.
    Caro JJ, Salas M, Ward A, Goss G (2001) Anaemia as an independent prognostic factor for survival in patients with cancer: a systematic quantitative review. Cancer 7:2214–2221CrossRefGoogle Scholar
  9. 9.
    Morisaki H, Sibbald WJ (2004) Tissue oxygen delivery and the microcirculation. Crit Care Clin 20:213–223PubMedCrossRefGoogle Scholar
  10. 10.
    Goodnough LT (2003) Risks of blood transfusion. Crit Care Med 31(suppl 12):678–686CrossRefGoogle Scholar
  11. 11.
    Williamson LM, Lowe S, Love EM, Cohen H, Soldan K, McClelland DB, Skacel P, Barbara JA (1999) Serious hazards of transfusion (SHOT) initiative: analysis of the first two annual reports. BMJ 319:16–19PubMedGoogle Scholar
  12. 12.
    BCSH (2001) Guidelines for the clinical use of red cell transfusions. Br J Haematol 113:24–31CrossRefGoogle Scholar
  13. 13.
    Madjdpour A, Spahn C (2005) Allogeneic red blood cell transfusions: efficacy, risks, alternatives and indications. Br J Anaesth 95:33–42PubMedCrossRefGoogle Scholar
  14. 14.
    Wigton RS, Hoellerich VL, Patil KD (1999) How physicians use clinical information in diagnosing pulmonary embolism: an application of conjoint analysis. In: Dowie J, Elstein A (eds) Professional Judgment: a reader in clinical decision making, 6th edn. Cambridge University Press, Cambridge, pp 130–149Google Scholar
  15. 15.
    Salem-Schatz SR, Avorn J, Soumarai SB (1993) Influence of knowledge and attitudes on the quality of physicians’ transfusion practice. Med Care 31:868–878PubMedCrossRefGoogle Scholar
  16. 16.
    Savage J (2006) Ethnographic evidence. J Res Nursing 11:383–393CrossRefGoogle Scholar
  17. 17.
    Spradley JP (1980) Participant Observation. Thomson Learning, BelmontGoogle Scholar
  18. 18.
    Hammersley M, Atkinson P (2007) Ethnography: principles in practice, 3rd edn. Routledge, LondonGoogle Scholar
  19. 19.
    Atkinson P (1995) Medical talk and medical work. Sage Publications, LondonGoogle Scholar
  20. 20.
    Foubert J, Wujcik D (2005) Nursing assessment and management of anaemia and fatigue. In: Bokemeyer C, Ludwig H (eds) Anaemia in cancer, 2nd edn. Elsevier Ltd, London, pp 105–121Google Scholar
  21. 21.
    Eddy DM (1999) Variations in physician practice: the role of uncertainty. In: Dowie J, Elstein A (eds) Professional judgment: a reader in clinical decision making, 6th edn. Cambridge University Press, Cambridge, pp 1–45Google Scholar
  22. 22.
    Eraut M, Hirsch J (2007) The significance of workplace learning for individuals, groups and organizations. Economic and Social Research Council Accessed 2 Dec 2008
  23. 23.
    Giddens A (2006) Sociology. Polity Press, LondonGoogle Scholar
  24. 24.
    Manley K, Mc Cormack B (2008) Person-centred care. Nurs Manage 15:12–13Google Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  1. 1.Guy’s and St Thomas’ NHS Foundation TrustGuy’s HospitalLondonUK
  2. 2.European Institute of Health and Medical SciencesUniversity of SurreyGuildford, SurreyUK

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