Application of Techniques, Interpretation and Differential Diagnosis —
Training activity: 1

Details

Perform and interpret morphology for:

• Peripheral blood
  • Normal
  • Red cells and platelets
  • Reactive white cells
  • Malignant
  • Malaria
• Normal bone marrow populations

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Local SOPs
• Guidelines and standards
• Maintenance and basic troubleshooting
• Reference intervals
• Limitations of the methods

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to interpreting different morphological findings, specifically Normal, Red cells and platelets, Reactive white cells, Malignant, and Malaria in peripheral blood, as well as Normal bone marrow populations.
• Consider how the learning outcomes apply, specifically in relation to selecting, performing, and interpreting techniques, describing limitations, applying quality control principles, and communicating results.
• Discuss with your training officer to gain clarity of what is expected when performing and interpreting morphology for the identified populations.

What is your prior experience of this activity?

• Think about what you already know about performing morphology, including aspects such as sample preparation, staining, and microscope use. Consider your prior experience interpreting morphology for the specified categories.
• Consider possible challenges you might face during the activity, such as poor slide quality, rare findings, or difficulty differentiating cell types, and think about how you might handle them.
• Recognise the scope of your own practice for this activity, meaning knowing when you will need to seek advice or help e.g., for difficult cases, uncertain findings and from whom.
• Acknowledge how you feel about embarking on this training activity, especially if you have limited experience with certain categories like malignant morphology or malaria.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, drawing upon previous experiences, such as improving your speed, accuracy, or ability to identify subtle abnormalities.
• Identify specific insights you hope to gain from engaging with the activity, for example, achieving better recognition of specific cell types or patterns associated with different conditions.

What additional considerations do you need to make?

• Consult actions identified following previous experience of undertaking morphology in the specified conditions.
• Identify important information you need to consider before embarking on the activity, such as:
  • Reviewing the principles of blood film preparation and Romanowsky staining for optimal cellular visualisation.
  • Familiarising yourself with the key morphological features of the specified conditions, for example, identifying blast characteristics in malignancy or trophozoite forms in Malaria.
  • Reviewing Standard Operating Procedures (SOPs) for conducting manual differential counts and assessing the normal architecture of cell populations in bone marrow.
  • Familiarising yourself with the application of quality control principles necessary for morphology, including assessing slide quality.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst interpreting the morphology?
• Are you encountering situations such as:
  • Identifying a rare or highly malignant cell population e.g., blasts, circulating tumour cells that requires immediate classification, despite the referral information suggesting a less severe reactive state?
  • Observing significant technical limitations in the slide quality e.g., uneven staining, poor cell distribution which complicates the ability to accurately perform a manual differential count or assess bone marrow cellularity?
  • A finding e.g., red cell inclusion body suggesting malaria where the clinical information is missing or does not initially support the severity of the morphological observation?
• How is this morphology review comparing with previous morphology experiences you have had?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to selection?
• Consider the steps you are taking in the moment, such as:
  • Immediately adjusting your scanning pattern or magnification to focus on specific areas of the film e.g., the feathered edge, areas of aggregation to confirm the unexpected finding?
  • Seeking immediate advice from a senior colleague or training officer to confirm the differentiation of cell types e.g., identifying a specific blast subtype to ensure accurate preliminary classification?
  • Immediately consulting external references or atlases to correctly classify a rare finding, such as a specific red cell inclusion body or parasite form?
• How are you feeling in that moment? For instance, are you finding it difficult to adapt your knowledge of cell differentiation? Is it affecting your confidence in your ability to interpret the sample?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully reaching a preliminary conclusion regarding the classification of the unexpected finding? Or are you needing support because the morphology is novel or requires specific correlative investigations (e.g., flow cytometry)?
• What are you learning as a result of the unexpected development? For example, are you learning a more effective technique for adapting your scanning pattern based on initial cell distribution, or gaining insight into the necessary escalation procedure for critical findings like malaria?

On action

What happened?

• Begin by summarising the key points of the experience of performing and interpreting the morphology for this specific sample. What were the main steps you followed, e.g., initial slide scanning, performing the differential count, and correlation with automated parameters?
• Consider specific events, actions, or observations which felt important during the morphology review, such as reviewing complex or unusual cell patterns e.g., specific red cell inclusion bodies, a mixed population of malignant cells, or significant architectural abnormality in bone marrow that significantly influenced your interpretation. Include your own feelings during the experience.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, changing your initial focus from red cell to white cell assessment based on an unexpected abnormality (e.g., a critical blast count) or realising a sample presented poor slide quality.

How has this experience contributed to your developing practice?

• Identify what learning you can take from the experience regarding systematic morphology review or cell classification, e.g., learning how to differentiate between specific reactive and malignant populations. What strengths did you demonstrate e.g., knowledge of specific red cell inclusions? What skills and/or knowledge gaps were evident e.g., unfamiliarity with specific malignant cell characteristics or assessing normal bone marrow cellularity?
• Compare this experience against previous morphology activities – were any previously identified actions for development achieved? Has your practice in morphology interpretation improved?
• Identify any challenges you experienced e.g., encountering complex or unfamiliar cells or poor staining quality and how you reacted to these. Did encountering complex or unfamiliar cells affect your ability to deal with the interpretation? Were you able to overcome the challenges?
• Identify anything significant about the activity. Did you need to seek advice or clarification e.g., from a senior colleague or Haematologist to confirm the differentiation of a critical finding? Did you need to escalate to ensure that you were working within your scope of practice?
• Acknowledge any changes in your own feelings now you are looking back on the experience.

What will you take from the experience moving forward?

• Identify the actions / ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received e.g., routinely reviewing specific malaria forms or bone marrow assessment guidelines.
• What will you do differently next time you review morphology? Has anything changed in terms of what you would do if you were faced with a similar situation again?
• Do you need to practise any aspect of the activity further e.g., specific cell differentiation skills?

Beyond action

Have you revisited the experiences?

• Have you reviewed your previous reflections for this activity in light of any new cases or training? You should consider how your understanding or interpretation of morphology has changed since the initial experience.
• Have you had further opportunities to perform and interpret morphology for peripheral blood and normal bone marrow populations since completing this activity? How did these subsequent experiences compare to your initial ones?
• Can you recall specific instances where identifying normal or abnormal morphology was crucial for patient diagnosis or management in other activities or routine work? For example, how did your foundational experience inform your approach when encountering a critical blast count in a subsequent urgent sample?
• Have you engaged in professional storytelling with peers, near peers, or colleagues about complex morphological findings? Did analysing specific features, such as the differentiation of specific Malignant cells or rare red cell inclusion bodies, with others change your perspective or deepen your understanding?

How have these experiences impacted upon current practice?

• How has this activity improved your confidence and competence in performing and interpreting blood and bone marrow morphology in your routine work?
• Do you now have a better understanding of the principles of morphology and the importance of identifying both normal and abnormal features for accurate diagnosis?
• Have the skills developed in this activity, such as microscopic analysis and pattern recognition e.g., distinguishing reactive white cells from malignant ones, been transferable to other areas of your work?
• How will a strong foundation in morphology prepare you for investigating more complex cases or different haematological conditions in the future, such as supporting your potential progression towards haematological malignancy diagnostics?

Relevant learning outcomes

#	Outcome
# 1	Outcome Select techniques for the investigation of clinical presentations in haematology, haemostasis and transfusion science and medicine.
# 2	Outcome Perform the laboratory techniques required for the investigation of clinical presentations in haematology, haemostasis and transfusion science and medicine.
# 3	Outcome Interpret the results of the laboratory investigations for cases including red and white cell disorders and haemostatic and platelet disorders, haematological malignancy and transfusion serology.
# 4	Outcome Describe the limitations of techniques applied in the investigation of clinical presentations in haematology, haemostasis and transfusion science.
# 5	Outcome Apply the principles of internal quality control and external quality assessment and draw conclusions about assay performance.
# 6	Outcome Demonstrate appropriate communication skills to present the results of investigations and cases clearly to healthcare professional colleagues.