Objective: collection, Knowledge, practice Introduction: Venous blood specimen collection

Objective: the study was carried out to was to investigate the effectivenessof structured teaching program on knowledge and practice regarding bloodspecimen collection among nurses Methods: Research design: A quaziexperimental design was utilized. Setting: Menoufia University Hospital atMenoufia governorate, Egypt. Subjects: A purposeful sample of 286 nurses fromdifferent departments in Menoufia university hospital, Menoufia governorate,Egypt. Tools for data collection: Interviewing questionnaire includessocio demographic date, structured knowledge questionnaire sheet: regardingblood specimen collection, and observational checklist. Results: morethan half of studied sample aged above 30 years, they mainly working insurgical department.

The measures taken to improve prominence of vein showedstatistically significant difference before and after structured educationalprogram, nurses’ knowledge regarding blood specimen collection showed obviousimprovement and good practice after structured educational program. Conclusions:The program helps the Staff nurses to improve their knowledge on BSC. Thiswill ultimately improve their practice that reflects on patient’s safety.

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Thefindings of the study indicate that there is improvement in knowledge of Staffnurses and practice even this improvement was less slightly which indicate thatthe STP is an effective in improving the knowledge and practice of the staffnurses. Key Words: blood specimencollection, Knowledge, practice    Introduction:Venous bloodspecimen collection (VBSC) is a common procedure in nursing care. A fundamentalresponsibility for nurses is to alleviate suffering. Repeated VBSC due todeficiencies in the organization or suboptimal VBSC practices can be prevented.Training in work technique is important for safety and well-being of patients.Good practical skills in nursing that combine technical, theoretical,psychosocial and physical elements are therefore needed.

(1).  Laboratoryresults play a key role in patient care. It is estimated that around two thirdsof important clinical decisions about admissions, discharge and medication arebased on laboratory test results that is also an important source of medical errorsthat can affect patient safety. (2)Venous bloodspecimen collection (VBSC) is one of the most common procedures that were donein every ward for disease diagnosis and prognosis.  (3). Errors in VBSCmay lead to patient suffering and endanger patient safety (4). .

Injuriesrelated to VBSC errors are caused most often by human mistakes and relativelyfew are related to technical errors (5). In addition, VBSC errorsare latent and distant from direct control and thus often go unrecognized.Therefore, VBSC practices should strictly follow guidelines based on evidenceand best practices. (6) Staff nursesworking in the clinical field are said to be backbone of the hospital. Most ofthe care of patients is taken by the staff nurses working in the hospital.

Sheis the person who stays most of the time with patient and their relatives whoare present in the hospital or comes in the clinic with patients. Obviously,the role of nurse is increased due to long stay with the patient. She has totake care of patients as well as she has to provide health education to patientand their relatives regarding necessary care for the prevention ofcomplications progressive to disease. (7) The role ofnurse is important for management of central venous access device.

She has toperform routine dressing and flushing of the device. She has the important rolein health education of patient and caregivers regarding venous access devicecare. (7)& (8) VBSC can beviewed as a dependent practical skill, meaning that different kinds ofprofessionals perform and encompass the totality of VBSC practices. Worldwide,different professionals perform VBSC, but venipuncture should be performed by educatedand competent personnel, because VBSC practices demand theoretical knowledge aswell as good practical skills (9& 10 &  6).

 Nurses inclinical practice collect blood from patients as part of routine laboratorytests. It is well known that these results are often erroneous due to severalfactors, one of which being incorrect performance of venous blood specimencollection. (3) Nursingeducation facilities assure that they follow the guidelines when teaching VBSCpractices, so the fact that health care staff does not always adhere to VBSCguidelines to the letter (8) .must mean that nursing studentsor newly graduated nurses are deviating from guideline practices over time.

Toimprove knowledge in regard to adherence to VBSC guidelines and patient safety,it is important to investigate to what extent nursing students in clinicalpractice adhere to VBSC guidelines and the reasons why they tend to deviate fromthose guidelines. (3) Nursingprofessionals must know the best practice technique for the management ofintravenous cannulation and complications caused by intravenous cannulationincluding ways to prevent and manage these complications. We need not forgetthat nurses are the ones mainly responsible for improving knowledge andapplication of best practice technique for the management of intravenouscannulation. As nurses, we are responsible for maintaining our skills andknowledge in relation to all aspects of patient care. (12). Theoretical frameworkIn nursingresearch there exists a lack of evidence-based knowledge focused on hands-onperformance in clinical settings. However, this focus is as important as takingcare of the mind and emotions. Attention should be given to physical andpractical aspects of how nurses develop and perform practical skills (11).

VBSC is a nursing skill that demands theoretical knowledge as well as goodpractical skills (13).A theorisation based on a model of practical skill performance in nursing (9)might contribute to a more holistic approach to VBSC. (6) Therefore,practical skills within nursing research must be worthy of interest. Using amodel for practical skills in nursing to describe VBSC in a more holistic and lesstechnical way might highlight VBSC as a practical nursing skill. (14).  Significanceof the study:             Itis important to assess the ability of nurses to create positive change in thepractice.

The correctness of the blood test is closely related to the sample.According to the recent reported data, 80 percentage unsatisfactory results ofthe clinical test are due to the poor quality of sample, especially the bloodsample (15). Clinical practice guide (CPG) is directly toinstruct the clinical nursing practice. And the recommendations in the clinicalpractice guide are based on the best available study evidences.  (16) Aim of the Study:The aim of the study was to investigate theeffectiveness of structured teaching program on knowledge and practice regardingblood specimen collection among nurses.1.To assess the knowledge and practice of nurses regarding blood specimencollection at different departments of selected hospital before and after structuredteaching program.

2.To find out association between knowledge score and practice score regarding bloodspecimen collection among staff nurses and selected demographic variables Research Hypothesis:Implement the structured teaching program regardingblood specimen collection will improve nurses’ knowledge and practice thatimprove patient safety.Inclusion criteria:1. Staff nurses who have completedgraduation in nursing.2. Nurses who are willing to participate in thestudy.

Exclusion criteria:1. Nurses who have completedspecialized course in venous access device care.2.

Nursing superintendent.Subjectsand Method:Design:The present research design was quasi experimental.Setting:Thepresent study conducted at different department (medical, surgical, orthopedicdepartments,……ect) of the Menoufia University Hospital at Menoufia governorate,Egypt.Subject: Apurposeful sample of 286 nurses from different departments in Menoufiauniversity hospital, Menoufia governorate, Egypt.  Sample size: Sample size was calculated utilizing the following Equation1: Where: n = sample size; N = total population number (1100);e = margin error (0.

05). A total 293 of nurses administeredwere recruited in the current study but 7 nurses refused to complete the studyso the final recruited number were 286. They were allocated into pre and post groups(286 nurses).

The data collection was carried out from June 2017 to September2017. Tools:Tool1: socio demographic data sheet to assess subjectcharacteristics as age, gender, professional status, department, years ofexperience Tool2: structured knowledge questionnaire sheet: regarding bloodspecimen collection. It was developed and used by the researchers afterreviewing the related literature (1, 14, 25) to assess patients’knowledge. It consisting of 20 items of open questions covering the followingareas: inspection of vein, Measures to Improve Prominence of Vein, strategiesafter blood collection to avoid complications, and safety aspects during bloodcollection. The scoring system was categorized as follow: •Poor knowledge  (< 50% (;       •Fairknowledge (50 - <75%       ; •Good knowledge(?75%) Tool3: Observation Checklist: items related topractice of blood specimen collection to check practice / performance of nurses.There were 25 items covering steps of blood specimen collection. Scoringsystem as follow:The checklist consists of twooptions; performed and not performed, for all 25 items. Score for 'performed'is '1'.

Score for ‘not performed’ is ‘0’. The scores range from minimum zero tomaximum 25.The levels of practice have beenclassified as:·        Un satisfied (Poor)Practice (0-13)·        Satisfied (Average)Practice (14-17)·        Good Practice(18-25)Validityand reliabilityToolswere tested for content validity by three experts in the field of Medical SurgicalNursing, Faculty of Nursing, Menoufia University, and two experts in the fieldof Medicine, Faculty of Medicine, Menoufia University and modifications weredone accordingly. All tools were tested for reliability using test retestmethod to ascertain consistency: patient’s knowledge regarding blood specimencollection r = 0.85, observation check list r = 0.73Field work_ the researcher will assess the knowledge through knowledgesheet regarding blood specimen collection, technique of blood specimen collectionthrough observational checklist) among nurses by the means of pretest._ the researcher will administer Structured TeachingProgram as the following:(1) Knowledge through one by one teaching (lecture) duringinterview.

(2)Practice regarding blood specimen collection. Through demonstration and returndemonstration procedure.(3)The researcher used audiovisual aids as colored booklet and instructionalvideos to provide knowledge and technique of blood specimen collectionAfterone month of nursing structured educational program (post test):(1)The researcher will assess the knowledge through knowledge sheet regarding bloodspecimen collection (2)Practice regarding blood specimen collection among nurses clients through observationalCheck-list to assess the technique of blood specimen collection and repeatedthis measurement after two months.

_The data were collected on first day as pretest and second post- test for thesame data was collected after one month, and after two months.Apilot study conducted by the investigators on (10%)28 nurses. These nurses excluded from the study sample. The purpose of thepilot study was to check and ensure the clarity, feasibility and applicabilityof the study tool.Administrativeand Ethical consideration The Ethical Committee of the faculty ofnursing approved the research. An official permission and official letter wasobtained from the responsible authoritiesafter explaining the aim of the study. Formal consentwas obtained from each participant.  Voluntaryparticipation, anonymity, and confidentiality were all guaranteed.

·        StatisticalAnalysis: The Data collected and entered into the personalcomputer. Statistical analysis done using Statistical Package for SocialSciences (SPSS version 16) software. Both descriptive and inferential statisticestablished. The level of significant was considered at P- value <0.05.Regarding demograohic data:  our study illustrated that more than halfof studied sample aged above 30 year old (55.2%), majority of these sample werefemale (87.9%).

More than 2 thirds (41.1%) have secondary/diplom education in nursing. In line with our study themean age of the participants in Wallin (17) study was 45years, and the mean duration of employment was 18 years. Of these subjects, 98%were women, whilein Deshmukh (7) study themajority of the subjects 70 % were 21-30years old and 30 % were in the agegroup of 31-40 years. In that study, females were 83.33 %. The majority of thesubjects 56.

67 % were having Diploma in general nursing and 43.33 % were BasicB.Sc. in Nursing. From researchers point of view, wide base of nurses havesecondary and diploma due to economic status that require working of all familymembers in our country while experience play important role that elevate levelof those nurses to be competent with nurses with bacholoric education. II- Our study illustrated thatnurses included in the study were mainly working in surgical (26.

22%) and medical(22.38%) departments, majority of them perform blood specimen collection as aroutine work (98.6%) nearly every day (60.14%). More than half of the studiedsample have experience more than 5 years (58.39%), matching with this result;  (Wallin; et al (17) study, A higher proportion of participantsin psychiatric (13%), intensive care (23%) and women’s health/paediatric (21%)wards, compared with all other wards (0–7.4%),and 85% worked full-time, and 39% performed VBS at leastweekly also; Deshmukh(7) In clinical experience, the majority ofsubjects 71.67 % were having clinical experience of 0-5 years of clinicalexperience, this discrepancy may be due to nature of work in different departmentand policy of hospital.

 In this study all subjects didn’t have specialtraining for VBSC  before conducting thisprogram; in the same line;  astudy of  (Zehra(18) who revealed that39.5% never received any recent education in blood sampling techniques in past10 years where as only 37.2% received it 5 years back. (Zehra(18). Also; Wallin;(17) study showed almost all participants inthe laboratories reported having a formal education in VBS (95%) and 30%reported having received further education in VBS. And Nkhoma (19)Showed that the majority of the staff, 69% had formal vein puncture training,while 31% attained the training informally. From researchers point of view,continuing training programs have positive effect on subjects’ practice/performance that reflected on patients’ safety.

 In this study; the dorsal hand veinwas the most common selected vein for blood specimen collection (61.19%)followed by median antecubital vein (31.82%) then subclavian vein (6.99%). Omiepirisa(20); illusterated that a superficial vein most commonly used for vein puncture.

Thebest sites for vein puncture of superficial veins of the upper limbs are themedian cubital vein. However, practices varyconsiderably between countries and between institutions and individuals withinthe same country. These differences include variations in blood samplingtechnique, use of safety devices, disposal methods. Concerning measures taken to improve prominence of vein, this study illustrated that after structured teaching program therewas obvious improvement in all measures taken to improve prominence of vein exceptapplication of a sterile adhesive plaster that should only be applied, whencompression is complete (68.18%). Oladeinde(21) study (Assessmentof venous blood collection practices among medical laboratory workers in EdoState, Nigeria) Practice of hand hygiene, use ofa pair of gloves per patient, proper skin disinfection and method of disposalof used syringes were observed to be poor.

This default maybe due to lack of facilities in our hospital.Proper disinfection of thecollection site is the single most important step in preventing false positiveblood collection sample. Although most (78%) of the nurses reported the use ofalcohol and povidone-iodine, the majority (75%) did not allow the adequatecontact time of 1.5—2 min for the maximal antiseptic effect (22).In addition, some nurses incorrectly believed that the stoppers of BC bottlesare sterile and do not need to have their tops cleaned, which can increase theopportunities for introduction of contaminants. (23) Regarding to strategies after blood collectionto avoid complications before and after teaching program, this study showedslightly improvement in many strategies after structured teaching program as; nearlyhalf of studied sample don’t know Areas to avoid when choosing vein before structurededucational program which improved after structured educational program.Regarding presence of any complication, how can nurse manage and Solute thisproblem 50.

35% give wrong answer which turn after nursing structurededucational program to only 52.1% who give wright complete. Safety aspects forusing tourniquet showed 51.05 % give wrong answer, but after structurededucational program 52.1% give complete wright answer.In studiedsample of Deshmukh (7); study, the mean score of practiceregarding venous access device care was increased from 15.

4 to 19.6 in thepost-test after structured education. When Cai  (24) reported during collection:Some studies reported that samples were collected in inappropriate Containers,preventing their analysis and causing harm to patients as a result of theneed for re-collection. And Bölenius.

(6) reported that theparticipants became aware of risks, achieved improvements in clinical practiceand felt strengthened in working as usual. Reflections on safety revealedduring the analysis could be identified in almost all subthemes and in relationto the educational structured educational program program. Differentiationin practice from study to another may be due to availability of supplies andtasks overloaded on nurses’ standard guideline to be followed not available.  Concerning nurses’knowledge regarding blood specimen collection; this study showed obvious improvement in nurse’sknowledge after structured teaching program.

Concerning our result; Eighty sixpercent participants thought that they had adequate knowledge regarding bloodsampling, but most of them were not adhering to standard protocols zehra (18).The methodical systematic procedure for disinfection, blood drawing, timelylabeling of test tubes and transportation is already framed (6) Nurses knew less on blood specimenquality control, probably because the nurses were more concerned about thephlebotomy procedure instead of quality of blood sample. This may also reflectthe inadequacy of phlebotomy training received by nurses.

  (25)            In studiedsample, the maximum of 43.33 % of subjects scored between 0-13 (Poor) knowledgescore in the pre-test before structured education and 65 % subjects scoredbetween 18-25 (Good) knowledge score in the post-test after structurededucation. (7).

 In studied groupof the study, the mean score of knowledge regarding venous access device carewas increased from 14.6 to 21.3 in the post-test after structured education.

It indicates that thestructured education is effective in increasing the knowledge scores ofsubjects regarding venous access device care (7). The participants reflected on lackof knowledge among VBSC personnel. Not knowing the content in the VBSCguidelines was experienced as risky. Before the educational structurededucational program program several of the participants did not know how tolabel test tubes and to perform VBSC with the correct sequence and the correctorder of tubes. After education, the participants increased their understandingof several VBSC practices. Transfer of information was described as a risk formisunderstanding and sample delay. The participants described those patientsand/or the professionals sometimes received wrong or no information at all,which was experienced as a safety risk.

(6)On the other hand; Cai et al. (25)mentionedthat the level of knowledge on phlebotomy among Chinese nurses was found to benot quite satisfactory. Compared with previous survey in China, some progress hadbeen made in the steps of patient preparation, tourniquet application time andtest tube labeling, while the survey also showed that the mastery of someknowledge on venous blood sampling needed to be improved Regardingnurse’s practice / performance during blood specimen collection; Improvementof nurses’ practice / performance after structured teaching program that havepositive effect in refreshing their knowledge.

Many studies explore in details nurses’ practice/performance during blood specimen collection which globally point to improvingpractice after teaching. In line with ourstudy; astudy of Bölenius.(6) several specific VBSCpractices were significantly improved, indicating that the educational structurededucational program program had an impact on the adherence to guidelinepractices. In the studiedgroup, the maximum of 75 % of subjects scored between 14-17 (Average) practicescore in the pretest before structured education and 48.33 % subjects scored between18-25 (Good) practice score in the post-test after structured education. (Deshmukh (7) In addition, around two thirds of the investigated nursesknew that gloves should be worn during phlebotomy, yet only about one thirdknew the proper time to put on gloves. (24)The correct rates on where to dispose needle,post-venipuncture education and tube labeling were relatively high (more than85%).

However, half of the investigated nurses considered the disposal of theneedle after detaching the device with both hands acceptable practice. Aroundone quarter of the nurses stated thatthere was no need of documenting the time and person of blood collection.(24).Also; All participants recapped used needles after venous draws. However, only20 (18.3%) of all 109 participants practiced the scoop technique of re-cappingneedles, (21).

 Concerningthe above results this might be attributed to thesatisfactory impact of the educational program on nurse’s performance andknowledgeConclusion: As a part of the study 286 Staff nurses weregiven the STP (structured teaching program regarding blood specimen collection).The program helps the Staff nurses to improve their knowledge on BSC. This willultimately improve their practice that reflects on patient’s safety. Thefindings of the study indicate that there is improvement in knowledge of Staffnurses and practice even this improvement was less slightly which indicate thatthe STP is an effective in improving the knowledge and practice of the staffnurses.