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

Objective: the study was carried out to was to investigate the effectiveness
of structured teaching program on knowledge and practice regarding blood
specimen collection among nurses Methods: Research design: A quazi
experimental design was utilized. Setting: Menoufia University Hospital at
Menoufia governorate, Egypt. Subjects: A purposeful sample of 286 nurses from
different departments in Menoufia university hospital, Menoufia governorate,
Egypt. Tools for data collection: Interviewing questionnaire includes
socio demographic date, structured knowledge questionnaire sheet: regarding
blood specimen collection, and observational checklist. Results: more
than half of studied sample aged above 30 years, they mainly working in
surgical department. The measures taken to improve prominence of vein showed
statistically significant difference before and after structured educational
program, nurses’ knowledge regarding blood specimen collection showed obvious
improvement and good practice after structured educational program. Conclusions:
The program helps the Staff nurses to improve their knowledge on BSC. This
will ultimately improve their practice that reflects on patient’s safety. The
findings of the study indicate that there is improvement in knowledge of Staff
nurses and practice even this improvement was less slightly which indicate that
the STP is an effective in improving the knowledge and practice of the staff
nurses.

Key Words: blood specimen
collection, Knowledge, practice

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Introduction:

Venous blood
specimen collection (VBSC) is a common procedure in nursing care. A fundamental
responsibility for nurses is to alleviate suffering. Repeated VBSC due to
deficiencies 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). 

Laboratory
results play a key role in patient care. It is estimated that around two thirds
of important clinical decisions about admissions, discharge and medication are
based on laboratory test results that is also an important source of medical errors
that can affect patient safety. (2)

Venous blood
specimen collection (VBSC) is one of the most common procedures that were done
in every ward for disease diagnosis and prognosis.  (3). Errors in VBSC
may lead to patient suffering and endanger patient safety (4). .Injuries
related to VBSC errors are caused most often by human mistakes and relatively
few are related to technical errors (5). In addition, VBSC errors
are latent and distant from direct control and thus often go unrecognized.
Therefore, VBSC practices should strictly follow guidelines based on evidence
and best practices. (6)

 

Staff nurses
working in the clinical field are said to be backbone of the hospital. Most of
the care of patients is taken by the staff nurses working in the hospital. She
is the person who stays most of the time with patient and their relatives who
are 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 to
take care of patients as well as she has to provide health education to patient
and their relatives regarding necessary care for the prevention of
complications progressive to disease. (7)

 

The role of
nurse is important for management of central venous access device. She has to
perform routine dressing and flushing of the device. She has the important role
in health education of patient and caregivers regarding venous access device
care. (7)& (8)

 

VBSC can be
viewed as a dependent practical skill, meaning that different kinds of
professionals perform and encompass the totality of VBSC practices. Worldwide,
different professionals perform VBSC, but venipuncture should be performed by educated
and competent personnel, because VBSC practices demand theoretical knowledge as
well as good practical skills (9
& 10
 &  6).

 

Nurses in
clinical practice collect blood from patients as part of routine laboratory
tests. It is well known that these results are often erroneous due to several
factors, one of which being incorrect performance of venous blood specimen
collection. (3)

Nursing
education facilities assure that they follow the guidelines when teaching VBSC
practices, so the fact that health care staff does not always adhere to VBSC
guidelines to the letter (8) .must mean that nursing students
or newly graduated nurses are deviating from guideline practices over time. To
improve knowledge in regard to adherence to VBSC guidelines and patient safety,
it is important to investigate to what extent nursing students in clinical
practice adhere to VBSC guidelines and the reasons why they tend to deviate from
those guidelines. (3)

Nursing
professionals must know the best practice technique for the management of
intravenous cannulation and complications caused by intravenous cannulation
including ways to prevent and manage these complications. We need not forget
that nurses are the ones mainly responsible for improving knowledge and
application of best practice technique for the management of intravenous
cannulation. As nurses, we are responsible for maintaining our skills and
knowledge in relation to all aspects of patient care. (12).

 

Theoretical framework

In nursing
research there exists a lack of evidence-based knowledge focused on hands-on
performance in clinical settings. However, this focus is as important as taking
care of the mind and emotions. Attention should be given to physical and
practical aspects of how nurses develop and perform practical skills (11).
VBSC is a nursing skill that demands theoretical knowledge as well as good
practical 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 a
model for practical skills in nursing to describe VBSC in a more holistic and less
technical way might highlight VBSC as a practical nursing skill. (14).

 

 

Significance
of the study:

 

            It
is important to assess the ability of nurses to create positive change in the
practice. The correctness of the blood test is closely related to the sample.
According to the recent reported data, 80 percentage unsatisfactory results of
the clinical test are due to the poor quality of sample, especially the blood
sample (15). Clinical practice guide (CPG) is directly to
instruct the clinical nursing practice. And the recommendations in the clinical
practice guide are based on the best available study evidences.  (16)

 

Aim of the Study:

The aim of the study was to investigate the
effectiveness of structured teaching program on knowledge and practice regarding
blood specimen collection among nurses.

1.
To assess the knowledge and practice of nurses regarding blood specimen
collection at different departments of selected hospital before and after structured
teaching program.

2.
To find out association between knowledge score and practice score regarding blood
specimen collection among staff nurses and selected demographic variables

 

Research Hypothesis:

Implement the structured teaching program regarding
blood specimen collection will improve nurses’ knowledge and practice that
improve patient safety.

Inclusion criteria:

1. Staff nurses who have completed
graduation in nursing.

2. Nurses who are willing to participate in the
study.

Exclusion criteria:

1. Nurses who have completed
specialized course in venous access device care.

2. Nursing superintendent.

Subjects
and Method:

Design:
The present research design was quasi experimental.

Setting:
The
present study conducted at different department (medical, surgical, orthopedic
departments,……ect) of the Menoufia University Hospital at Menoufia governorate,
Egypt.

Subject: A
purposeful sample of 286 nurses from different departments in Menoufia
university hospital, Menoufia governorate, Egypt. 

Sample size:
 

Sample size was calculated utilizing the following Equation
1: Where: n = sample size; N = total population number (1100);
e = margin error (0.05). A total 293 of nurses administered
were recruited in the current study but 7 nurses refused to complete the study
so 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 September
2017. Tools:Tool
1: socio demographic data sheet to assess subject
characteristics as age, gender, professional status, department, years of
experience Tool
2: structured knowledge questionnaire sheet: regarding blood
specimen collection. It was developed and used by the researchers after
reviewing the related literature (1, 14, 25) to assess patients’
knowledge. It consisting of 20 items of open questions covering the following
areas: inspection of vein, Measures to Improve Prominence of Vein, strategies
after blood collection to avoid complications, and safety aspects during blood
collection. The scoring system was categorized as follow: •Poor knowledge  (< 50% (;        •Fair knowledge (50 - <75%       ; •Good knowledge (?75%) Tool 3: Observation Checklist: items related to practice of blood specimen collection to check practice / performance of nurses. There were 25 items covering steps of blood specimen collection. Scoring system as follow:The checklist consists of two options; 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 to maximum 25.The levels of practice have been classified as:·         Un satisfied (Poor) Practice (0-13)·         Satisfied (Average) Practice (14-17)·         Good Practice (18-25)Validity and reliabilityTools were tested for content validity by three experts in the field of Medical Surgical Nursing, Faculty of Nursing, Menoufia University, and two experts in the field of Medicine, Faculty of Medicine, Menoufia University and modifications were done accordingly. All tools were tested for reliability using test retest method to ascertain consistency: patient's knowledge regarding blood specimen collection r = 0.85, observation check list r = 0.73Field work_ the researcher will assess the knowledge through knowledge sheet regarding blood specimen collection, technique of blood specimen collection through observational checklist) among nurses by the means of pretest._ the researcher will administer Structured Teaching Program as the following:(1) Knowledge through one by one teaching (lecture) during interview.(2) Practice regarding blood specimen collection. Through demonstration and return demonstration procedure.(3) The researcher used audiovisual aids as colored booklet and instructional videos to provide knowledge and technique of blood specimen collectionAfter one month of nursing structured educational program (post test):(1) The researcher will assess the knowledge through knowledge sheet regarding blood specimen collection (2) Practice regarding blood specimen collection among nurses clients through observational Check-list to assess the technique of blood specimen collection and repeated this measurement after two months._ The data were collected on first day as pretest and second post- test for the same data was collected after one month, and after two months.A pilot study conducted by the investigators on (10%) 28 nurses. These nurses excluded from the study sample. The purpose of the pilot study was to check and ensure the clarity, feasibility and applicability of the study tool.Administrative and Ethical consideration The Ethical Committee of the faculty of nursing approved the research. An official permission and official letter was obtained from the responsible authorities after explaining the aim of the study. Formal consent was obtained from each participant.  Voluntary participation, anonymity, and confidentiality were all guaranteed. ·         Statistical Analysis: The Data collected and entered into the personal computer. Statistical analysis done using Statistical Package for Social Sciences (SPSS version 16) software. Both descriptive and inferential statistic established. The level of significant was considered at P- value <0.05.Regarding demograohic data:  our study illustrated that more than half of studied sample aged above 30 year old (55.2%), majority of these sample were female (87.9%). More than 2 thirds (41.1%) have secondary/ diplom education in nursing. In line with our study the mean age of the participants in Wallin (17) study was 45 years, and the mean duration of employment was 18 years. Of these subjects, 98% were women, while in Deshmukh (7) study the majority of the subjects 70 % were 21-30years old and 30 % were in the age group of 31-40 years. In that study, females were 83.33 %. The majority of the subjects 56.67 % were having Diploma in general nursing and 43.33 % were Basic B.Sc. in Nursing. From researchers point of view, wide base of nurses have secondary and diploma due to economic status that require working of all family members in our country while experience play important role that elevate level of those nurses to be competent with nurses with bacholoric education. II- Our study illustrated that nurses included in the study were mainly working in surgical (26.22%) and medical (22.38%) departments, majority of them perform blood specimen collection as a routine work (98.6%) nearly every day (60.14%). More than half of the studied sample have experience more than 5 years (58.39%), matching with this result;  (Wallin; et al (17) study , A higher proportion of participants in 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 least weekly also; Deshmukh (7) In clinical experience, the majority of subjects 71.67 % were having clinical experience of 0-5 years of clinical experience, this discrepancy may be due to nature of work in different department and policy of hospital. In this study all subjects didn't have special training for VBSC  before conducting this program; in the same line;  a study of  (Zehra (18) who revealed that 39.5% never received any recent education in blood sampling techniques in past 10 years where as only 37.2% received it 5 years back. (Zehra (18). Also; Wallin; (17) study showed almost all participants in the 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 vein was 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. The best sites for vein puncture of superficial veins of the upper limbs are the median cubital vein. However, practices vary considerably between countries and between institutions and individuals within the same country. These differences include variations in blood sampling technique, use of safety devices, disposal methods. Concerning measures taken to improve prominence of vein, this study illustrated that after structured teaching program there was obvious improvement in all measures taken to improve prominence of vein except application of a sterile adhesive plaster that should only be applied, when compression is complete (68.18%). Oladeinde (21) study (Assessment of venous blood collection practices among medical laboratory workers in Edo State, Nigeria) Practice of hand hygiene, use of a pair of gloves per patient, proper skin disinfection and method of disposal of used syringes were observed to be poor. This default may be due to lack of facilities in our hospital.Proper disinfection of the collection site is the single most important step in preventing false positive blood collection sample. Although most (78%) of the nurses reported the use of alcohol and povidone-iodine, the majority (75%) did not allow the adequate contact time of 1.5—2 min for the maximal antiseptic effect (22). In addition, some nurses incorrectly believed that the stoppers of BC bottles are sterile and do not need to have their tops cleaned, which can increase the opportunities for introduction of contaminants. (23) Regarding to strategies after blood collection to avoid complications before and after teaching program, this study showed slightly improvement in many strategies after structured teaching program as; nearly half of studied sample don't know Areas to avoid when choosing vein before structured educational program which improved after structured educational program. Regarding presence of any complication, how can nurse manage and Solute this problem 50.35% give wrong answer which turn after nursing structured educational program to only 52.1% who give wright complete. Safety aspects for using tourniquet showed 51.05 % give wrong answer, but after structured educational program 52.1% give complete wright answer.In studied sample of Deshmukh (7); study, the mean score of practice regarding venous access device care was increased from 15.4 to 19.6 in the post-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 the need for re-collection. And Bölenius.(6) reported that the participants became aware of risks, achieved improvements in clinical practice and felt strengthened in working as usual. Reflections on safety revealed during the analysis could be identified in almost all subthemes and in relation to the educational structured educational program program. Differentiation in practice from study to another may be due to availability of supplies and tasks overloaded on nurses' standard guideline to be followed not available.  Concerning nurses' knowledge regarding blood specimen collection; this study showed obvious improvement in nurse's knowledge after structured teaching program. Concerning our result; Eighty six percent participants thought that they had adequate knowledge regarding blood sampling, but most of them were not adhering to standard protocols zehra (18). The methodical systematic procedure for disinfection, blood drawing, timely labeling of test tubes and transportation is already framed (6) Nurses knew less on blood specimen quality control, probably because the nurses were more concerned about the phlebotomy procedure instead of quality of blood sample. This may also reflect the inadequacy of phlebotomy training received by nurses.  (25)            In studied sample, the maximum of 43.33 % of subjects scored between 0-13 (Poor) knowledge score in the pre-test before structured education and 65 % subjects scored between 18-25 (Good) knowledge score in the post-test after structured education. (7). In studied group of the study, the mean score of knowledge regarding venous access device care was increased from 14.6 to 21.3 in the post-test after structured education. It indicates that the structured education is effective in increasing the knowledge scores of subjects regarding venous access device care (7). The participants reflected on lack of knowledge among VBSC personnel. Not knowing the content in the VBSC guidelines was experienced as risky. Before the educational structured educational program program several of the participants did not know how to label test tubes and to perform VBSC with the correct sequence and the correct order of tubes. After education, the participants increased their understanding of several VBSC practices. Transfer of information was described as a risk for misunderstanding and sample delay. The participants described those patients and/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) mentioned that the level of knowledge on phlebotomy among Chinese nurses was found to be not quite satisfactory. Compared with previous survey in China, some progress had been made in the steps of patient preparation, tourniquet application time and test tube labeling, while the survey also showed that the mastery of some knowledge on venous blood sampling needed to be improved Regarding nurse's practice / performance during blood specimen collection; Improvement of nurses' practice / performance after structured teaching program that have positive effect in refreshing their knowledge. Many studies explore in details nurses' practice/ performance during blood specimen collection which globally point to improving practice after teaching. In line with our study; a study of Bölenius.(6) several specific VBSC practices were significantly improved, indicating that the educational structured educational program program had an impact on the adherence to guideline practices. In the studied group, the maximum of 75 % of subjects scored between 14-17 (Average) practice score in the pretest before structured education and 48.33 % subjects scored between 18-25 (Good) practice score in the post-test after structured education. (Deshmukh (7) In addition, around two thirds of the investigated nurses knew that gloves should be worn during phlebotomy, yet only about one third knew 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 than 85%). However, half of the investigated nurses considered the disposal of the needle after detaching the device with both hands acceptable practice. Around one quarter of the nurses stated that there was no need of documenting the time and person of blood collection. (24). Also; All participants recapped used needles after venous draws. However, only 20 (18.3%) of all 109 participants practiced the scoop technique of re-capping needles, (21).  Concerning the above results this might be attributed to the satisfactory impact of the educational program on nurse's performance and knowledgeConclusion:  As a part of the study 286 Staff nurses were given the STP (structured teaching program regarding blood specimen collection). The program helps the Staff nurses to improve their knowledge on BSC. This will ultimately improve their practice that reflects on patient's safety. The findings of the study indicate that there is improvement in knowledge of Staff nurses and practice even this improvement was less slightly which indicate that the STP is an effective in improving the knowledge and practice of the staff nurses.