Rajivgandhiuniversity of Health Sciences, Karnataka

RajivGandhiUniversity of Health Sciences, Karnataka,

Bangalore

PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1 / NAME OF THE
CANDIDATE AND ADDRESS / MRS.ANIAMMA.C.JOSEPH
W/O MR.SCARIA VARGHESE
#108,`C’BLOCK,HIMAGIRI ENCLAVE-2KAGGADASAPURA,
C.V.RAMAN NAGAR,
BANGALORE-93.
2 / NAME OF THE
INSTITUTION / M.S.RAMAIAH INSTITUTE OF NURSING EDUCATION AND RESEARCH
M.S.R.I.T POST
BANGALORE-560054
3 / COURSE OF STUDY
AND SUBJECT / M.Sc NURSING
I YEAR
MEDICAL-SURGICAL NURSING
DISSERTATION PROTOCOL
4 / DATE OF ADMISSION TO COURSE / 15-06-2007
5 / TITLE OF THE STUDY
THE KNOWLEDGE OF REGISTERED NURSES ON SAFE PRACTICE OF BLOOD TRANSFUSION WORKING AT SELECTED HOSPITALS, BANGALORE.

6. BRIEF RESUMEOFTHEINTENDEDWORK

Introduction:

“People travel by many means but we are not aware of the transportation system in our body, without which no man can survive”.

Blood is essential for human life. Blood is like the body’s transportation system, busy making deliveries and pickups. As blood circulates throughout the body, it delivers oxygen and nutrients to all the places they are needed. Blood also collects waste products, such as carbon dioxide, and carries them to the organs responsible for making sure the wastes leave the body. In a lot of ways, everybody’s blood acts the same. However, when we take close look, distinct differences are apparent.

It was an Austrian named KarlLand Steiner who first classified blood, in early 20thcentury. His findings have changed modern medicine and science immensely. Every year, 1st October the birthday of Karl Land Steiner is celebrated as the National Voluntary Blood Donation Day1.

When Land Steiner looked at the Blood through a microscope, he discovered two distinct chemical molecules on the surface of red blood cells. He called one ‘A’ and the other ‘B’, sometimes the blood had only “A” or ‘B” molecule and in other cases, he saw a mixture of both. He called this mixture type ‘AB’. In more rare instances, he saw neither molecule ‘A” nor ‘B” andhe called that type ‘O’. 44 % of the general population belongs to blood group ‘O’ and 45 % group ‘A”, 8% of the population belongs to group ‘B’ and 3% belongs to ‘AB’ Group1.

Blood is not everyone’s favorite topic. In fact you’d probably feel a lot better if it just stayed inside your body where it belongs. But blood transfusions save lives everyday. Hospitals need blood for people who are injured, as well as for patients having heart surgery, organ transplants, cancer treatments, and treatments for other diseases that affect the blood, like sickle cell anemia. In fact, about 5 million people each year in the United States get blood transfusions2.

The medical council of India has already recognized transfusion medicine as a speciality and is planning a MD course in this subject. Another step in this direction is the upgrade of the existing blood banks in the medical colleges to function as department of Transfusion medicine. The Supreme Court of India directed the Union of India and State Government to take a number of steps towards revamping the entire blood transfusion services addressing various critical areas. The Supreme Courtjudgment provided a good opportunity to reorganize the blood transfusion services3.

In 1997, a survey conducted in 45 Toronto area hospitals in U.K, 65 % of the allogenic RBC’s used were administered to patients undergoing operative procedures and at many occasions it saves the life of people with anemia and more often, the life of trauma patients. Therefore, blood transfusions are an unavoidable circumstances at times, and are given much importance in the field of medical care. According to the federal agency for Health Care Research and Quality from 1993 to 2003, patients requiring at least one blood transfusion during their hospital stay increased from 8,29,000 cases to nearly two million cases4.

6.1. Need for the Study.

There is no other fluid, which can totally substitute blood in the human body. Blood contains nutrients, oxygen in adequate quantities and help in maintaining a balanced temperature of the body. The transfusion of blood and blood products remains a highly effective and potentially life saving treatment for many clients. However, blood is a living tissue and its transfusion from one individual to another is not without risk. Tragically, in the intervening years, patients have continued to die following the transfusion of incompatible blood. Serious hazards of transfusion (SHOT) and new concerns regarding the theoretical risk of blood borne transmission of new variant disease have ensured that the transfusion of blood and blood components has remained in the public and professional spot light5.

In many cases transfusion of blood becomes necessary to save the life of an individual. A Clinical and immunologic study of blood–transfusion and post operative bacterial infection revealed that, patients receiving allogenicblood had a significantly higher hospital infection rate, 20.8% vs, 9days of fever, received more antibiotics and stayed in the hospital longer (12.3 days vs,9.7) than the other group.Anemia is less well tolerated in patients, and transfusions become inevitable to save the life of many6.

Serious hazards of transfusion (SHOT) Annual report 2000-2001 by the British Blood Transfusion society emphasized the participation and reporting of incorrect blood transfusion. In 2000-2001, 379/413 (92%) hospitals participated in the SHOT scheme compared with 72%, the previous year. A Study in SHOT regarding “wrong Blood” incidents during 2000-2001, revealed that hospital blood–transfusion laboratories were the sites of the largest category of originating errors(36%) and 36% of all laboratory errors occurred out of hours.

There were 103 cases (54.2%) with multiple errors and 344 errors in total indicating that problems still occur at all stages of the transfusion process and that the final bedside check may fail to detect mistakes made earlier in the transfusion chain5.When all errors (344) were analyzed, 29% occurred in hospital transfusion laboratories, 35% during bedside administration, 8% during the collection of blood component from the hospital storage site, 7% from other administrative errors. A study conducted by SHOT during 2002 among 90% of UK hospitals revealed that, out of 1630 events 64% were errors in the transfusion process5.

Joint commission on Accreditation of Health care Organization (JCAHO) as well as WHO has recommended all blood transfusions be evaluated in order to confirm that clear medical indication for transfusion exist, as well as a safe transfusion is practised6.

Saillour Glennison F, Tricaud. S with a group of people conducted a survey in February, 2002 in France. Participants were, a random sample of 1090 nurses from 14 hospitals in France, and data collected by structured interview methods. The result showed that 47% of nurses are having poor knowledge and practice concerned mainly the bedside compatibility check, delay in preservation of blood unit in the ward, and recognition of abnormal reaction after transfusion. They came into the conclusion that, low training and transfusion activity were the key determinants of poor transfusion related knowledge7.

The Times of India on 10th November, 2007 reported that in All India Institute of Medical Sciences, New Delhi one of the premierMedical Institute in India, a wrong blood have been transfused to a 50 year old patient, who had under went a knee replacement after which he suffered acute renal failure and under went more than seven dialysis and still battling for life8.

The bedside check is the final opportunity to prevent an error in blood transfusion. Blood Transfusion Nursing is a small but rapidly developing speciality. Hospital based transfusion practice has largely been neglected. Directing practice and educational initiatives to the bedside could ensure optimal provision of care, adequate standards of safety and proper use of resources within the National Health Service. It has been recognized that the Transfusion Nurse Specialist is the ideal person to take these initiatives forward9.

A survey was done by Tramallon. D and Auperin. A in 2005 at the Gustave – Rowsy institute in Australia, on evaluation of implication of nurses and transfusion safety and knowledge assessment and practice evaluation. In this study, the first survey on nurses’ transfusion practices revealed poor knowledge. Good transfusion practices were written, a training programme was implemented and a second survey was carried out two years later. Behaviours were evaluated by checking the pre-transfusion procedures. The result showed a significantimprovement in knowledge of good practices between the first and second surveys. Pre-transfusion protocol checks have improved significantly. The conclusion wasthat, the implementation of good practice has significantly improved nurses’ knowledge about transfusion safety requirement but is essential to continue and adopt the training, and check regularly the impact of these implementations10.

The WHO has recommended certain key elements ofeffective clinical use of blood. The education and training of clinicians, nurses and blood transfusion service staffs involved in transfusion process monitoring and evaluation of the implementations of the national policy and guidelines and the use of monitoring data in quality improvement, and education programme to assist clinicians and nurses to improve the practice, are few among those10.

The above facts and the investigator’s personal experience in the clinical area of various hospitals motivated her to do this study and prepare a protocol on guidelines in blood transfusion.

6.2 Review of Literature

Literature review was done for the present study and presented under the following headings

Incidence of blood transfusion errors
Nurses’ role in blood- transfusion procedure
Effect of teaching programme on safe practice of blood transfusion
Need of protocol for safe practice of blood transfusion in hospitals.

6.2.1 Incidence of blood transfusion errors

Recognition of the importance of systematic surveillance of adverse effect of transfusion has led to the development of haemovigilance schemes, of which the serious hazards of transfusion (SHOT), launched in 1996 was one of the first. The SHOT focused on learning from adverse events. Ten years after its inception, SHOT has analyzed 2630 transfusion safety events, publishedeight annual reports with recommendations, and presented datanationally and internationally. These recommendations have underpinned key initiatives, in

particular the UK department of health “Better Blood Transfusion “strategy. SHOT has encouraged open reporting of adverse events. Detailed analysis of events has identified weaknesses in the transfusion chain. The importance of education and training to improve bedside practice has been emphasized. The UK blood services have developed strategies to reduce these risks11.

6.2.2 Nurses’ role in blood transfusion procedure

The SHOT reports have repeatedly identified that errors in blood transfusions are wholly avoidable. Nurses as health care professionals ultimately responsible for the bedside check, have the final opportunity to prevent a mis-transfusion. The educational strategies implemented will be explained and evidence that applying structured learning programmes in the UndergraduateNursing Curriculum can improve student’s knowledge. A structured questionnaire was employed to assess students’ knowledge on the process of transfusing blood components pre-and post teaching and evaluate the effectiveness of the teachingpack. The result showed a positive effect of a teaching package to acquire the essential knowledge for competent practice in blood transfusion administration12.

6.2.3 Need of Protocol for safe practice of blood transfusion in hospitals.

Pirie. ES and Gray. MA conducted a study on blood transfusion competency in October 2006 in Scotland. They explored the nurses’ experience of clinical competency in the administration of blood components. The study describes the development of and evaluation of a tool for assessing clinical competency for staff involved in transfusing blood. The study participants were of the opinion that assessing clinical competency using a criterion –referenced tool gave practitioners the opportunity to relate theory to practice, promote best practice and encourage adherence to hospital transfusion policies.

Formal assessment of clinical competency is therefore, a vehicle that could be used to promote safe transfusion practice, ensuring the safety of patients is paramount13.

Hainsworth T comments in Nursing Times July,2004 that administering a blood transfusion is a common part of nursing practice and a life-saving intervention. However, new guidance published by the Royal College of Nursing (RCN) 2004 highlights that this is an area of practice with frequent errors. The guidance gives clear recommendations for good practice in the areaof sample collection, pre-administration bedside checking, and monitoring torecognize adverse reactions13.

6.2.4 Need of protocol for safe practice of blood transfusion in hospitals

According to Australian Nursing Federation in 2005 – on transfusing safely, a 2006 guide for nurses says that nurses play a vital role in safe transfusion therapy,which begins with the donor and ends with the recipient. Nurses play a very vital and critical role along this path, and this update offers best practice guidelines for nurses involved in this practice. In 2001, the National Health and medical Research Council and the then Australian Society of blood transfusion developed Australian guidelines based on best evidence for the appropriate use of blood and blood products. The WHO’s principles for clinical transfusion practice also emphasized the same guidelines14.

Transfusion is a vein to vein process. The blood supply in Australia is extremely safe in terms of viral risk, although a ‘Zero Risk” blood transfusion is never possible. Safe transfusion practice continues to rely on highly trained and experienced staff undertaking procedures correctly, within a safety and quality framework that includes an adverse event reporting system14.

An article in,Journal ofNurse Education and Practice in July 2007 reports that, the study conducted in UK by Mole L J and Hogg G on evaluation of a teaching packagedesigned forNursing Students to acquire the essential knowledge for competent practice in blood transfusion administrationreveals that, applying structured learning programmes in the undergraduate Nursing Curriculum can improve students knowledge15.

National Aids Control Organization (NACO) ministry of health and family welfare, Government of India developed a national guideline for appropriate use of Blood. The guidelines are adopted from the WHO guidelines of different documents and with the able guidance of transfusion experts of various hospitals in India16.

6.3PROBLEM STATEMENT

A study to assess the knowledge of registered nurses on safe practice of blood transfusion, working at selected hospitals, Bangalore in a view to develop protocol.

6.3.1 Objectives of the Study:

1. To assess the knowledge of registered nurses regarding safe practice of

Blood transfusion.

2. To determine the association of level of knowledge with selected Socio-

demographic variables.

3. To develop a protocol for nurses on ‘Safe Practice of Blood Transfusion’.

6.4 Hypothesis:

H1: There is a significant association between the level of Nurse’s knowledge and selected Socio- Demographic variables on safe practice of blood transfusion.

6.5 Operational Definitions:

6.5.1Knowledge: - It is the correct response of Nurse’s to questions regarding safe practice of Blood Transfusion, measured by a structured knowledge questionnaire

6.5.2 Registered Nurses: - A trained nurse, licensed by a State Nursing Council, working in selected hospitals for the study.

6.5.3 Safe Practice of Blood Transfusion:- Refers to the correctsequential steps of activities performed by the Registered Nurse in relation to blood transfusion, which would not bring any harm to the patient.

6.5.4 Protocol:A set of guidelines developed after knowledge assessment on ‘safe practice of blood transfusion’, for nurses to follow in hospitals which will be accepted and validated by concerned authority

7. Materials and Methods:

7.1 Sources of Data : Nurses working in selected hospitals,

Bangalore

7.2 Methods of Data Collection: By administering structured knowledge

Questionnaire to nurses regarding safe Practice of Blood Transfusion.

7.2.1 Type of Study & Approach: Descriptive Study, Survey approach

7.2.2 Research Design :Non– experimental Descriptive design.

7.2.3Variables of the study:

Study Variable : Knowledge of Staff Nurses.

Attribute variables : Age, gender, Professional qualification,

Area of residence, area of work,

Work experience, type of hospital, average number of Blood Transfusions per week

7.2.4 Sampling Technique.: Non-probability simple random

sampling.

7.2.5 Sample size : 100 Nurses

7.2.6 Follow-up : There is no follow up since it is a

Descriptive study

7.2.7 Comparison Parameters : No Comparison as it is only one group

Descriptive study

7.2.8 Duration of study : One Month

7.2.9 Inclusion & Exclusion criteria :

Inclusion criteria : Nurses who are willing to participate and

available at the time of study.

Exclusion criteria : Nurses who had previous training on safe

Practice of blood transfusion.

Nurses who are not available at the time

of data collection

7.2.10 Instruments used :

Section A : Socio-demographic profile consists of Age, gender,

Professional qualification, Area of residence, area of

work, work experience, type of hospital ,

average number of Blood Transfusion per week.

Section B : Structured knowledge questionnaire to assess the

knowledge regarding safe practice blood transfusion.

7.2.11 Data Collection Procedure

Obtaining permission from concerned authority.
Getting the written consent from subjects.
Purpose of the study will be explained.
Data will be collected through structured knowledge questionnaire.

7.2.12 Statistical methods used:

The data obtained will be tabulated and analyzed in terms of the objectives of the study using descriptive and inferential statistics. The plan of data analysis is as follows:

Descriptive Statistics ;

Frequency and percentage distribution will be used to assess the Socio-Demographic data and knowledge scores.
Mean, mean percentage, frequency, and standard deviation will be used to assess the level of knowledge.

Inferential Statistics.

‘Chi’ Square test will be used to determine the association between level of knowledge and selected socio-demographic variables

Correlation r’ to find the relationship between level of knowledge and selected socio-demographic variables.

7.3 Does the study require any investigation or intervention on patients or otherHumans / animals? If so please describe briefly.

Yes,the knowledge of nurses on safe practice of blood transfusion will be assessed by using structured knowledge questionnaire. As such, no intervention is provided.

7.4 Has ethical clearance been obtained?

Ethical clearance will be obtained from the ethical committee and permission from the concerned authority.
Written consent will be obtained from subjects.
Confidentiality and anonymity of subjects will be maintained.