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© Borgis - New Medicine 2/2015, s. 71-77 | DOI: 10.5604/14270994.1169801
*Veronika Rajki1,2, Mária Csóka1, Tibor Deutsch3, Judit Mèszáros4
Reliability and validity of a new questionnaire for the assessment of nursing skills and knowledge in relation to transfusion therapy
1Department of Nursing, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
Head of Department: Dr. Zoltán Balogh
2Doctoral School, Semmelweis University, Budapest, Hungary
Head of Department: Dr. Gyula Domján
3Department of Picture Imaging Diagnostic Analysis and Medical Instrumentation, Semmelweis University, Budapest, Hungary
Head of Department: Dr. Attila Doros
4Department of Nursing, Faculty of Health Sciences, Semmelweis University, Budapest, Hungary
Head of Faculty: prof. Zoltán Zsolt Nagy, MD, PhD
Summary
Introduction. All medical staff members involved in transfusion therapy, have professional-, legal- and ethical responsibility for their own actions.
Aim. This paper aims at reviewing nursing competencies assessing nurses’ knowledge about transfusion therapy regulations and how it is reflected in their daily practice.
Material and methods. In the observational, cross-sectional, descriptive pilot study data was collected using questionnaire and interview method. Reliability and validity of the self-made questionnaire were characterized by Cronbach’s alpha- and Pearson correlation coefficients, respectively.
Results. The level of the nurses’ overall knowledge related to the current transfusion regulations was almost 90%, and 56.2% of nurses systematized the nursing functions correctly. Significant differences were found between the institutions in the practice of transfusion therapy and practice as well as in the use of relevant documentation. 75% of the institutions have their own transfusion protocol, and assigned nurses responsible for transfusion care work in more than fifth of the wards.
Conclusions. The developed survey tool may be useful for nursing teachers and nursing leaders to discover gaps between knowledge and decision-making skills, to deal with these problems Nursing aspects of transfusion therapy should be more carefully supervised by nursing leaders along with raising the colleagues’ professional responsibility.
INTRODUCTION
Nursing teachers always considered essential to assess the professional knowledge of nurses, and to compare this theoretical knowledge with daily practice. This is especially true in transfusion practice where knowledge, competency-based activities, use of guidelines and procedures specified in the Transfusion Regulation (1) is essential for safe implementation of transfusion according to the relevant legislation.
It’s well-known that blood transfusion is a relatively common procedure, and needs necessary skill for many nurses working in a range of clinical environments. Blood transfusion carries a degree of risk, and avoidable mistakes can result in serious or fatal consequences. Adverse events are largely associated with human error, so knowledge and skills are essential. It is crucial for nurses to have sufficient knowledge of situations, amount of and methods of using blood components, possible side effects and necessary cares. While local and national policies go some way to reducing clinical risk, a comprehensive knowledge of the blood grouping system and compatibility, and the ability to recognize, respond to and report reactions, are also necessary to optimize patient safety. The lack of knowledge could be detrimental to patient safety.
Publications in the Hungarian literature do not address the practice of blood donation/ blood transfusion from nursing perspective with the exception of the professional „Transfusion-related nursing care” protocol developed by the College of Nursing. This research aims to remedy these deficiencies based on useful results achieved abroad.
An educational program was developed by The Scottish National Blood Transfusion service. Its aim was to ensure high standard of care for blood transfusions in order to minimize risk to patients and healthcare practitioners. It was investigated whether understanding and knowledge of, and attitudes towards, safe transfusion practice decreased over time following completion of module 1 of the program. Healthcare practitioners who had completed the module were involved in the online survey, and comparisons were made between participants 6-8 weeks, 12-14 months and 22-24 months since module completion. To explore attitudes in more detail in-depth interviews were conducted with a sub-sample of survey respondents. The results have shown that mild, but statistically significant decrease was observed over time among the respondents in understanding the importance of transfusion factors. The authors didn’t find any difference in knowledge between those who took the course more recently and those who were up to two years post-module. The study’s findings suggest that frequent refresher courses are important to maintain safe practice (2).
A research project of the Scottish National Blood Transfusion Service, ascertained student nurses’ knowledge retention of safe transfusion practice following a standardized teaching and learning program in Scotland, UK. A questionnaire was used to assess the level of students’ knowledge (n = 118) attained on the day of the session, and 4–6 months and 11-12 months thereafter.
An insight into the effectiveness of a standardized teaching approach was provided by this study focusing on areas for review in the light of incorrect answers. Despite the attendance of the Standardized Program, there was a wide range of initial overall scores achieved. The study demonstrated a clear decline of knowledge during the study period. The influence of experience on knowledge retention appears to have a positive effect at 6 months but no appreciable effect at 12 months. These results should be confirmed by larger, multicenter investigations (3).
Another article described the evaluation of a teaching package designed for nursing students to acquire the knowledge required for safe administration of blood transfusions. Nurses, as the health care professionals ultimately responsible for the bedside check, have the final opportunity to prevent a miss-transfusion. Applying structured learning programs in the undergraduate nursing curriculum can improve students’ knowledge. A structured questionnaire was applied to assess students’ knowledge of the process for transfusing blood components pre- and post-teaching and evaluate the effectiveness of the teaching pack. The results from this evaluation questionnaire proved that this teaching pack provided students with essential knowledge for administering blood transfusions safely under supervision but will require further development in collaboration with teacher colleagues and from the Blood Transfusion Service. It appeared relevant to students’ learning needs and assisted many to improve their knowledge. This teaching pack was an important step towards ensuring that newly qualified nurses have the required knowledge to ensure the right patient receives the right blood at the right time (4).
An online „Nursing Times Learning” unit on safe blood transfusion was launched in 2013 (5).
Important results were derived from a study involving two consecutive surveys conducted in a hospital in France in 2005. Poor nurses’ awareness of transfusion practice was found in the 1st survey. A second survey was carried out two years following the implementation of a „Good Transfusion Practices” training program. 4 questions were identical to those in the first survey in order to assess the impact of this training strategy. These 4 questions were related to blood sample identification, checking patient identification, checking „use by date” on blood product bag and the pre-transfusion bedside compatibility test. Nurses’ behaviors were also evaluated by checking the pre-transfusion procedures, including interpretation of bedside compatibility tests. The impact of attendance at the training course, the period of employment, day versus night shift were also investigated as potential correlates to the results of the 2nd survey. Significant improvement in knowledge of Good Practices between the first and the second survey was found (p < 0.0001), but the multivariate analysis showed training to have heterogeneous impact on different outcomes. Both pre-transfusion protocol checks (p = 0.05) and pre-transfusion bedside compatibility test interpretation of ABO compatibility (p = 0.007) were improved significantly (6).
A survey was conducted between January and April 2010 in three main teaching hospitals of Bamako and Kati and in six referral health centers of the district of Bamako. The study’s aim was to determine the level of knowledge and practice of medical staff personnel on transfusion medicine. A questionnaire was used for the survey, the sample consisted of specialized practitioners (15%), general practitioners (21.4%), nurses (41.6%), and midwives (22%). 70.9% of the staff did not receive any training in blood transfusion since their graduation. The general knowledge about blood transfusion was insufficient in 53.9% of staff and excellent in 46.1%. Only 42.9% of medical staff has a good basic knowledge of blood products, their indications, and related accidents. This survey also highlighted the weaknesses in transfusion system in Bamako with incomplete knowledge of the professional staff, as well as their little experience (7).
In the United Arab Emirates nurses’ knowledge of blood transfusion also has been investigated. A few surveys conducted earlier in this topic also pointed out both the knowledge and the practical shortcomings. This descriptive, cross-sectional study was made in two general hospitals in Abu Dhabi, in which 248 nurses were taken into by random sampling. The response rate was 94.3%. The knowledge-questionnaire consisted of six parts, 49 items was developed for the test. Data were analyzed using descriptive and inferential statistics. The overall knowledge scores of nurses were generally low ranging from 27-56 of a possible score of 70. There were statistically significant relationship between nurses’ knowledge and the work setting, the country where they trained and type of qualifications (8).
Another cross-sectional descriptive study investigated nurses’ knowledge of blood transfusion. 117 nurses in medical training hospitals of Shahrekord University of Medical Sciences participated in the study in 2004. Data was collected with a questionnaire including 4 sections and 29 questions. Sections included demographic data, nurses’ knowledge of blood components, nurses’ knowledge of infusion techniques, and nurses’ knowledge of indication and side effects of blood components infusion. Knowledge scores were coded at first and then categorized in three levels of „good”, „average”, and „poor”. Data were analyzed by using SPSS software. The nurses’ knowledge was average in relation to blood and blood component, techniques of blood components infusion, and its indication and side effects (66.7%, 65.8% and 59%, respectively). The findings showed that the nurses’ knowledge of blood and blood component was average and insufficient. Therefore, the authors recommended to activate the blood transfusion committees in hospitals to improve the quality of this common procedure and prevent side effects by in-service trainings of nurses (9).
AIM
The aim of our study was to elaborate various nursing competencies associated with different nursing tasks involved in transfusion therapy along with the analysis of professional-, legal- and ethical aspects of nursing care. Our objectives can be specified as follows:
– to develop and test a special questionnaire for evaluating transfusion-related nursing knowledge;
– to compare current practice with the recommended guidelines specified in the Transfusion Regulation’s directions, issued in 2008;
– to assess medical and nursing competencies associated with transfusion therapy such as blood products request, completion of the pre- and post-transfusion laboratory tests, follow-up of the changes in the Transfusion Regulation, bed-side blood-grouping, devices of blood-heating, the execution of biological probe, the use of rubber gloves, the storage of bags and administration set (fitment), and the local practice for documenting complications;
– to collect data before-, during and after transfusion procedure in hospital wards, where the implementation of nursing tasks are monitored;
– to explore the causes of similarities and differences in transfusion therapy along with the examination of transfusion rules that were adopted;
– to evaluate the local blood transfusion practice;
– to explore the extent according to which head nurses and nurses working on different patient wards know the rules relating to the transfusion therapy in all institutions involved;
– to analyze the paper-based and electronic documentation of the transfusion therapy, the local protocols and the professionalism of nursing documentation in some hospital wards.
MATERIALS AND METHODS
To answer descriptive research questions, an observational, cross-sectional design was adopted. Both quantitative methods (survey/questionnaires) and qualitative methods (interview) have been employed.
Transfusion-related knowledge and practice have been surveyed using a new questionnaire. The questionnaire has been developed following the structure of the current Transfusion Regulation published in 2008 (1). The questionnaire items corresponded to the order of transfusion procedure, the elements of the professional-, legal- and ethical aspects of nursing care, and the acquired experiences during direct observation. The questionnaire contains 29 questions divided into three parts: (I) Socio-demographic questions (8 items), (II) Transfusion therapy-related knowledge assessment (12 items), and (III) Transfusion therapy practice-related questions (9 items). Each received answers (variables) were recorded in SPSS, after coding.
Transfusion therapy practice-related information was assessed via direct observation during institution visits. Data were collected in three hospitals, where direct observation and interview were made with the involvement of local participants. In the first county hospital a chief physician, the head nurse and the nurse assigned for transfusion management were involved (n1 = 3 persons). In the second hospital (in the capital city) on the first ward a doctor, the head nurse and a nurse, and on the second ward the head nurse participated in the study (n2 = 4 persons). In the third (rural) hospital the head assistant of the Transfusion Department and on a ward the head nurse took part in the conversation (n3 = 2 persons). The institution visits took place on the first week of July 2014 and one month thereafter in August. The organization of the observations and survey was supported by the directors of nursing.
Data collection about the characteristics of local practice of transfusion therapy and transfusion therapy-related knowledge was made with the questionnaire among nurses and head nurses on certain hospital wards performing transfusion therapy. The respondents were selected using the unknown probability sampling method.
A selected sample of 30 nurses and head nurses in three hospitals participated in the assessment of the measuring instrument (10 participant in each institution). Although the number of respondents remained the same in each institution, different nurses were involved in the repeated surveys. The „July” respondents are marked with nj, while those participating in the „August” survey are represented with na.
The reliability of the new instrument has been evaluated using the standard deviation (SD), test-retest analysis, Pearson correlation coefficients and Cronbach alpha (10, 11,12). The statistical analysis was performed using the SPSS program (version 20).
Our research protocol has been approved by the ethical committee of the Semmelweis University in conformity with the rules of data protection.
RESULTS
30 nurses were asked to participate in the evaluation of the survey questionnaire. The number of returned and properly filled-in questionnaires was 29 during testing, and this figure dropped to 27 when the instrument was retested.
Reliability of the questionnaire

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Piśmiennictwo
1. Barótinè Tóth K: Blood Transfusion Policy: methodological letter by Hungarian National Blood Transfusion Service 2nd edition. [Transzfúziós szabályzat: az OVSZ módszertani levele 2. kiad.] Országos Vèrellátó Szolgálat, Budapest 2008: 1-113. 2. Smith A, Gray A, Atherton, I et al.: Does time matter? An investigation of knowledge and attitudes following blood transfusion training. Nurse Educ Pract 2014; 14(2): 176-182. 3. Smith FC, Donaldson J, Pirie L: Pre-registration adult nurses’ knowledge of safe transfusion practice: Results of a 12 month follow-up study. Nurse Educ Pract 2010; 10(2): 101-107. 4. Mole LJ, Hogg G, Benvie S: Evaluation of a teaching pack designed for nursing students to acquire the essential knowledge for competent practice in blood transfusion administration. Nurse Educ Pract 2007; 7(4): 228-237. 5. Higgins D, Jones D: Ensuring patient safety blood transfusision. Nurs Times 2013; 109(4): 22-23. 6. Tramalloni D, Auperin A, Oubouzar N et al.: Implication of nurses in transfusion safety: knowledge assessment and practice evaluation at the Gustave-Roussy institute. Transfus Clin Biol 2005; 12(6): 427-432. 7. Diakite M, Diawara SI, Tchogang NT et al.: Knowledge and attitudes of medical personnel in blood transfusion in Bamako, Mali. Transfus Clin Biol 2012; 19(2): 74-77. 8. Hijji B, Parahoo K, Hussein MM et al.: Knowledge of blood transfusion among nurses. J Clin Nurs 2013; 22(17-18): 2536-2550. 9. Aslani Y, Etemadyfar S, Noryan K: Nurses’ knowledge of blood transfusion in medical training centers of Shahrekord University of Medical Science in 2004. Iran J Nurs Midwifery Res 2010; 15(3): 141-144. 10. Tóthnè Parázsó L: The mathematical foundations of research methodology. [A kutatásmódszertan matematikai alapjai.] Eger: Eszterházy Károly Főiskola. Available from: http://www.tankonyvtar.hu/en/tartalom/tamop425/0005_31_kutatasmodszertan_pdf/adatok.html; (acces date 11-07-2013). 11. Sajtos L, Mitev A: Handbook of research and data analysis using SPSS. [SPSS kutatási ès adatelemzèsi kèzikönyv.] Aliena Kiadó, Budapest 2007: 203-214. 12. Falus I, Ollè J: Empirical research practice: data processing and statistical analysis. [Az empirikus kutatások gyakorlata: adatfeldolgozás ès statisztikai elemzès.] Nemzeti Tankönyvkiadó, Budapest 2008: 186-205, 323-325.
otrzymano: 2015-05-11
zaakceptowano do druku: 2015-06-10

Adres do korespondencji:
*Veronika Rajki
Doctoral School Semmelweis University Budapest, Hungary
1088 Budapest, Vas utca 17
tel.: tel.: +36 1-486-58-36
e-mail: rajki.veronika@se-etk.hu

New Medicine 2/2015
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