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Adherence to Venous Blood Specimen Collection Practice Guidelines Among Nursing Students and Healthcare Staff Karin Nilsson
Department of Nursing
Department of Medical Biosciences, Clinical Chemistry
Umeå University, 2016
Responsible publisher under Swedish law: the Dean of the Medical Faculty
This work is protected by the Swedish Copyright Legislation (Act 1960:729)
ISBN: 978-91-7601-444-8
ISSN: 0346-6612
Elektronisk version tillgänglig på http://umu.diva-portal.org/
Printed by: Print & Media, Umeå University
Umeå, Sweden 2016
‘Knowing is not enough; we must apply.
Willing is not enough; we must do’.
Johann Wolfgang von Goethe (1749-‐1832)
i
Table of Contents
Table of Contents i Abstract iii Original papers v Abbreviations vi Enkel sammanfattning på svenska vii Preface 1 Introduction 1 Background 3
Adherence 3 Patient safety 4 Clinical practice guidelines 5 Adherence to clinical practice guidelines 7 Factors influencing guideline adherence 8 Adherence to venous blood specimen collection guidelines 9 Rationale for the thesis 10 Aim 11 Specific aims 11
Materials and methods 12 Student context 12 Participants and settings 13 Data collection and analysis 16 Study I 16 Study II 18 Study III 19 Study IV 20 Ethical considerations 22
Results 23
The impact of workplace affiliation on venous blood specimen collection
guideline adherence 23
Adherence to venous blood specimen collection practice guidelines and factors
associated with adherence among nursing students 25
Summary of studies regarding ‘Always ask the patient to state name and
national registration number’ 28
Discussion 29 Patient identification practices 30 Test tube labelling and test request handling practices 33 Incongruence between training on campus and training at the clinical setting 35 Bridging the gap 36
ii
Methodological considerations 39 Design 39 Participants 39 Data collection 40
Questionnaires 40 Focus group interviews 41
Conclusions 42 Postface 44 Tack 45 References 47
Paper I-IV
iii
Abstract
Background Patient safety is an undisputable part of healthcare. The use of
clinical practice guidelines, usually based on evidence-based practice/best
practice, promotes patient safety and high quality care, reduces unnecessary
patient suffering, and healthcare costs. Analysing results from venous blood
specimen collection is one of the most commonly used services within
healthcare, and a substantial number of decisions on diagnosis, treatment,
and treatment evaluation are based on the results. Hence, the accuracy of
these tests are vitally important. Earlier research has demonstrated that
healthcare staff report suboptimal adherence to venous blood specimen
collection guidelines together with the need for improved practices. Blood
sample collection is carried out by several professionals, among them
registered nurses and, as a consequence, nursing students too. University
nursing students learn and practice venous blood specimen collection in one
of their first semesters. After initial skill training at clinical skill laboratories,
they continue to perform the task during clinical placements in various clinical
settings. Few or no studies have been performed on nursing students, hence it
seemed important to assess guideline adherence to venous blood specimen
collection among university students as well as to further explore adherence
to guidelines among healthcare staff. Therefore, the overall aim for this thesis
was to explore adherence to, and factors influencing venous blood specimen
collection guidelines practice among university nursing students and
healthcare staff.
Methods The thesis includes four studies. Study I-III had a quantitative,
cross-sectional design, study IV had a qualitative approach. Study I included
164 healthcare staff from 25 primary healthcare centres. Study II included 101
nursing students in their 5th and 6th semesters, and study III included 305
nursing students in their 2nd, 4th, and 6th semesters. To assess adherence to
venous blood specimen collection guidelines, data were collected using the
Venous Blood Specimen Questionnaire, completed with background variables
(I, II, III) and additional scales (III). Descriptive statistics, multilevel and
multiple logistic regression analyses were used to analyse the data. In study
IV, data were collected through five focus group interviews among 6th
semester nursing students (n=26). Data were analysed using qualitative
content analysis.
Results Workplace affiliation was found to explain variances in reported
adherence between different primary healthcare centres. Associations
between reported venous blood specimen collection practices and individual
as well as workplace factors were revealed. Nursing students were found to
increasingly deviate from guideline adherence during their education. Also
among students, several associations between guideline adherence and other
iv
factors were revealed. Reported research use at clinical practice was
associated with higher levels of adherence, as were higher capability beliefs
regarding both evidence-based practice and academic ability. Analyses from
focus group interviews summarised students’ reflections on deviations from
VBSC guidelines in the overall theme ‘Striving to blend in and simultaneously
follow guidelines’.
Conclusion Both healthcare staff at primary healthcare centres and nursing
students demonstrate decreasing levels of guideline adherence with time.
Factors influencing adherence are both individual as well as contextual. This
indicate that both students and staff are subjected to socialisation processes
that influences levels of adherence. In order to enhance venous blood
specimen collection practices and thereby patient safety, actions must be
taken - both in healthcare clinical contexts and by educators. The use of
models in practical skill training, and in the ambition to bridge the theory-
practice gap may be the path to success. It is reasonable to assume that
collaboration between, on the one hand, education representatives and on the
other, supervising RNs in clinical settings, will be fruitful. Finally, by
empowering students their self-efficacy may be strengthened, and hence their
ability to maintain guideline adherence.
Keywords
Adherence, Clinical practice guidelines, Experiences, Nursing student, Patient
safety, Pre-analytical errors, Primary healthcare, Questionnaires, Venous
blood specimen collection
v
Original papers
The thesis is based on the following papers, and each paper will be referred to
in the text by its Roman numeral.
I. Nilsson, K., Juthberg, C., Söderberg, J., Bölenius, K., Grankvist,
K., Brulin, C., & Lindkvist, M. (2015). Associations between workplace affiliation and phlebotomy practices regarding patient identification and test request handling practices in primary healthcare centres: a multilevel model approach. BMC Health Services Research, 15(1), 503.
II. Nilsson, K., Grankvist, K., Juthberg, C., Brulin, C., & Söderberg, J. (2014). Deviations from venous blood specimen collection guideline adherence among senior nursing students. Nurse Education Today, 34(2), 237-242.
III. Nilsson, K., Brulin, C., Grankvist, K., Juthberg, C. Factors Associated with Nursing Students' Adherence to Venous Blood Specimen Collection Practice Guidelines - A Cross Sectional Study. Re-submitted.
IV. Nilsson, K., Brulin, C., Grankvist, K., Juthberg, C. Senior Nursing
Students’ Reflection on Deviations from Guideline Adherence regarding Venous Blood Specimen Collection Practice: A qualitative study. In manuscript.
The papers have been reprinted with the kind permission of each journal.
vi
Abbreviations
CI Confidence interval
CPG Clinical practice guidelines
EBP Evidence-based practice
ID Identification
LANE Longitudinal Analysis of Nursing Education
MOR Median odds ratio
OR Odds ratio
PHC Primary healthcare centre
RN Registered nurse
VBSC Venous blood specimen collection
VBSQ Venous blood specimen questionnaire
vii
Enkel sammanfattning på svenska
Bakgrund Patientsäker vård anses som en självklarhet inom hälso- och
sjukvård. Genom att använda riktlinjedokument, ofta baserade på evidens
eller bästa tillgängliga erfarenhet, säkerställs kvaliteten på den vård som
bedrivs. Det innebär också minskad risk för onödigt lidande samt minskade
kostnader för hälso- och sjukvården. Venös blodprovstagning är mycket
vanlig inom hälso- och sjukvård eftersom en stor del av diagnostisering, beslut
om behandling samt utvärdering av behandling baseras på resultat från dessa
blodprov. Därför är det av yttersta vikt att de är tillförlitliga. Studier bland
vårdpersonal har visat bristande följsamhet till riktlinjer för venös
blodprovprovstagning. Venös blodprovstagning utförs av flera personal-
kategorier; biomedicinsk analytiker, undersköterskor, läkare, sjuksköterskor
och följaktligen också sjuksköterskestudenter. Utbildningsmomentet venös
blodprovstagning introduceras oftast i någon av de första terminerna i
utbildningen. Efter att ha lärt och praktiserat momentet vid kliniska
träningscentra på campus, fortsätter studenterna att utföra momentet under
handledning i klinisk verksamhet vid verksamhetsförlagd utbildning. Endast
ett fåtal studier har genomförts på sjuksköterskestudenter i ämnet, därför är
det viktigt att studera följsamhet till riktlinjer gällande venös
blodprovstagning bland dessa, men också ytterligare studera följsamhet bland
vårdpersonal. Det övergripande syftet för denna avhandling ’att undersöka
följsamhet, samt faktorer som inverkar på följsamheten, till riktlinjer gällande
venös blodprovstagning bland sjuksköterskestudenter och vårdpersonal’.
Metod Avhandlingen består av fyra delstudier. Studie I-III hade kvantitativ
ansats med tvärsnittsdesign, studie IV hade kvalitativ ansats. I Studie I deltog
164 vårdpersonal från 25 hälsocentraler. I studie II deltog 101 sjuksköterske-
studenter i termin 5 och 6, slutligen i studie III, 305 sjuksköterskestudenter i
termin 2, 4 och 6. Data samlades in med hjälp av Venous Blood Specimen
Questionnaire. Enkäten kompletterades med bakgrundsfrågor (I, II, III),
tillika andra instrument (III) rörande individuella, miljö- samt
utbildningsrelaterade faktorer. Data i studie I-III analyserades med hjälp av
deskriptiv statistik, multilevel samt multipel logistisk regressionsanalys. Data
till studie IV samlades in via fem fokusgruppintervjuer av 26 studenter i
termin 6. Intervjuerna analyserades med hjälp av kvalitativ innehållsanalys.
Resultat Variationen av självskattad följsamhet till riktlinjer mellan olika
hälsocentraler förklarades till viss del av arbetsplats. Resultatet visade också
på samband mellan självskattad följsamhet till riktlinjer och individuella samt
arbetsplatsrelaterade faktorer. Sjuksköterskestudenter visade på minskad
följsamhet till riktlinjer med varje avklarad termin. Dessutom fanns ett
positivt samband mellan följsamhet och 1) användning av forskning under
verksamhetsförlagd utbildning, 2) högre tilltro till evidensbaserad vård, och
viii
3) högre tilltro till akademisk förmåga. Data från fokusgruppsintervjuer
utmynnade i det övergripande temat ‘Att försöka smälta in och samtidigt följa
riktlinjer’.
Konklusion Personal vid hälsocentraler och sjuksköterskestudenter visade
på bristande följsamhet till riktlinjer. Både individuella och miljörelaterade
faktorer påverkade följsamheten. Fynden pekar mot att både personal och
studenter utsätts för socialiseringsprocesser som möjligen påverkar
följsamheten. Förbättrade venprovtagningsrutiner, och därmed ökad
patientsäkerhet, är därför nödvändig. I ambitionen att öka följsamheten till
riktlinjer bör representanter för både hälso- och sjukvård samt
sjuksköterskeutbildningar agera. Ett sätt kan vara att använda modeller för
lärande av praktiska moment både inom utbildning och i klinik. När det gäller
sjuksköterskestudenter är nyckeln till framgång förmodligen också ökat
samarbete mellan dessa två parter. Genom att stärka studenters tilltro till
evidensbaserad vård kan ansatsen att hålla fast vid riktlinjer för venös
blodprovstagning, och därmed också patientsäkerhet, förbättras.
Nyckelord
Enkäter, Erfarenheter, Följsamhet, Patientsäkerhet, Preanalytiska fel,
Primärvård, Riktlinjer, Sjuksköterskestudenter, Venprovtagning.
Introduction
1
Preface
In my work as a registered nurse (RN) I have come across and performed
venous blood specimen collection (VBSC) on countless occasions. After some
twenty years in clinic, I had the opportunity to lecture on the nursing
programme. I was, among other tasks, assigned to teach VBSC, theoretically
as well as skill training at the clinical skills laboratory. In this regard, I
reviewed the literature and the guidelines and realised first, that I had not
checked the guidelines for a very long time, and second, that my VBSC routine
was not exactly in line with national guidelines. This experience gave me
several insights: procedures performed on a daily basis such as VBSC might
become second nature, you consider yourself to know how it is supposed to be
done. Second, that it might not be common to reflect on matters of guideline
adherence.
My entry into doctoral studies was through the ongoing research project on
correct VBSC practice for increased patient safety, an interdisciplinary
collaboration between the Department of Nursing and the Department of
Medical Biosciences, Clinical Chemistry, Umeå University.
Introduction
The decision-making and management of healthcare procedures is often
supported by clinical practice guidelines (CPG). They are usually a consensus
statement on best available practice/evidence-based practice (EBP) in a
certain area aiming to identify and maintain high quality care. Adherence to
guidelines has been proven to both enhance patient safety by reducing
improper variations in performance (Eccles, Grimshaw, Shekelle,
Schünemann, & Woolf, 2012; Kennedy, Leathley, & Hughes, 2010), and to be
cost effective (Green, 2013; Simon-Tuval, Neumann, & Greenberg, 2016) by,
for example, reducing rates of hospitalisation (Sloan, Bethel, Lee, Brown, &
Feinglos, 2004) as well as emergency department visits (Cloutier, Hall,
Wakefield, & Bailit, 2005). However, it has been shown that CPG adherence
in general may be poor (Asch et al., 2006; McGlynn et al., 2003), hence, it is
a larger issue than merely adherence to a specific procedure.
One of the most common practical procedures within healthcare, VBSC, is a
key element since a considerable number of decisions about diagnosis,
treatment, and treatment evaluation are based on results from these analyses
(Hallworth, 2011; Kalra, 2004; Lippi, Salvagno, Montagnana, Franchini, &
Guidi, 2006; Plebani, 2006; Wians, 2009). Hence, the quality of testing and
reporting of these analyses is of utmost importance (Forsman, 1996). The
process from the point when an analysis is requested until the result of the
analyse is returned, is referred to as the total testing process (TTP) (Figure 1)
Introduction
2
(Lundberg, 1981) and covers three phases; the pre-analytical phase, the
analytical phase, and the post-analytical phase (Hawkins, 2012; J. Kalra,
2004).
Figure 1. The total testing process, inspired by the “brain-to-brain loop” (Lundberg, 1981), and Lippi, Mattiuzzi, and Favaloro (2015).
The VBSC guidelines covers the pre-analytical phase, i.e. from the point when
the analysis is requested to the point when the sample reaches the laboratory.
One of the procedures during the pre-analytical phase, blood drawing, is
carried out by phlebotomists (i.e. the person drawing the blood), who are staff
from various professions for example RNs, and as a consequence also nursing
students. To ensure correct analysis of results for decisions on diagnosis,
treatment and evaluation, adherence to VBSC practice guidelines is essential.
Earlier studies on VBSC practice guideline adherence among phlebotomy staff
at hospital wards and in primary healthcare centres (PHC) demonstrate
suboptimal performance (Bölenius, 2014; Söderberg, Wallin, Grankvist, &
Brulin, 2010; Wallin et al., 2008). However, as far as I know, few studies have
been performed on nursing students. The accuracy of VBSC analysis results is
essential to meet the demands of high quality care. In this regard, this thesis
will further explore adherence to VBSC guidelines among nursing students
and healthcare staff.
Background
3
Background
Although the issue of suboptimal adherence to CPGs within healthcare is
general, this thesis solely addresses adherence to VBSC practices guidelines.
The background section covers the core concepts adherence, patient safety,
and adherence to clinical practice guidelines.
Adherence
Within healthcare, there are several concepts describing the willingness to
follow, for example a suggested treatment, but also the ambition to follow a
suggested procedure among both patients and staff. ‘Adherence’ is related to
the verb adhere, meaning “to stick” and describes the willingness to stick or
be faithful to, for example, laws or obligations. ‘Compliance’ originates from
Latin meaning to fill up and hence to complete an action, transaction, or
process and to fulfil a promise. Both ‘compliance’, ‘adherence’ and to some
extent ‘concordance’ have been widely used in medical and pharmaceutical
literature. The term ‘compliance’ has been utilised since the 1950s, mainly to
describe a patient-physician relationship. The most commonly used definition
of ‘compliance’ is the one put by Haynes, Taylor, and Sackett (1979): ‘The
extent to which the patient’s behaviour matches the prescriber’s
recommendations’. The term has been criticised because of the negative
connotations implying lack of patient involvement (Stimson, 1974), and the
underlying suggestion that compliance implies obedience without
consideration of the patients’ independence (Robinson, Callister, Berry, &
Dearing, 2008), and the use is therefore declining. In the 1990s, terminology
in the literature began to shift to adherence rather than compliance (Vrijens
et al., 2012). The term was adopted by many, particularly within the
psychological and sociological literatures, as an alternative to compliance. A
commonly used definition of ‘adherence’ is ‘The extent to which the patient’s
behaviour matches agreed recommendations from the prescriber’ (Barofsky,
1978), which again implies a patient-physician relationship.
Adherence is also used when addressing healthcare workers obedience to
rules and guidelines, which is the outcome variable in this thesis. Factors
influencing healthcare workers adherence to guidelines are presented under
the section ‘Adherence to Clinical Practice Guideline’.
In summary, the literature covering guideline adherence uses both ‘adherence
to’ and ‘compliance with’ interchangeably (Gardner, 2015). In this thesis, I will
use ‘adherence to’ when addressing this issue. Furthermore, the underlying
idea of the concept of ‘adherence’ implies that there are benefits with
adhering. Hence, the rules or regimes to adhere to are assumed to be of good
quality and to promote safety.
Background
4
Patient safety
Patient safety is one of several nursing core competencies (The Swedish
Society of Nursing), important in education as well as in daily care. In this
regard, patient safety is also one of several elements in the nursing care model,
developed at the Department of Nursing, Umeå University (2015). The model
states that nursing is understood from a relational aspect, as well as a care task
aspect that are intertwined into an inseparable whole. The relation is always
mutual and dependent on the care tasks to be performed, e.g. procedures such
as VBSC (Department of Nursing, Umeå University, 2015).
The World Health Organisation (WHO) describes that ‘the discipline of
patient safety is the coordinated effort to prevent harm, caused by the process
of health care itself, from occurring to patients’, and defines patient safety as
‘the absence of preventable harm to a patient during the process of health care’
(World Health Organization, 2016). The US Institute of Medicine (IOM)
considers patient safety ‘indistinguishable from the delivery of quality health
care’ and defines the concept as ‘the prevention of harm to patients’ (Aspden,
Corrigan, Wolcott, & Erickson, 2004).
Within healthcare, and in contrast to other areas such as aviation, adverse
events and errors have historically been considered as inevitable conse-
quences of care (Sharpe & Faden, 1998). In the 1960s, and for the first time in
modern professional literature on the subject, researchers included the
negative consequences of medical and nursing healthcare errors, for instance
in the studies by Reichel (1965) and Ogilvie and Ruedy (1967). However, the
last decades, ever since the IOM report ‘To err is human’ revealed figures of
nearly 100,000 possible deaths yearly due to healthcare errors in a US context
(Kohn, Corrigan, & Donaldson, 2000), the patient safety issue has been
targeted and is now an undisputable ingredient in healthcare (Grol &
Grimshaw, 2003; World Health Organization, 2011). In this regard, and to
underline the importance of patient safety as a global healthcare issue, the
WHO Member States agreed on a World Health Assembly resolution on
patient safety in 2002 (Donaldson & Philip, 2004). More recent US figures
suggest that preventable medical harm events may be ten times higher than
in the IOM-report, which implies an unimaginable total cost of nearly $1
trillion (Andel, Davidow, Hollander, & Moreno, 2012). In Sweden, recent
statistics shows decreasing numbers of deaths and injuries due to healthcare
errors. Still, approximately 1,400 deaths stem from errors in healthcare, and
every 10th patient is injured – of which some 3,000 suffer permanent damage
(Swedish Board of Health and Welfare, 2015).
The term medical error is defined by the IOM as ‘the failure of a planned action
to be completed as intended (i.e., error of execution) or use of a wrong plan to
achieve an aim (i.e., error of planning)’. Furthermore, that ‘some medical
Background
5
errors might lead to an adverse event, such as an injury resulting from a
medical intervention, but not due to the underlying condition of the patient’
(Kohn et al., 2000). Medical errors might originate from a variety of subjects
including mistakes by humans, medical technology, and systems, which occur
during processes within a health care system. Hence, medical errors may
occur through failures of systems and processes such as safety leadership,
safety culture, and safety initiatives (McFadden, Henagan, & Gowen, 2009) as
well as corrective systems (Lee, Hong, & Kim, 2014). Moreover, errors may
occur during interactions between medical staff and medical equipment
and/or systems (Garrouste-Orgeas et al., 2012; Reason, 2000).
The recognition of the patient safety concept, preventable adverse events, and
errors have created a desire to focus on prevention, primarily to avoid patient
suffering but also to enhance healthcare finances (Brilli et al., 2013). Isolated
interventions are unlikely to reduce the underlying causes of hospital errors
(Singer & Vogus, 2013). However, improved patient safety using various
quality improvement strategies, such as implementing culture and system
changes have been demonstrated to be efficient (Brilli et al., 2013; Morello et
al., 2013; Muething et al., 2012). Hence, in order to effectively create and
sustain a safety culture and reduce errors, systemic interventions that address
the interrelated processes of a safety culture in a balanced manner are
required (Singer & Vogus, 2013). An example of such actions was revealed in
a recently published Dutch review on preventable adverse events, where it was
concluded that a national “Prevent harm, work safely” programme reduced
the frequency of preventable adverse events (Baines, Langelaan, de Bruijne,
Spreeuwenberg, & Wagner, 2015). Other, more direct and hands-on actions to
promote patient safety include the use of CPGs, which are often based on
evidence-based practice (EBP).
Clinical practice guidelines
The taxonomy in this area contains several expressions. A ‘Guideline’ is a
statement that determines a course of action and aims to streamline particular
processes according to sound practice in line with best practice. ‘Best practice’
is described as a technique or a method that is believed to be more effective at
delivering a particular outcome than any other techniques or methods.
‘Evidence-based practice’ (further described later) involves a technique or
method tested by means of best practice which can be adopted as a standard
process and be used as a guideline. By definition, following a guideline is never
mandatory. However, by following, maintenance of best practice is kept
without jeopardising its quality (Department of Veterans Affairs, 2016).
According to the Institute of Medicine, “Clinical practice guidelines are
statements that include recommendations intended to optimise patient care
Background
6
that are informed by a systematic review of evidence and an assessment of the
benefits and harms of alternative care options” (Field, Lohr, Guidelines, &
Medicine, 1992; Steinberg, Greenfield, Mancher, Wolman, & Graham, 2011).
In an early review covering publications from 1985 up to June 1997,
Shaneyfelt, Mayo-Smith, and Rothwangl (1999) concluded that CPG
developers did not fully adhere to the established methodological standards
in the synthesis of scientific evidence. In parallel, during the same period, the
term evidence-based practice (EBP) emerged, defined as ‘the integration of
best research evidence with clinical expertise and patient values’ (Sackett,
2000). Ever since, for some twenty years, it has been used and is now an
undisputable part of both healthcare and healthcare education (Eddy, 2011).
EBP is also considered a nursing core competence (The Swedish Society of
Nursing) aiming to incorporate science into practice and enhance safety.
Based on the intention in the definitions described above, tools and methods
for guideline development have been drafted; the Guideline International
Network (G-I-N) Standards (www.g-i-n.net), the Institute of Medicine (IOM)
Standards (Graham, Mancher, Wolman, Greenfield, & Steinberg, 2011), the
Appraisal of Guidelines for Research & Evaluation (AGREE) II (Brouwers et
al., 2010), and Guidelines 2.0 (Schunemann, Fretheim, Oxman, & Research,
2006). In this regard, CPGs are usually, or should be, consensus statements
based on EBP or best practice, developed to ascertain professional and
scientific-based care (Eddy, 2011; Grol & Grimshaw, 2003; Qaseem et al.,
2012; Steinberg et al., 2011). However, as the cost of guideline development
can be capped at $200,000 per guideline (the US) (Graham et al. 2011), the
process has been questioned as regards just when guidelines are “good
enough” (Browman, Somerfield, Lyman, & Brouwers, 2015).
The use of CPGs enhances the quality of care and promotes patient safety
through evidence-based practice (Harrison, Légaré, Graham, & Fervers,
2010). Areas improved by the use of guidelines or care bundles are for
example, decreased catheter associated blood-stream infections as a result of
enhancing hygiene routines (Ista et al., 2016; Marschall et al., 2014; Miller et
al., 2010; Pérez-Granda, Guembe, Rincón, Muñoz, & Bouza, 2015; Wilson,
2015), decreased ventilator associated pneumonia due to enhancing oral
health (El-Rabbany, Zaghlol, Bhandari, & Azarpazhooh, 2015; Eom et al.,
2014; Kaneoka et al., 2015; Klompas et al., 2014; Speck et al., 2016;
Zuckerman, 2016), and decreased incidence of pressure ulcers by relieving the
pressure (Niederhauser et al., 2012; Reddy, Gill, & Rochon, 2006; Sullivan &
Schoelles, 2013).
Since CPGs aim to transform evidence into practice, adherence to CPGs
among healthcare staff is urged by healthcare organisations as a path to
enhancing patient safety.
Background
7
Adherence to clinical practice guidelines
Guideline adherence in general, as assessed in recent reviews, demonstrates
divergent results, as does the sustainability of adherence over time showing
both improved adherence (Luangasanatip et al., 2015), and decreased levels
after intervention (Ament et al., 2015). One of the most studied practices is
infection control by adhering to hand hygiene guidelines, and may therefore
serve as an example. Healthcare related infections within Swedish healthcare
are one of the most common injuries, alone causing about 750,000 extra
hospital days yearly and an extra cost of more than $700 million, not to
mention the unnecessary patient suffering (Swedish Board of Health and
Welfare, 2015). European statistics reveal about 37,000 deaths yearly due to
healthcare related infections (Zingg et al., 2015). The concept of cleaning
hands more thoroughly, together with using an antiseptic agent in order to
prevent infections, emerged in the early 19th century. The most famous
pioneer in this area was probably Ignaz Semmelweis, a young physician at the
General Hospital of Vienna, who in 1847, found dramatically reduced
maternal mortality rates with the use of an antiseptic handwashing solution
(Carter, 1983). Although these findings were not fully accepted by the
contemporary establishment, the result of the seminal studies by Semmelweis
and others meant that handwashing gradually became accepted as one of the
most important measures for preventing transmission of pathogens in
healthcare facilities. Ever since, numerous recommendations and guidelines
on hand hygiene have been published worldwide (Public Health Agency of
Sweden, 2013; Tacconelli et al., 2014; Us Centers for Disease Control and
Prevention, 2002; World Health Organization, 2013).
Even though hand hygiene has been an issue for some 170 years, guideline
adherence still needs to be targeted. In a review of 96 studies by Erasmus et
al. (2010) on adherence to hand hygiene guidelines, an overall median
adherence rate of 40% was found. Adherence was further studied in a review
covering only qualitative studies where it is concluded that the problem of low
hand hygiene guideline adherence is best targeted by using theories that
underpin work environment and behaviour motivation issues to gain a better
understanding of factors influencing guideline adherence (Smiddy, O'Connell,
& Creedon, 2015). Studies on nursing students’ adherence to hand hygiene
guidelines have also been performed, for example by Cruz, Cruz, and Al-Otaibi
(2015) who revealed gender differences regarding hand hygiene guideline
adherence where women demonstrated higher levels than men. Moreover,
Shinde and Mohite (2014) found nursing students to report significantly
higher levels of adherence to hand hygiene guidelines compared to the nurses
in their study.
Background
8
Studies on guideline adherence regarding other clinical practice procedures,
for example on peripheral venous catheters handling guidelines explored by
Förberg et al. (2014), show varying but suboptimal levels of adherence.
Furthermore, knowledge about pressure ulcer prevention guideline content
has been shown to be poor, approximately 50%, among nursing students
(Simonetti, Comparcini, Flacco, Di Giovanni, & Cicolini, 2015).
Research use, which is defined as the intention to use EBP in practice (Groot,
Wouden, Hell, & Nieweg, 2013), for example by adhering to CPGs, varies.
Studies conducted among Swedish RNs showed overall low research use one
year after graduation and even lower levels after three years (Forsman,
Gustavsson, Ehrenberg, Rudman, & Wallin, 2009). The same research team
identified a number of factors associated with low research use, for example
clinical setting (psychiatric care), role ambiguity, being male, and low student
activity during undergraduate education among RNs two years post-
graduation (Forsman, Rudman, Gustavsson, Ehrenberg, & Wallin, 2012).
Furthermore, about half of the graduating nursing students in Forsman,
Wallin, Gustavsson, and Rudman (2012) study reported the intention to use
research on at least half of all work shifts, which also predicted research use
one year post graduation. Adherence to CPGs are in line with high levels of
research use, provided that the CPG are based on EBP/best practice. In this
thesis I will consider adherence to CPG as a possible confirmation of high
research use.
In summary, studies addressing nursing students’ guideline adherence are
numerically fewer compared to studies among healthcare staff. In this regard,
further studies on guideline adherence as well as factors influencing guideline
adherence among both healthcare staff and nursing students are of great
interest in order to optimise care.
Factors influencing guideline adherence
Various barriers to healthcare workers’ adherence to guidelines have been
reported in the literature. The barriers are both connected to individual,
contextual, and CPG characteristics. In a review by Travers, Martin‐Khan, and
Lie (2009) on barrier to CPG use among physicians in primary care, factors
such as the awareness, familiarity, agreement, self-efficacy, and outcome
expectancy of CPG adherence were shown to be of importance. Furthermore,
ability to overcome the inertia of previous practice, and absence of external
barriers to perform recommendations (Cabana et al., 1999; Kochevar & Yano,
2006) are also important. Meijers et al. (2006), identified six context factors
in their review of ten studies in the nursing field: role, access to resources,
organisational climate, support, education and time to participate in research.
In other nursing reviews, some of these ‘context’ factors (e.g. role, education)
are also identified as individual factors important to knowledge acquisition
Background
9
(Estabrooks, Floyd, Scott-Findlay, O'Leary, & Gushta, 2003; Squires et al.,
2011). Also, guideline characteristics such as relevance, easy/difficult to
follow, compatible with existing norms and values etc., are of major
importance for adherence (Burgers et al., 2003). Factors influencing nursing
students’ adherence to CGP are for example knowledge of CPGs, perceived
barriers, adequacy of training, management support, influence of nursing staff
(Cheung et al., 2015), and the perceived social climate at the setting (Chan,
2002).
Adherence to venous blood specimen collection guidelines
Adherence to VBSC guidelines is essential to maintain high quality. The
Swedish VBSC guidelines are available online in the Handbook for Healthcare
and are almost identical to the international guidelines (CLSI, 2010), and
cover areas relevant to the pre-analytical phase (Figure 1). In a recently
published observation study by the European Federation of Clinical Chemistry
and Laboratory Medicine Working Group for the Pre-analytical Phase aiming
to assess the level of adherence to the international CLSI H3-A6 guidelines in
12 European countries, the overall level was found to be unacceptably low
(Simundic et al., 2015). Furthermore, it was found that patient identification
and tube labelling practices were the most critical parts needing immediate
attention. Also, in Swedish contexts, studies on VBSC guideline adherence
demonstrate suboptimal levels among both hospital ward staff (Wallin et al.,
2008; Wallin et al., 2010) and PHC staff (Bölenius et al., 2013; Söderberg,
Brulin, Grankvist, & Wallin, 2009). Chemistry laboratory staff, however,
reported higher levels of adherence compared to other healthcare staff
categories performing phlebotomy (Melkie, Girma, & Tsalla, 2014; Wallin et
al., 2008).
The overall laboratory error rate ranges from <0.05-10% depending on
definitions and the methods used to identify frequencies (Lippi & Guidi,
2007). Apart from the unnecessary patient suffering, the cost for pre-
analytical errors has been estimated to represent on average between 0.23%
and 1.2% of total hospital operating costs (Green, 2013). In a recently
published review, Giuseppe Lippi et al. (2015) concluded that the pre-
analytical phase is undeniably the most vulnerable to a variety of errors
impairing the reliability of test results. With the vast majority of all laboratory
errors occurring in the pre-analytical phase (Bonini, Plebani, Ceriotti, &
Rubboli, 2002; G. Lippi et al., 2015; Simundic & Lippi, 2012), this phase needs
to be targeted as regards quality improvement. Errors in the pre-analytical
phase are for example identification errors, which are considered the most
serious (Kalra, 2004; Lippi et al., 2009) ranging between 0.2% and 6% for
outpatients, and 1% to 2% for inpatients (Lippi & Guidi, 2007). Identification
errors are for example if the patient is not asked to state name and national
Rationale
10
registration number, if coherence between test request, test tube labels and
patient ID is not checked, or the miss-labelling of test tubes occurs (Lippi,
Sonntag, & Plebani, 2011). Furthermore, passive agreement, i.e. when a
patient just agrees with the name and national registration number suggested
by the phlebotomist, is not considered as guideline adherence (Grissinger,
2014).
Studies on nursing students’ adherence to VBSC practice guidelines are few.
However, in a recent Swedish observation and questionnaire study, 98% of
the students successfully performed correct patient identification, and 96%
labelled the test tubes correctly. No significant associations between
performance and self-efficacy were found (Ahlin, Löfmark, Klang-Söderkvist,
& Johansson, 2012). The conviction that errors in the pre-analytical phase can
be detected and prevented (Kaushik & Green, 2014) gives the incentive to
further address this issue.
Rationale for the thesis
The use of CPGs is crucial to guarantee high quality healthcare and patient
safety. Adherence to VBSC practice guidelines ensures the safety when relying
on results from VBSC analyses, which is essential in healthcare, since a great
deal of decisions are made based on these results. Suboptimal adherence to
VBSC guideline practice has been demonstrated among both healthcare staff
on hospital wards as well as among staff in PHCs. Of all errors, non-adherence
or suboptimal adherence to patient identification guidelines are considered
the most serious, since decisions about diagnosis, treatment and evaluation of
treatment might be based on results from the wrong patient if correct
procedure is not followed. This might cause the patient unnecessary suffering
due to the need for supplementary blood sampling, the feeling of being unsafe,
and also an unwanted extra cost for society.
Earlier research found suboptimal adherence to VBSC guidelines among
phlebotomy staff. However, no or few studies have explored to what extent
workplace affiliation explains variation in reported adherence. With the
assumption that students learn correct VBSC practice in line with guidelines
in one of their first semesters at university, together with earlier findings
revealing that RNs deviate from guidelines, the need to further explore both
nursing students’ VBSC practice during their training as well as their
reflections on VBSC practices, is warranted. There is also a need to further
explore the extent to which workplace affiliation explains variation in VBSC
guideline adherence. We hypothesised work context to impact levels of
adherence to VBSC guidelines, and nursing students to be influenced by
contextual factors when attending clinical practice. To the best of our
knowledge, few studies have explored nursing students’ adherence to VBSC
Aims
11
guidelines and factors associated with guideline adherence, and no or few
studies have explored workplace affiliation in relation to VBSC guideline
adherence.
Aim
The overall aim of this thesis was to explore adherence to, and factors
influencing, venous blood specimen collection practice guidelines among
university nursing students and healthcare staff.
Specific aims
Study I: To explore to what extent workplace affiliation explains variation
of self-reported adherence to VBSC practices regarding patient ID
and test request handling, taking into consideration fixed PHC
workplace and individual phlebotomist characteristics.
Study II: To investigate senior nursing students' adherence to the national
VBSC guidelines regarding patient identification, test request
handling, and test tube labelling.
Study III: To explore nursing students’ adherence to venous blood specimen
collection practice guidelines regarding patient identification and
test-request management in association with clinical experience,
capability beliefs, research use, and the impact of perceived social
climate in clinical contexts.
Study IV: To describe senior nursing students’ perceptions of deviations
from venous blood specimen collection practice guidelines.
Materials and methods
12
Materials and methods
This thesis applied both quantitative and qualitative methods in order to
obtain a more comprehensive picture of the phenomenon under investigation.
An overview of the studies is presented in Table 1.
Table 1. A schematic overview of Studies I – IV
Study Status
Design Participants Data collection Year
Analysis
I Published
Cross sectional
164 phlebotomy staff from 25 PHCs
VBSQ 2006-2007
Multilevel logistic analyses
II Published
Cross sectional
101 nursing students in their 5th and 6th semester
VBSQ 2007
Multiple logistic regressions
III Re-submitted
Cross sectional
305 nursing students in their 2nd, 4th, and 6th semester
VBSQ Capability beliefs regarding EBP Research use Capability beliefs regarding academic ability QPS Nordic CS 2012
Multiple logistic regressions
IV In manuscript
Qualitative 26 nursing students in their 6th semester
Focus group interviews 2015
Qualitative content analysis
PHC: Primary healthcare centre, VBSQ: Venous blood sampling questionnaire, QPS: General Nordic Questionnaire for Psychological and Social Factors at Work, CS: Climate scale
Student context
VBSC is one of several practical nursing skills in the Swedish nursing
programme curriculum. It is usually learnt in one of the first semesters and
contains both theoretical and practical training in line with current guidelines.
Theory and skill training usually take place on campus under the supervision
of an education representative (teacher/lecturer). During clinical placement
in different healthcare settings such as on hospital wards and in primary
healthcare, the students continue VBSC skill training under the supervision of
their assigned supervisors or other healthcare staff.
The students in this thesis participated in VBSC training in their second
semester out of six. Prior to practical skill training at clinical skills
laboratories, the students were urged to study the national guidelines.
Practical training was then carried out in groups of 8-12 students by several
university lecturers. The students initially practiced on dummy arms, after
which they had the opportunity to proceed on to practicing on each other. The
Materials and methods
13
training sessions lasted approximately 180 minutes. All utensils used, such as
vacutainer tubes, needles, test requests and labels, were the same or similar
to the types used in the clinical settings, to which the students were assigned
later on. After the VBSC training and prior to clinical placement, students had
the opportunity to further practice by signing up for training sessions with
amanuensis, or by practicing on their own at the clinical skills laboratory.
Finally, VBSC was examined, both theoretically and the actual skill. In order
to pass, the students must demonstrate VBSC in line with the guidelines, as
well as deliver correct answers to questions. The students always had online
access to the guidelines, provided they had necessary devices and access to the
Internet.
Participants and settings
In study I, participants were drawn from a sample consisting of 298
phlebotomists from 70 PCHs (response rate 93%). Only participants from
PHCs with a minimum of five respondents were included. The final sample
consisted of 164 phlebotomists (registered and enrolled nurses) from 25
PHCs. The PHCs were situated in two county councils in northern Sweden, in
both urban and rural areas, and were either privately or publicly run. Small
PHCs were significantly more often located in rural areas than large (p<.001)1.
Participant and, PHC characteristics are presented in Table 2 and 3.
1 Result from additional analysis
Materials and methods
14
Table 3. Primary healthcare centre characteristics study I
Variable
PCHs location, county n (%) County A 13 (52)
County B 12 (48)
PHC’s location urban/rural setting n (%) Urban* 12 (48)
Rural* 13 (52)
Governance n (%) Federally run 23 (92) Privately run 2 (8)
Size of PHC n (%) (tot # employees) Small (<20) 6 (24)
Medium (20-34) 11 (44)
Large (>34) 8 (32)
*: Defined by the Swedish National Rural Development Agency (2007) Urban= settings with >3000 inhabitants Rural= settings with <3000 inhabitants
Table 2. Participant characteristics, study I
Variable
Sex n (%)
Female 155 (95) Male 9 (5)
Occupation n (%)
Enrolled nurses 64 (39) Registered nurses 100 (61)
Years in profession m (Sd) 19.6 (10.1) Md (Q1; Q3) 20 (11;27)
Participants’ years employed at worksite n (%) < 5 years 53 (34) 5-15 years 52 (34) >15 years 49 (32)
Participants’ workplace county n (%) County A 93 (57) County B 71 (43)
Participants’ workplace size n (%) (tot # employees) Small (<20) 38 (23) Medium (20-34) 70 (43) Large (>34) 56 (34)
Participants’ workplace setting urban/rural n (%) Urban* 78 (48) Rural* 86 (52)
Governance n (%) Federally run 154 (94) Privately run 10 (6)
VBSC frequency n (%)
Every workday 89 (56) Every week or less 70 (44)
Age years
m (Sd) 49.1 (9.34) Md (Q1;Q3) 50 (43;56) *: Defined by the Swedish National Rural Development Agency (2007) Urban= settings with >3000 inhabitants Rural= settings with <3000 inhabitants
Materials and methods
15
Study II included a sample of 101 nursing students out of 178 possible
(response rate 57%) in their penultimate (5th) and final (6th) semesters,
attending both campus and web-based education programmes at a medium
sized Swedish university. They were mostly women (86%) and attending the
campus based programme (68%). The median age was 26 years (min 22, max
49). The majority (n=64, 64%) had no formal healthcare education prior to
university studies.
In study III, 305 university nursing students out of 411 possible (response rate
74%), were included. The students attended their 2nd, 4th, and 6th semester
(out of six) at a campus based programme at the same medium sized Swedish
university described above (II). The median age was 23 years (min 19, max
47). The majority (n=164, 57%) had no formal healthcare education prior to
university studies.
In study IV, a purposive sample of 26 nursing students (21 women, 5 men)
attending their final (6th) semester at the same medium sized Swedish
university described above (II) was used. The median age was 25.5 years (min
22, max 50).
A summary of participant background characteristics in study II-IV is
presented in table 4.
Table 4. Background characteristics participants study II - IV
Characteristics Study II Study III Study IV
n=101 n=305 n=26
Age (years)
m (Sd) 28.5 (6.84) 24.9 (4.87) 26.6 (5.41) Md (Q1;Q3) 26 (24;30) 23 (22;26) 25.5 (24;27)
Sex n (%)
p Female (%) 87 (86) 251 (83) 21 (81) p Male (%) 14 (14) 52 (17) 5 (19)
Semester n (%)
2nd camp – 107 (35) – 4th camp – 82 (27) – 5th web 32 (32) non existing non existing
5th camp 42 (41) – – 6th camp 27 (27) 116 (38) 26
Former healthcare work experience n (%) – 79 (60) –
Former healthcare education n (%) 36 (36) 122 (43) –
Non-existing: No available web-based students at the time of data collection
Materials and methods
16
Data collection and analysis
Study I
Data collection and instruments
Data were collected between November 2006 and January 2007 by one of the
research team members. Permission to perform the study was obtained by the
head of each unit. Each head also provided the research team with a list of all
available VBSC staff, their professional status, sex and working hours. The
coded questionnaires were delivered by postal mail to each PHC, where an
assigned staff member assisted in the distribution and collection of the
questionnaires. Each questionnaire was accompanied by an information letter
describing the purpose of the study together with the information that
participation was voluntary, with the right to withdraw at any point without
giving a reason why. The participants who chose to participate completed a
paper version of the questionnaire, which was considered informed consent.
After having completed the questionnaire, the participants were asked to put
it in an anonymous reply envelope, seal it, and hand it in to the staff member
responsible for collecting the questionnaires. Completed surveys were then
returned by postal mail to the research team. A reminder mail was sent after
2-4 weeks.
The Venous Blood Specimen Questionnaire (VBSQ), developed within
the project, shows acceptable face and content validity (Bölenius, Brulin,
Grankvist, Lindkvist, & Söderberg, 2012; Wallin et al., 2008) and reliability
(Bölenius et al., 2012).The VBSQ consists of 13 questions addressing VBSC
practices out of which 9 have underlying items. In total, respondents are asked
to consider 41 items/statements based on the national VBSC guidelines
(Handbook for Healthcare) as recommended by the Swedish National Board
of Health and Welfare. Each item is responded on a 4-point Likert scale
(‘never’, ‘seldom’, ‘often’, and ‘always’) where usually only one alternative is
considered correct. It was clearly pointed out that the participants should
mark alternatives in line what they usually did, not how the task was supposed
to be done according to guidelines. The questionnaire was complemented with
questions on background data.
Analysis
Multilevel logistic regression analysis considers the individual probability of a
specific action to also be statistically dependent on the contextual
circumstances (cluster) of the subjects, in this study, the workplaces (PHCs).
Moreover, that the dependence on the context needs to be accounted for to
obtain correct regression estimates (Rodriguez & Goldman, 1995), The
median odds ratio (MOR) (Larsen & Merlo, 2005; Larsen, Petersen, Budtz-
Materials and methods
17
Jorgensen, & Endahl, 2000) quantifies cluster variance, and is directly
comparable with the commonly used odds ratio (OR) (Merlo et al., 2006). In
this study, the MOR represents the median value of the odds ratio between a
PHC at the highest probability of adherence and a PHC at the lowest
probability of adherence. Thus, the MOR demonstrates the extent to which
the phlebotomist’s probability of adherence to VBSC guidelines is determined
by workplace affiliation. For example, if the MOR is equal to 1, there are no
differences between workplaces in the probability of guideline adherence. If
the MOR is equal to 1.5, the heterogeneity between workplaces increases by
1.5 times the individual odds of adhering to guidelines. Hence, if a participant
would change workplace and start working at a workplace with higher
probability of adherence, the chance for the individual to adhere to guidelines
will (in median) increase 1.5 times. The intra class correlation (ICC),
calculated according to the latent variable method, represents the percentage
of reporting in line with guidelines accounted for by the cluster (PHC) level
(Merlo et al., 2006).
Prior to statistical analysis, data were dichotomised into correct/incorrect
procedure, with only one alternative out of four considered to be correct.
Dependent variables were Always ask patient to state name and national
registration number (item 1), Never neglect asking for ID with the reason
“known” (item 2), Always compare patient ID with ID on test request (item
3), and Always make sure test request and test tube label ID numbers are
consistent (item 4). In order to quantify the variation between different
workplaces, three models with independent variables were created for each
item to apply to our data: 1) The empty model containing estimates only for
the workplace-level (PHC) random intercept of adherence with VBSC
guidelines and intended to act as a baseline for comparison with the full and
adjusted models that take into account both fixed variables and random effect
terms. 2) The full model containing both workplace (PHC size, urban/rural
setting, and governance) and individual (age, sex, occupation, years of
employment at site, and VBSC frequency) characteristics. 3) The adjusted
model was created in a manual stepwise backward elimination procedure
starting with the full model and then deleting variables one at a time until only
significant variables were left. ICC and MOR were used for evaluation of
random effects for the different models.
Furthermore, to investigate the impact of individual and workplace
characteristics on the outcome reporting in accordance with guidelines, ORs
and their corresponding 95% confidence intervals (CI) from the logistic
regression analyses were used. Descriptive statistics were assessed by using
SPSS (IBM SPSS Statistics 20, IBM, New York, US). The R-package ‘eha’ was
used to estimate the multilevel logistic regression models.
Materials and methods
18
Study II
Data collection and instruments
Study II was carried out with data collected in 2007 using an adjusted version
of the VBSQ (described under study I) to fit students, and complemented with
questions on background data, such as sex, age, educational background,
semester, and campus. All students in the 5th and 6th semester attending the
campus education programme were invited personally in class by two of the
research team. Before handing out the questionnaires, the students were
informed of their voluntary participation, and that they could withdraw at any
time without declaring any reason and, furthermore, that data would only be
presented at group level. Those who chose to participate filled in the
questionnaire and handed it to the researchers. Participation was considered
informed consent. The 5th semester students attending the web-based
programme were invited and informed about the study in writing on the
learning platform used for their education. The web-students completed an
exactly worded online version. The survey was both delivered and collected
anonymously by a test tool within the platform. It was clearly pointed out that
the participants should mark alternatives in line what they usually did, not
how the task was supposed to be done according to guidelines.
Analysis
Multiple logistic regression analyses were used to study associations between
the background characteristics and reported practices. Categorical variables
were compared by using chi-squared test or Fisher’s exact test, continuous
data were presented using mean and standard deviation. Only variables with
a p-value <0.05 in the univariate analyses were included in the multiple
logistic regression. Dependent variables were 1) labelling the test tube before
entering the patient's room, 2) comparing patient ID with the test
request/tube label, and 3) identifying the patient by checking his/her
healthcare card. Independent variables for the respective models were
campus-/web-based, semester, other healthcare education prior to present
university studies, age, and sex. To measure association, ORs and their
corresponding 95% CI were used. Statistics were assessed by using SPSS (IBM
SPSS Statistics 20, IBM, New York, US).
Materials and methods
19
Study III
Data collection and instruments
Study III was carried out with data collected in June 2012. All students in the
2nd, 4th, and 6th semester were invited personally in class at campus by KN.
They were informed about the purpose of the survey both orally and in writing
and, furthermore, that only the researcher (KN) had access to the codes and
the corresponding names, that data would only be presented at group level,
and finally that they could withdraw from the study at any time without giving
a reason why. Finally, the assurance that participation would not affect their
education or assessments in any way. Students who chose to participate gave
their written informed consent prior to filling in the surveys. Completed
surveys were collected by KN or, in a few cases, by a lecturer who handed them
to KN. An e-mail was sent to students who were absent from class at the time
of invitation.
In addition to demographic questions on sex, age, semester, previous
healthcare work experience, previous healthcare education, and most recent
clinical placement, the questionnaire consisted of a compilation of items from
five existing tools:
VBSQ (described under study I). Adjusted version to fit students.
Capability beliefs regarding EBP scale (Wallin, Boström, & Gustavsson,
2012) based on the conceptualisation of EBP by Sackett (2000) and examined
for item-content validity by Boström, Ehrenberg, Gustavsson, and Wallin
(2009). The scale consists of six items developed for use in the Longitudinal
Analysis of Nursing Education (LANE) study. Participants respond on a scale
from 0 (cannot) to 10 (definitely can). A mean across all six items is then
computed for each individual, reflecting the individual’s overall score on the
scale. Hence, the possible value of the mean score ranges from 0 to 10.
Research use (RU), measured as three single items, originally developed by
Estabrooks (1999), translated and adapted for use in a Swedish context by
Rudman, Omne-Pontén, Wallin, and Gustavsson (2010). Participants
respond on a scale from 1 (never) to 5 (on almost every shift).
Capability beliefs regarding academic ability scale developed for use
in the LANE study by Rudman et al. (2010). The questionnaire consists of six
items responded on a scale from 0 (cannot) to 10 (definitely can). A mean
across all six items is then computed for each individual, reflecting the
individual’s overall score on the scale. Hence, the possible value of the mean
score ranges from 0 to 10.
Materials and methods
20
Social climate section from the General Nordic Questionnaire for
Psychological and Social Factors at Work (QPSNordic) (Dallner, 2000)
developed to measure psychological, social, and organisational conditions in
the analysis of work organisations. The social climate section consists of three
items, and participants respond to statements on a 5-point Likert scale from 1
(to a very low extent or not at all) to 5 (very much). A mean across all three
items is then computed for each individual, reflecting the individual’s overall
score on the scale. Hence, the possible value of the mean score ranges from 1
to 5.
The students who chose to participate completed a paper version of the
questionnaire. It was clearly pointed out that the participants should mark
alternatives in line what they usually did, not how the task was supposed to be
done according to guidelines.
Analysis
Multiple logistic regressions were used to estimate the association between
VBSC adherence regarding patient ID procedure and test-request handling as
the dependent variables, and age, sex, healthcare work experience prior to
present university studies, semester, VBSC frequency, perceived value of
VBSC practice at clinical placement, research use at clinical placement,
capability beliefs regarding EBP, capability beliefs regarding academic ability,
and perceived social climate at clinical placement as the independent
variables. Prior to statistical analysis, ordinal data from the VBSQ were
dichotomised into correct (1) or incorrect procedure (0), with only one
alternative out of four considered to be correct. Comparisons between groups
were made by chi-square test for categorical variables and by Student’s t-test
for continuous variables. Continuous data were presented as means and
standard deviations, and categorical data were presented as absolute numbers
and percentages. Of the associations in the univariate analyses, only variables
with a p-value <0.05 were included in the multiple logistic regression.
Associations are presented as ORs and their corresponding 95% CI. Statistics
were assessed by using SPSS (IBM SPSS Statistics 20, IBM, New York, US).
Study IV
Data collection
Focus groups were used for data collection. According to Morgan (1996) a
focus group is ‘a research technique that collects data through group
interaction on a topic determined by the researcher’. The method has
increasingly been used in healthcare research as a useful and effective
mechanism in which a group jointly constructs meaning about a topic (Shaha,
Wenzel, & Hill, 2011), and is considered suitable for nursing research
Materials and methods
21
(Jayasekara, 2012). Several studies (Jonsén, Melender, & Hilli, 2013; Kenny,
2002; Sharif & Masoumi, 2005) have also used focus groups within nursing
education to embrace the students’ perspective and experiences of teaching
and learning. This study used focus group discussions to shed light on
quantitative data already collected and analysed (cf Krueger & Casey, 2014).
Five focus group interviews, four with both men and women and one with
solely women, were carried out on campus by the first author (moderator) and
the last author (assistant moderator) in September 2015 using an interview
guide developed and agreed on in the research team. The moderator gave
information on the purpose of the focus group, and the students had the
opportunity to ask questions. The assistant moderator made sure that the
subject had been fully covered, and that all participants had the opportunity
to speak. First, two questions about the learning process in clinical skills
laboratories and during clinical placement were asked: “Could you please tell
me what it was like to learn how to perform VBSC at the clinical skills
laboratory?” and “What was it like to continue practicing VBSC during clinical
placement?”. Thereafter, the core question/statement, which the students
were asked to reflect on, was presented: “Earlier research has found senior
nursing students increasingly deviate from VBSC guidelines with every
completed semester. Can you please reflect on this finding?” If necessary,
additional probing questions were asked in order to have the students clarify
or elaborate what they were sharing.
Analysis
Qualitative content analysis was used to analyse the interviews. The method
aims to systematically analyse written or verbal communication (Krippendorff,
2004). The interpretation focuses on differences and similarities between
various parts of the text, resulting in the organisation of data into categories or
themes. The audio recorded focus group interviews were transcribed verbatim
by the first author and subjected to qualitative content analysis. The process
of analysis was inspired by the steps described by Graneheim and Lundman
(2004). First, the text was read through a couple of times to gain an
understanding of the whole. Second, units of text addressing the aim of the
study were chosen, condensed and coded. Third, codes with similar content
were grouped into subthemes, which were further abstracted into themes.
After further analysis, an overall theme emerged capturing the essence of the
data.
The first steps of the analysis were undertaken using the R-package ‘RQDA’.
Materials and methods
22
Ethical considerations
Studies I, II, and III took a quantitative approach using questionnaires. The
information letters contained information about the studies, the assurance of
confidentiality, as well as the information that participation was voluntary,
and that they had the right to withdraw at any point without giving reasons
why. In order to avoid identification of individuals, the results were presented
at group level. In study I and II, the decision to fill in the questionnaire and
thus participate was considered accepted informed consent. In study III,
participants gave their written informed consent to participate. The students
participating in study II and III were informed that participation would not
affect their education in any way.
In study IV, focus group interviews were used for data collection. Prospective
participants were informed both orally and in writing, and those who chose to
participate gave their written informed consent. There is always a risk that
participants do not feel comfortable in a focus group and hence remain silent,
which may influence the result. With the ambition that all participants should
feel involved, the interviewer paid attention to this and addressed these
participants directly, when/if the situation arose. The fact that participants
were free to choose any group may have influenced the results, since there is
a risk that they chose a group with friends who share the same values, a
scenario that may have interfered with the variation sought.
The studies in this thesis conform to the principles in the Declaration of
Helsinki (World Medical Association, 2013). All studies were approved by the
Regional Ethical Review Board in Umeå with the following references: Study
I and II (Dnr 06-104M), study III and IV (Dnr 2013-270-31M).
Results
23
Results
The presentation of results is based on the aims and findings from each study.
First, I describe the impact of workplace affiliation together with specific
workplace and individual factors on VBSC guideline practice adherence
(Study I). Second, I describe VBSC guideline practice adherence, together with
factors associated with guideline adherence among university nursing
students (Studies II and III), and third, perceptions on deviations from VBSC
practice guideline adherence among university nursing students (Study IV).
The impact of workplace affiliation on venous blood specimen collection guideline adherence
In study I, the aim was to explore to what extent workplace affiliation explains
variation of self-reported adherence to VBSC practices regarding patient ID
and test request handling, taking into consideration fixed PHC workplace and
individual phlebotomist characteristics.
The main finding in study I was that workplace affiliation largely explains
variance in levels of adherence to VBSC practice guidelines in three out of four
guideline practices. The results from the adjusted models, taking also
individual and workplace factors into consideration, show that the MOR
values were between 3.20 and 4.21 regarding three out of four of the selected
guidelines practices, namely: Always ask patient to state name and national
registration number (item 1), Never neglect asking for ID with the reason
‘known’ (item 2), and Always make sure test request and test tube label ID
numbers are consistent (item 4). Furthermore, they show that workplace
affiliation significantly explained 31 % to 41 % of the total variation between
workplaces in self-reported adherence regarding these items (Table 5).
The adjusted models revealed a few associations between guideline adherence
and individual and workplace characteristics in item 1, 2 and 3:
Regarding the guideline practice to Always ask patient to state name and
national registration number (item 1), adherence was reported by 53%. Staff
working at large PHCs were more likely to adhere to guideline practice (OR:
9.32) than staff at small PHCs.
Regarding guideline practice to Never neglect asking for ID with the reason
‘known’ (item 2), adherence was reported by 38%. Staff working at medium
or large PHCs were more likely to report adherence to guidelines (OR: 9.87
and OR: 28.36 respectively) than staff working at small PHCs.
Results
24
Table 5 Measures of association between primary healthcare centre, and participant characteristics and the outcomes in primary healthcare centres in two counties in northern Sweden, 2007, adjusted for age, occupation, setting (urban/rural), and governance (private/public). Bold characters represent significant (p <0.05) values.
Measures of workplace variation
1. Always ask patient to state name and national registration number
2. Never neglect asking for ID with the reason ”known”
3. Always compare patient ID with ID on test request
4. Always make sure test request and test tube label ID numbers are consistent
Adjusted model*
MOR 3.49 3.20 1.93 4.21
Sd (SE), p 1.31 (0.38), <0.001 1.22 (0.41), 0.002 0.69 (0.42), 0.14 1.51 (0.42) <0.001
ICC 0.34 0.31 0.13 0.41
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Sex
Male 1 Female 5.42 (1.12-26.20)
Employed at worksite (yrs)
>15 1 1 5-15 1.39 (0.44-4.36) 2.27 (0.80-6.39) <5 4.66 (1.41-15.39) 3.35 (1.09-10.23)
PHC size (tot # staff)
Small, ≤19 1 1 Medium 20-34 5.06 (0.87-29.47) 9.87 (1.36-71.86) Large, ≥35 9.32 (1.35-64.30) 28.36 (3.06-262.75)
VBSC frequency
Every day 1 ≤ Every week 2.76 (1.04-7.29)
Adjusted model*: random intercept of adherence with VBSC guidelines in combination with remaining significant variables after stepwise backward elimination procedure MOR: median odds ratio; CI: confidence interval; OR: odds ratio: ID: identification; EN: enrolled nurse; RN: registered nurse. Urban/Rural: defined by the Swedish National Rural Development Agency (2007)
Results
25
Staff employed less than five years at the site were more likely to report in
accordance with guideline (OR: 4.66) compared to staff employed more than
15 years. Finally, staff who performed VBSC every week or less often were
more likely (OR: 2.76) to report in line with guidelines compared to staff who
drew blood on a daily basis.
Regarding Always compare patient ID with ID on test request (item 3),
adherence was reported by 79%. Females were found to be more likely to
report in line with guidelines (OR: 5.42) than men, and staff employed less
than five years at site more likely to report guideline adherence (OR: 3.35)
than staff employed more than 15 years (Table 5).
Regarding Always make sure test request and test tube label ID numbers are
consistent (item 4), adherence was reported by 59%. No significant
associations were found
Adherence to venous blood specimen collection practice guidelines and factors associated with adherence among nursing students
The main finding was that the students were more likely to deviate from VBSC
practice guidelines with every completed semester (II, III). Associations were
found between reported practice and type of education programme (II),
individual factors such as capability beliefs (III), as well as perceived social
climate at the clinical placement, and also the extent of research use during
clinical practice (III). Moreover, the desire to blend in was perceived to
influence practice (IV).
Table 6 Multiple logistic regression analyses of factors associated with guideline adherence in study II between participant characteristics and the outcomes among nursing students (n = 101) at a medium sized Swedish university, 2007, adjusted for age and sex. Significant values (p <0.05) in bold.
Patient identification Test tube labelling Never checking patient ID by using health care card
Always comparing name and national registration number with test request and label
Never label the test tube before entering the patient’s room
OR (95% CI) OR (95% CI)
Programme sem
Camp 6th 1.0 1.0 1.0
Web 5th 11.32 (2.42-52.97) 41.81 (4.30-406.22) 0.49 (0.08-2.88)
Camp 5th 3.87 (1.18-12.69) 2.32 (0.67-8.07) 0.50 (0.10-2.50)
Former HCE
No 1.0 1.0 1.0
Yes 1.16 (0.36-3.73) 0.49 (0.15-1.66) 0.34 (0.09-1.31)
Camp: campus based programme; Web: web-based programme; sem: semester; HCE: healthcare education;
Results
26
Regarding the guideline practice to Always ask patient to state name and
national registration number, the majority of the students in both study I and
II (81% and 82%, respectively) reported in line with guidelines. However, the
analyses of semester groups revealed decreasing levels of adherence over time
(II, III). In the multiple logistic regression analysis, 2nd semester students
were more likely to report guideline adherence (OR: 3.16) than 6th semester
students (III), as were students reporting research use ‘on at least half of the
work shifts’ (OR: 2.38) compared to those reporting ‘never/on a few shifts’
(III) (Table 7).
Regarding the guideline practice to Always compare patient ID with ID on
test request, the majority of the students reported in line with guidelines; 74%
(II) and 80% (III). Analyses of semester groups, however, revealed decreasing
levels of adherence over time (II, III). The multiple logistic regression analyses
showed that 5th semester students attending the web-based programme (II)
were more likely to report in line with guidelines (OR: 41.81) than 6th semester
campus students2 (Table 6). Students with previous healthcare work
2 Result from additional analysis
Table 7. Multiple logistic regression analyses of factors associated with guideline adherence in study III between participant characteristics and the outcomes among nursing students (n = 305) at a medium sized Swedish university, 2012, adjusted for age, sex, and VBSC frequency. Significant values (p <0.05) in bold.
Patient identification and test request handling
Always ask the patient to state name and national registration number
Always check coherence between patient ID and ID on test request
OR (95% CI) OR (95% CI)
Semester
6th 1.0 1.0
4th 1.82 (0.74-4.45) 3.19 (1.43-7.10)
2th 3.16 (1.27-7.87) 6.37 (2.61-15.51)
Former healthcare work experience
No 1.0
Yes 0.49 (0.15-1.66)
VBSC is highly valued at clinical placement site
Totally disagree 1
Agree to some extent 1.74 (0.77-3.92)
Totally agree 1.63 (0.59-4.52)
Students’ RU at clinical placement site
Never/on a few shifts 1
On at least 50% of the shifts 2.38 (1.12-5.06)
Cap beliefs of EBP scale 1.24 (1.01-1.54)
Cap beliefs of academic ability scale 1.19 (0.95-1.48) 1.34 (1.06-1.69)
Social climate scale 1.27 (0.87-1.85)
RU: research use; EBP: evidence-based; Cap: capability
Results
27
experience (III) were less likely (OR: 0.49) to report in line with guidelines
than those without. Furthermore, 2nd and 4th semester students were more
likely to report guideline adherence (OR: 6.37 and 3.19, respectively)
compared to 6th semester students (III) (Table 7). Finally, students reporting
higher capability beliefs of EBP and academic ability were more likely (OR:
1.24 and 1.34, respectively) to report in line with guidelines (Table 7).
Regarding the guideline practice to Never check patient ID using the patient’s
healthcare card, adherence levels decreased with semester (II). In the
multiple logistic regression analysis, both 5th semester students attending the
web-based programme and 5th semester students attending the campus
programme were more likely to report in line with guidelines (OR: 11.32 and
3.87, respectively) compared with 6th semester campus students (II) (Table 6).
Regarding the guideline practice to Always label the test tube alongside the
patient prior to phlebotomy only 2% of the students in study II reported
guideline adherence. No significant associations with independent variables
were found.
Students’ perceptions about deviations (IV) from, for instance correct ID
procedures such as always asking patients to state name and national
registration number, revealed reasons of, for example the impact of
experiences at clinical placements. Students observed staff occasionally skip
the procedure giving the reason ‘I know this patient – I have cared for him for
days’. As students were worried about their assessments, they sometimes did
not want to risk it by commenting on suboptimal practice, although they were
well aware of the incorrectness. This emerged in the theme Being in a position
of dependency, and furthermore in the theme Striving to fit in since students
talked about the fact that it was very important to be a group member, even
though it may effect practice and as a consequence also guideline adherence.
Table 8. Overall theme, theme, and subthemes from analyses in study IV
Overall theme Striving to blend in and simultaneously follow guidelines
Themes Being in a position of dependency Striving to fit in
Questioning guideline content
Subthemes
Feeling u
nco
mfo
rtable
abo
ut co
mm
entin
g on
p
ractical perfo
rman
ce
Follo
win
g role m
od
els
Emb
racing d
ifferent
cultu
res
Ad
aptin
g to b
e liked
Perceivin
g guid
elines
interferin
g with
the
prevailin
g truth
Bein
g un
certain ab
ou
t gu
idelin
e usefu
lness
Results
28
It was perceived that doing as everyone else, and thereby fitting in, was
sometimes more important than adhering to guidelines, although they strived
to follow them. Furthermore, the students reflected on the fact that after
repeatedly having asked for name and national registration number, you often
know it by heart. In this regard, the students eventually sometimes asked
themselves if it is reasonable to always ask for ID, especially when you have
met and cared for a certain patient for days. This was shown in the theme
Questioning guideline content. Students’ reflection on the decreasing levels of
adherence with every completed semester was formulated in the overall theme
Striving to blend in and simultaneously follow guidelines (Table 8).
Summary of studies regarding ‘Always ask the patient to state name and national registration number’
In an attempt to gain an overview regarding guideline adherence to one of the
most important practices ‘Always ask the patient to state name and national
registration number’ (Kalra, 2004; Lippi et al., 2009), the results3 from all
four studies were merged and presented in figure 2. The overview
demonstrates decreasing levels of adherence with time within the nursing
programme (II, III). Furthermore, it also shows a continuing decrease after
graduation (I). The experiences of a need to ‘blend in’ with practice
performance was revealed among final semester students in study IV. The
blue arrow indicating the phenomenon of ‘blending in’ fades after graduation,
which indicates the absence of data among participants in study I.
3 In part, result from additional analysis
Figure 2.
Guideline adherence regarding ‘Always ask the patient to state name and national registration number’ from education start to graduation, and post-graduation at <5 years of employment, 5-15 years of employment, and >15 years of employment
Discussion
29
Discussion
The overall aim of this thesis was to explore adherence to, and factors
influencing, venous blood specimen collection guideline practices among
university nursing students and healthcare staff. The main findings show that
nursing students tend to increasingly deviate from VBSC guideline adherence
with every completed semester (II, III), which partly can be understood
through the findings in study IV, where students perceived an unspoken
demand to blend in into the culture at the clinical practice setting in order to
be liked. The different cultures at clinical settings might originate from
different agendas regarding VBSC procedures, which the findings in study I
indicates, to which both students (II, III) and employees (I) at the setting
adapt (Figure 2).
In order to deepen the understanding of the findings in this thesis, the results
will be discussed in relation to a model of professionalisation (Figure 3)
adapted after Weidman et al. (2001). According to Weidman et al. (2001),
socialisation among students refers to the process through which individuals
gain knowledge, skills, and values needed for a successful entry into a
professional career, in which advanced levels of specialised knowledge and
skills are required. The process is nonlinear, which implies that socialisation
processes are dynamic and ongoing, without a definite beginning or end, and
present both on campus (university institutional culture), as well as at clinical
placements (clinical institutional culture), which is illustrated in figure 3. The
ellipses have broken lines to point out the permeable and shifting boundaries
among the concepts in the model. The adapted model (Figure 3) covers the
professional socialisation process of nursing students as well as those newly
graduated and comprises knowledge, skills, and values needed for a successful
entry into a professional career of an RN. The prospective student possess
individual abilities and capabilities (predisposition) prior to entering the
university context. At university, they are subjected to new cultures, to
socialisation processes, changing both their personal and professional
communities, with new friends and registered nurses as supervisors in clinics.
Both in the university institutional culture, as well as in the clinical
institutional culture, knowledge acquisition is expected and sought. Thus,
nursing students are socialised into both university contexts, as well as in to
the professional context which they are aiming at (cf Dimitriadou, Pizirtzidou,
& Lavdaniti, 2013). In the discussion below, the different aspects from the
professionalisation model will be highlighted in italics for clarifications.
Discussion
30
Patient identification practices
The results demonstrated decreasing levels of adherence regarding the vitally
important practice of ‘Always ask the patient to state name and national
registration number’ among nursing students throughout the programme (II,
III), and even beyond graduation (I) (Figure 2). Earlier studies have
demonstrated suboptimal levels of guideline adherence both among hospital
ward staff (52.5%-83%) (Melkie et al., 2014; Simundic et al., 2015; Wallin,
Söderberg, Van Guelpen, Brulin, & Grankvist, 2007), and among PHC staff
(54%) (Söderberg et al., 2010). Although, adherence to guidelines among the
nursing students was not total, it was found to 88% and 85%, respectively in
2nd and 4th semesters (III). The 5th semester did not contain clinical practice,
whereas the 2nd, 3rd, 4th, and 6th semester did. It is notable that there is a
substantial difference between the 4th semester levels of adherence and the 6th
semester, from 85% to 74% (Figure 2). As nursing students’ professional
communities include institutional cultures at universities/clinical settings
(Figure 3), students are subjected to socialisation processes both in the on
campus context, as well as in the clinical setting context (Bisholt, 2012;
Weidman et al., 2001). The awareness of guideline content might have faded
in favour of other tasks during theory periods in the 5th semester. When the
PROSPECTIVE NURSES
Background Predispositions
PROFESSIONAL COMMUNITIES Practitioners’ associations
Institutional culture
Clinical setting Organisation Guidelines
NURSING STUDENTS Institutional Socialisation culture processes
University Integration programme Interaction Learning
Knowledge acquisition
Socialisation processes
Integration Interaction Learning
PERSONAL COMMUNITIES
Family Friends
Knowledge acquisition
NEWLY GRADUATED NURSES
Figure 3. Model of nursing professionalisation adapted after Weidman, Twale, and Stein (2001), and inspired by Píšová (2013)
Discussion
31
students encounter clinical settings again after theory periods, and with the
perceived need to blend in (IV), they might have abandoned guideline
adherence in favour of the local agenda on how VBSC should be performed,
which occasionally is not in line with guidelines (Bölenius et al., 2013;
Söderberg et al., 2009; Wallin et al., 2007). This is in line with the findings in
Henderson, Cooke, Creedy, and Walker (2012) review revealing students to
adopt survival strategies such as ‘learning the rules’ and focusing on ‘fitting in’
to practice environment rather than adopting a critical reflective stance.
In study I, 53% reported guideline adherence regarding ‘Always ask the
patient to state name and national registration number’, which in itself is a
remarkably low proportion, and only 38% regarding ‘Never neglect asking for
patient ID with the reason ‘known’, which is even more remarkable.
Furthermore, the MOR values concerning the two items in the adjusted
model, 3.49 and 3.20, indicate that workplace affiliation have a substantial
influence on VBSC practice. Regarding ‘Never neglect…’, earlier findings
demonstrate suboptimal levels of guideline adherence among hospital ward
staff (54%) (Wallin et al., 2007), and PHC staff (41%) (Söderberg et al., 2010)
which is similar to our findings. Positive patient identification is undoubtedly
essential in all aspects of care, but failure to accurately identify patients during
blood sampling can lead to serious adverse events, in the worst scenario death
(Bolton‐Maggs, Wood, & Wiersum‐Osselton, 2015). Theoretically, nothing but
total adherence should be accepted, an unquestionable goal. However, as
Giuseppe Lippi et al. (2015) concluded; in order to achieve total quality, it is
necessary to look beyond analytical quality, and realise that a pre-analytical
culture is the key to promoting quality and disseminating worldwide. In this
regard, safe VBSC practice training at university may encourage guideline
adherence and promote a high quality pre-analytical culture. Students who
are well aware of guideline content and consequences of non-adherence and
also trained to keep to adherence, might in the long term positively influence
VBSC practice at their forthcoming workplaces and thereby reduce variations
in performance.
The literature demonstrates identification adverse events as the most serious,
and a substantial body of literature stresses the importance of improving
patient identification procedures to enhance patient safety (Bölenius, 2014;
Kaushik & Green, 2014; Kim, Dotson, Thomas, & Nelson, 2013; Lippi et al.,
2009; Salinas et al., 2013). Adherence to guidelines regarding ‘Always ask…’
should reasonably be accompanied by adherence to ‘Never neglect…’, since
they clearly have aspects in common. The participants in study I only asked
approximately every second patient to state name and national registration
number, and at the same time, they neglected to ask about 2 out of 3 patients
to state name and national registration number with the reason that they
‘knew’ them. Participants working at large PHCs were more likely to adhere to
Discussion
32
guidelines both regarding ‘Always ask…’ and ‘Never neglect…’ than staff
working at small PHCs (Table 5). Thus, larger PHCs seem to provide safe
identification practices to a higher extent compared to small. Small PCHs were
mostly situated in rural areas where people tend to know/know about each
other to a greater extent than in urban areas. In Desjarlais-deKlerk and
Wallace (2013) study on the doctor-patient interaction, it was demonstrated
that knowing patients outside the clinic seemed to change the nature of the
interaction, and, in turn, the doctor-patient relationship itself. Interactions
between rural doctors and their patients tended to be highly interpersonal,
often involving considerable socioemotional communication and relationship
building (Desjarlais-deKlerk & Wallace, 2013). It is reasonable to believe that
nurses and other healthcare staff working at rural PHCs in our study too were
involved in such relations. The relationships in rural areas, as described by
Desjarlais-deKlerk and Wallace (2013) may have been one reason for the staff
in study I, working at small PHCs and likely to be familiar with most patients
encountered at the PHC, to neglect asking for patient ID. In this regard,
students in study IV described how they eventually questioned the practice of
‘Always ask…’ when you have cared for a patient for several days. As a
consequence, they often remembered the patient’s name and even their
national registration number, and therefore sometimes abandoned guideline
practice.
Decreasing levels of adherence to guidelines were found also among
phlebotomy staff with years of employment at the site (I) (Figure 3). Thus,
students report, if not total adherence, higher levels regarding ‘Always ask…’
compared to the healthcare staff in study I. To conclude, staff working at small
PHCs in rural areas were more likely to deviate from identification guidelines.
This might be interpreted as hazardous practice, however, as long as the
sample is associated with the correct information, practice is safe. The main
issue is whether it is good enough to know the patients name and national
registration number by heart, or, if it should be mandatory praxis to always
ask for ID even if you are certain about name and national registration
number. The only reasonable answer taken for granted is of course ‘no, you
always have to ask for patient ID’. Our results indicate that guideline practice
may decrease with time, therefore, a simple and safe solution might be to
never abandon safe patient ID practice. Moreover, the patient might feel safer
and more secure if staff ask for ID, hence, also an incitement for asking. Staff
employed less than five years at the site were more likely to adhere to ‘Never
neglect…’ than staff employed more than 15 years. To my knowledge, there are
no previous results on VBSC practices to compare this finding. However,
regarding the advice to smokers for decreasing tobacco use, and in opposite to
our findings, Hung, Leidig, and Shelley (2014) found no significant
associations with years employed at the primary healthcare clinic and
Discussion
33
frequency of advice given. To speculate, the staff employed less than five years
at site had not observed the VBSC routines of their peers for as long as those
employed longer. Neither had they encountered as many patients as those
employed more than 15 years. Hence, the longer staff are employed, the more
opportunities to familiarize themselves with the patients. As a consequence,
and in line with our findings, staff employed shorter time might be less likely
to abandon the guideline practice to ‘Never neglect…’, as they have had less
opportunities to get acquainted with the patients.
To conclude, the issue of enhancing patient identification practices is still very
topical and will certainly remain so. Reasons why staff deviate from patient
identification guidelines are probably several. However, as previously
mentioned, it is reasonable to assume that one is the opinion that it is
considered not needed, and even embarrassing when the patient is familiar.
However, it is not the ‘I know the patient’ part that is critical for VBSC safety,
it is the assurance that test tubes are affiliated with correct test request and
labelled with the correct ID (cf Lippi et al., 2011).
Test tube labelling and test request handling practices
In study II, an extremely low proportion, only 2%, of the students reported
guideline adherence regarding labelling of test tubes, which is similar to the
levels of adherence demonstrated among hospital ward staff (2.4%-4%)
(Wallin et al., 2007; Wallin et al., 2008; Wallin et al., 2010). The Swedish
guidelines suggested that test tubes should to be labelled prior to phlebotomy.
This has been questioned, for example by Hawkins (2011) who argues that
labelling directly after collection must be considered acceptable practice.
Considering international protocols, the practice to label after collection is
actually not in opposition to guidelines (CLSI, 2010; World Health
Organization, 2010), as long as tubes are labelled alongside the patient, it is
considered safe practice. As data on whether the students labelled the tubes
directly after collection were not available, checking this possibility was not
present in this study. However, to speculate, it is reasonable to assume that a
vast majority of the students labelled the tubes afterwards, which hence may
be considered acceptable practice according to current international standard.
Labelling tubes prior to collection may cause additional work if the
phlebotomy is not successful, since the label must then be removed and
attached to another tube. This might have been one reason why the students
most likely labelled the tubes afterwards. In order to successfully enhance
VBSC guideline adherence regarding both labelling and other practices, the
guidelines must be worded succinctly and concisely with the minimum of
bullet points. The current guidelines are extensive with numerous practice
steps, and hence often difficult to remember (Simundic et al., 2015).
Discussion
34
Therefore, efforts to reduce them to a minimum should be initiated with the
mantra ‘less is more’.
Guideline adherence regarding ensuring the coherence between patient ID
and test request, and the coherence between test request and test tube labels
were demonstrated by the vast majority, 74%-80% (I, II, III). Earlier findings
demonstrate 90% of the hospital ward staff (Wallin et al., 2008), and 68%-
80% of the PHC staff (Söderberg et al., 2009) to report guideline adherence.
Since the two are closely linked, safe practice in one depends on the other, by
means of the ‘wrong blood in tube’ risk. The expression ‘wrong blood in the
tube’ addresses the issue of mislabelling test tubes and includes when blood is
taken from the wrong patient and is labelled with the intended patient’s details
(in other words ‘miscollected’) or when blood is taken from the intended
patient, but labelled with another patient’s details (in other words
‘mislabelled’) (Bolton-Maggs, 2013). Earlier findings demonstrate the
incident of mislabelled tubes 0,3-0.5% (Hill et al., 2010; Quillen & Murphy,
2006). The human factor is considered as problematic considering safe test
tube labelling. Hence, with the mission to enhance patient safety by reducing
specimen identification errors, technical solutions (Snyder et al., 2012;
Strobel, 2013) as well as campaigns and education (Cottrell et al., 2013) have
been proposed. There are no data on ‘wrong blood in tube’ in this thesis.
To conclude, the students in study II reported similar levels of guideline
adherence, as those of staff at hospital wards and PHCs. In the light of the
model (Figure 3) adapted after Weidman et al. (2001), this finding might
originate from the students’ interaction with practitioners, such as
supervisors, in the professional communities at the clinical setting during
clinical placement (clinical institutional culture). After having acquired
sufficient cognitive knowledge (knowledge acquisition in the university
institutional culture), the student must acquire knowledge such as normative
expectations associated with the professional role sought (knowledge
acquisition in clinical institutional culture). However, guideline content has
been questioned and international guidelines are contradictive. To address
this issue, the mantra ‘the right test at the right time on the right patient’ (cf
Thomas, 2014) (preferably with the addition ‘tube labelled alongside patient’),
is now expressed to meet the demands of reducing adverse events, and should
definitely be used in skill training sessions at the clinical skills laboratories,
and also stressed at clinical settings.
Discussion
35
Incongruence between training on campus and training at the clinical setting
Students in this thesis experienced incongruence between training at clinical
skills laboratories on campus and the practice at clinical placements (IV), a
finding in line with other studies among both nursing students (Sharif &
Masoumi, 2005; Zarshenas et al., 2014) and newly graduated nurses (Feng &
Tsai, 2012). Clinical settings aim to offer nursing students the opportunity to
improve their clinical skills, to socialise within a clinical context, to develop
relationships with experienced nurses, and ultimately to promote the transfer
of knowledge from the classroom into the clinical setting (Charleston &
Happell, 2005; Severinsson & Sand, 2010). It is therefore reasonable to
assume that encountering new contexts, as described above, influences
students in several directions. The students in study IV described the
dependency situation during clinical placement as problematic, since they
occasionally deviated from guidelines and copied the supervisor’s routines
(master-apprentice relationship), just to please him/her although they knew
it was incorrect. Hence, the norms among the students may have been
influenced by their supervisors’ stated or unstated opinions. Merely observing
repeated sessions of suboptimal VBSC procedures might have influenced the
students to increasingly deviate from guideline adherence in favour of the
practices at the clinical setting (cf Levett-Jones & Lathlean, 2009).
The students described how they followed role models, which meant learning
experiences from both good and bad examples (cf Felstead & Springett, 2016)
balancing the two, so as not to risk their assessment. This finding indicates
that students perceive the supervisor’s role as evaluative more than teaching
(cf Sharif & Masoumi, 2005), which might restrict the learning process in
clinical practice (Bisholt, Ohlsson, Engstrom, Johansson, & Gustafsson,
2014). Such scenarios do not facilitate knowledge translation of best
practice/EBP, since the prevailing truth reigns without being questioned.
However, it might be extremely difficult to differentiate between
organisational socialisation and students’ learning processes. The student’s
knowledge acquisition is most likely a result of a combination of both
students’ predispositions and the participation and interaction in social or
professional communities (Figure 3). In this respect, it is possible that both
students and newcomers adapted to the behaviours of a charismatic staff who
had taken, or been given a leader role. The students in study IV confirm this
by expressing “You tend to do as your supervisor does” and “You adapt to the
practices at the setting”. Hence the overall theme in study IV, ‘Striving to blend
in and simultaneously follow guidelines’, might describe, not only the
perceptions of the students during training, but also the situation in work life
situation.
Discussion
36
The phenomenon of incongruence, commonly known as the theory-practice
gap, implies that theoretical knowledge, such as research findings, does not
automatically make it into practice, where it should be implemented (Upton,
1999). In line with those findings, the overall results in this thesis indicate that
there is a gap between VBSC guidelines and the VBSC performance in clinical
settings among both nursing students and healthcare staff. The ambition to
close these gaps is often referred to as knowledge translation, ‘the methods for
closing the gaps from knowledge to practice’ (Straus, Tetroe, & Graham,
2009), which nicely captures the circumstances within healthcare.
Bridging the gap
Development of knowledge translation interventions should include context
factors (Wallin, 2009) and the use of theories (Grol, Bosch, Hulscher, Eccles,
& Wensing, 2007), also context-specific theories (Estabrooks, Thompson,
Lovely, & Hofmeyer, 2006), since context has been shown to be associated
with levels of research use and adverse events (Cummings, Estabrooks,
Midodzi, Wallin, & Hayduk, 2007). The overall findings in this thesis indicate
that context may have a substantial impact on VBSC behaviour (I, III, IV). In
this regard, efforts to enhance guideline adherence by targeting not only
individuals, but also contextual factors are warranted (cf Jacobs, Weiner, &
Bunger, 2014). Bölenius et al. (2013) revealed significant improvements in
certain VBSC practices after a large scale education intervention programme
among phlebotomy staff. Other studies suggest a combination of education,
practical skill training and audio feedback for sustainable change (Ista, van
Dijk, & van Achterberg, 2013). In this respect, interventions should target
components such as enhancing staffs’ familiarity with guideline content,
increasing the awareness of the importance of adhering to guidelines, but also
the consequences of non-adherence (Hammerling, 2012). In the univariate
analysis in study III, students who reported total or partial agreement with the
statement ‘VBSC is highly valuated at clinical placement’ were more likely to
‘Always ask…’ than those reporting total disagreement. It is reasonable to
believe that those students were subjected to a positive institutional culture
when they interacted with the professional community, its practitioners and
acquainted knowledge by learning and integration. Successfully adopted
interventions among staff within a unit or organisation will entail these
individuals becoming key stakeholders and acting as agents for successful
implementation and sustainability. Therefore, it is important to encourage
suitable individuals to act as internal implementation leaders, but so too
should individuals in leader positions. Without organisational support,
successful and sustainable implementation is unlikely. Individuals who might
act as ‘local champions’ (Abrahamson, Fox, & Doebbeling, 2012) are – in order
to be successful – those with natural positive qualities, who peers look up to
Discussion
37
as role models. In addition, such trust in an employee probably increases the
sense of responsibility which may have an additional positive effect on the
implementation process among the peers.
Repetitive training has been shown to increase adherence over the course of
studies (Scheithauer et al., 2012), which may be achieved by using a model for
skill training, as suggested by Bölenius (2014). ‘The Model of Practical Skill
Performance’ (Bjørk & Kirkevold, 2000) further developed by constructing an
instrumental supplement (Nielsen, Sommer, Larsen, & Bjørk, 2013) aims to
facilitate knowledge translation among nursing students, and is therefore a
suitable alternative. The involvement of students in the development of skills
learning material might also be an option. The nursing faculty staff may hold
the key to what students should learn based on curricula and national
guidelines, and the students may contribute by describing how their learning
could be most constructively achieved (Haraldseid, Friberg, & Aase, 2016).
However, as indicated in this thesis, the contextual impact on practice may be
substantial, also other initiatives must be taken into consideration in
supporting students to adhere to guidelines. This is challenging as the context
where students spend a substantial amount of time (during clinical
placement) is beyond the reach of educator impact. Thus, the responsibility to
enhance guideline adherence within the clinical settings undoubtedly lies with
the healthcare organisation itself. Nevertheless, as a possible path for
sustainability among students, educators should act in order to empower
students to keep up adherence. If students are aware of guideline content and,
even more importantly, consequences of non-adherence, they have good
prospects for success. Also, as students possess an up to date knowledge, the
mere presence of students at the setting may enhance guideline adherence
among staff, as demonstrated in Lymer, Richt, and Isaksson (2004) study –
an optimal scenario. However, this implies that the staff at the settings
welcome the students’ knowledge and are willing to reflect on these issues.
According to Bandura (1997), a self-efficacy belief is ’the belief in one’s
capabilities to organise and execute the courses of action required to manage
prospective situations’. The findings in this thesis indicate that individual
factors, such as self-efficacy (capability beliefs regarding EBP and academic
ability), and research use at the clinical placement influenced guideline
adherence (III). In study III, we assessed associations between EBP capability
beliefs as well as capability beliefs regarding academic ability (both concepts
based on Bandura’s work), and the dependent variables. In the univariate
analyses, students reporting higher capability beliefs were more likely to act
in line with guideline adherence. These findings indicate that educators
should target actions to enhance capability beliefs among students, in order
to encourage students to adhere to EBP, such as guidelines regardless of what
is the prevailing truth at the clinical placement. Thus, if educators manages to
Discussion
38
empower students, and strengthen their self-efficacy, which is obviously a
very delicate matter, they may become strong enough to keep to VBSC
guideline adherence.
In order to successfully target the issue of strengthen students’ self-efficacy,
the CCARE model of clinical supervision (communication, collaboration,
application, reflection, and evaluation) (Baxter, 2007), might be feasible. It
focuses on the individuals, both within the culture of academe and the clinical
setting. The purpose of this model is to enable both educators from the
educational culture and practicing nurses from the clinical environment to
understand the importance of relationships, behaviours and attitudes and
how they are necessary to bridge the gap between the two cultures thereby
decreasing the theory/practice gap. Hence, in line with the need to engage
individual staff to act as internal implementation leaders when planning for
interventions, there is also a need to engage suitable educator representatives
as well as practicing nurses from the clinical settings in a collaborative team
to enhance CPG practice among nursing students. Success is probably
achieved only if stakeholders from both sides collaborate, which is a goal to
aim for in the mission to enhance patient safety.
Nursing and medical curricula have been revealed to lack the expression
‘patient safety’ (Attree, Cooke, & Wakefield, 2008; Wakefield et al., 2005). In
a more recent review, the concept was still not necessarily obvious (Tella et al.,
2013). The university programme curriculum for the students in this thesis
did not contain the expression ‘patient safety’, nor ‘safety’ or ‘safe’, an
unfortunate fact according to the literature. Furthermore, the expression
‘evidence’ was not present, nor ‘evidence-based’. To my knowledge, no or very
few studies have examined the relationship between ‘patient safety’ in
education curricula and student practice performance, which should provoke
further studies. Also studies using an observational design might be an
alternative approach where nursing students are observed objectively by an
observer to determine their VBSC guideline adherence (cf Ahlin, 2015). In
addition, further research should be conducted to explore the phenomenon of
influence of healthcare staff on nursing students in the clinical settings.
Finally, as the power of habit has been proven to be strong (Lally & Gardner,
2013; Limayem, Hirt, & Cheung, 2007) and VBSC routines most likely are
habitual, the collaboration with scientists within the habitual research area
might shed further light on this issue.
Methodological considerations
39
Methodological considerations
Design
The use of several scientific theoretical approaches will shed further light on
the research topic. The interviews in this thesis (Study IV) explored the results
in studies II-III. In studies I-III, a cross-sectional design was used. One
limitation with the cross sectional design is that causality cannot be
established as data concerning information concerning outcome and exposure
are collected at the same time. Still, cross-sectional studies can give valuable
information about ‘dose-response’ relationships, however, the results must be
interpreted with some caution.
Participants
Regarding the phlebotomists at the PHCs, all staff performing VBSC and on
duty at each PHC were invited. Regarding the nursing students, all students
in the included semesters were invited. Both staff at PHCs and nursing
students perform VBSC and were therefore suitable for the research question.
Based on a staff population as well as a student population in northern part of
Sweden, it is reasonable to assume that the results in this thesis are
generalizable to both PHC staff as well as nursing students in a Swedish
contexts. Reasons therefore, are the homogeneity in Swedish PHCs, they are
all organised in a similar way with the same professions employed. Similarly,
when considering nursing programmes, the organisation of nursing
programmes is set by the government, and hence similar across Swedish
universities.
The most prominent limitation in study I was the relatively small cluster size,
where some clusters included only five participants. This fact indicates the risk
for a type 1 error. During the analysis process, we conducted several analyses
with both larger (10 participants/PHC) and smaller (2 participants/PHC)
cluster size. The MOR values were found to be similar to those reported in this
study I. However, large confidence intervals indicate small sample size, which
indicate that the result should be interpreted with caution.
The response rate in study II (57%) is close to the rule of thumb (60%), and
therefore considered acceptable (Johnson & Wislar, 2012). However, it is still
a cause for concern as it indicates that there is a potential problem with non-
response bias. Since no data to perform drop-out analysis were available, it
was not possible to deduce the nature of any potential non-response bias. To
compare, the response rate in study III was 74%. When comparing the results
in study II and III, there are similarities, hence results from both studies may
be trusted under the circumstances. Nevertheless, as no drop-out analysis was
Methodological considerations
40
performed in either of the studies, the results in both study II and III should
be interpreted with caution.
In study IV, the included students were all in their final semester, at the same
university, and attending the same university nursing programme. The
students may have signed up to participate in a specific group together with
friends, which may have contributed to less variation. A commonly suggested
adequate group size ranges between six and ten participants, but with a
minimum of three. Large groups place less responsibility on participants, but
also provide less opportunities to talk. The group sizes in our study ranged
from three to seven. As the amount of interest in the research topic influences
the willingness to talk (Morgan & Krueger, 1998), smaller groups may also be
valuable (Morgan & Bottorff, 2010). Regarding the number of focus groups,
three to five groups are usually sufficient (Morgan & Krueger, 1998). We
conducted five focus group interviews.
Data collection
In this thesis, data were collected using self-reported questionnaires and focus
group interviews.
Self-reported questionnaires are beneficial in order to collect data from a large
sample in order to use statistical analyses. However, the self-reported
questions can be under- or overestimated due to different circumstances
influencing the responders at that time (Polit & Beck, 2004). In addition,
collecting data during a period of eight years will probably be influenced by
changes over time. During this period of time, a large scale education
programme on VBSC practices was launched in county A, which may have
influenced the results in this thesis by improving adherence among
participants working in county A. Moreover, students performing their
clinical placements in county A, who may have been positively influenced by
staff working at settings in county A.
Using the group dynamics in focus groups to generate deeper and richer data
is beneficial compared to the data obtained from individual interviews, if
aiming at clarifying experiences and perceptions in common, and related to a
specific topic (Rabiee, 2004). It is reasonable to assume nursing students in
the final semester are suitable to reflect on nursing students’ VBSC practice
guideline adherence during training.
Questionnaires
Questionnaires were used for data collection in study I-III. As demonstrated
in the review by Adams, Soumerai, Lomas, and Ross-Degnan (1999), there is
always a risk for exceeded self-reported adherence rates compared to the
Methodological considerations
41
objective rates, resulting in elicit self-presentation tendencies such as high
levels of adherence (i.e. the tendency to present oneself in a positive light).
The term validity refers to how well an instrument measures what it intends
to measure (Polit & Beck, 2004). The instruments used in this thesis showed
acceptable validity as follow:
The VSBQ, showing acceptable validity (Bölenius et al., 2012; Wallin, 2008),
and reliability (Bölenius et al., 2012) was used to assess the dependent
variables. In study I and II, an early version of the questionnaire was used,
hence before it was tested for validity and reliability, which may have
influenced the results. Independent variables were assessed using background
variables (I, II, III), as well as scales and single items (III). The psychometric
analyses of the Capability beliefs regarding EBP scale support a one-
dimension scale and show promising properties of concurrent validity (Wallin
et al., 2012). The measure of students’ extent of Research use has
demonstrated evidence for content validity (Estabrooks, 1999), as well as
supporting validity evidence for single-item measures (Squires et al., 2011).
Regarding the Capability beliefs regarding academic ability scale,
information on validity and reliability is not available. However, it has been
used in the LANE study (Rudman et al., 2010), consist of items adapted from
Bandura's self-efficacy scales (Bandura, 2006), and is similarly constructed as
the previously described Capability beliefs regarding EBP scale. Finally, the
Social climate section from the General Nordic Questionnaire for
Psychological and Social Factors at Work (QPSNordic) which has demon-
strated sufficient construct validity as well as criterion validity (Dallner,
2000).
Focus group interviews
In study IV, focus group interviews were used for data collection to explore
experiences and perceptions in a nursing student group. A focus group should
consist of homogeneous participants who have in common something central
to the issue to be discussed, and it should provide the participants with the
freedom to express thoughts, feelings and behaviours candidly (Morrison &
Peoples, 1999). One risk with focus group interviews is that some participants
may dominate the discussion, which might bias the findings. The assistant
moderator’s role was therefore to ensure that all participants had the
opportunity to talk, and that the subject had been fully covered (cf Morgan &
Krueger, 1998). There were no differences in data obtained from the smaller
Conclusions
42
groups compared to the larger. Hence, also small groups gave rich interviews.
Smaller groups also provide a beneficial intimate interaction (cf Toner, 2009).
To ensure trustworthiness of interpretations within qualitative content
analysis, arguments for the most probable interpretations should be
presented. In this regard, findings should be presented in a way that allows
the reader to look for alternative interpretations (Graneheim & Lundman,
2004). The concept of trustworthiness also includes the question of
transferability, which refers to ‘the extent to which the findings can be
transferred to other settings or groups’ (Polit &Beck, 2004, s.734). With the
ambition to facilitate transferability, a description of the context, selection and
characteristics of participants, data collection and process of analysis was
presented in this thesis. KNs personal history might have influenced the
interpretation process (cf Graneheim & Lundman, 2004).
Although KN did not encounter any of the students in educational contexts
during the study period, the mere fact that KN has a teacher position at the
department may have influenced the studies (II, III, IV).
Conclusions
Guideline adherence within healthcare is crucial in achieving and maintaining
patient safety. The findings in this thesis indicate that both students and
healthcare staff were subjected to professional socialisation processes in
clinical contexts. Earlier findings demonstrating suboptimal adherence to
VBSC guidelines among healthcare staff were confirmed in the results,
together with the new findings of decreasing adherence among nursing
students as well. Hence, guideline adherence in general needs to be improved.
In this thesis, individual factors among nursing students were found to be
associated with guideline adherence, e.g. capability beliefs about EPB and
capability beliefs about academic ability. In this regard, nursing educators
need to target these factors by providing students with tools and strengthening
their capability beliefs to be able to stand up for, and defend patient safety
issues and the use of CPGs. However, education representatives do not have
sufficient impact on clinical practice and social environment, and therefore
the responsibility of enhancing patient safety through the use of CPG and
safety cultures formally lies with the healthcare organisations. Still, with the
mission to bridge the theory-practice gap, the CCARE model of clinical
supervision might be useful, since it focuses on the individuals both within the
culture of academe and the clinical setting and facilitates collaboration
between the two groups of stakeholders.
The power of habit is known to be strong. For example, hand hygiene routines
have been suggested to be learnt behaviour (Larson, Early, Cloonan, Sugrue,
Conclusions
43
& Parides, 2000; Whitby, McLaws, & Ross, 2006), which implies that it is
carried out without much thoughts about the procedure. With respect for all
the studies performed in this area for decades, and still are, together with the
fact that the issue of hand hygiene guidelines has been around for almost two
centuries, it is reasonable to assume that habits are very difficult to change.
From the behavioural point of view, VBSC procedures too may become, at
least in part, an unconscious behaviour once they are implemented into
everyday life at the clinical setting. Therefore, the habitual part of VBSC
practice needs to be further targeted.
Conclusions
44
Postface
When I entered the world of education, I became aware of my shortcomings
regarding VBSC practices. I did not intentionally put patients at risk by
deviating from guidelines, and I am also convinced that no other healthcare
staff do either. It is probably a case of performing routines without actually
considering them very often, you just do them the way you always have, or the
way your peers do – it becomes a habit.
Being part of the research world, has meant a tremendous amount to me, and
as I have made this journey my views on many things have changed. I am
grateful for having had the opportunity, and am looking forward to continuing
my journey.
Tack
45
Tack Tiden som doktorand är över. Det har varit en fantastisk tid med både upp- och nedförsbackar, men den sammanfattande känslan så här i slutet är ändå; det har varit toppen! Jag vill här ta tillfället i akt och framföra ett speciellt tack till ett antal som har varit speciellt viktiga under den här tiden:
Provtagande personal och studenter som gjort det möjligt att genomföra studierna. Utan er medverkan hade det här inte varit möjligt.
Medicinska fakulteten, Stiftelsen JC Kempes Minnes Stipendiefond, Anna Cederbergs Stiftelse.
Mina fantastiska handledare; Christine, Kjell och Christina för att ni tog med mig ’på tåget’ och lät mig uppleva den här resan, för utomordentlig och pedagogisk handledning, för roliga och givande diskussioner.
Christine, för din skarpa blick som inte undgår något, för din uppriktighet och tydlighet i sättet att handleda.
Kjell, för din ämneskunskap, dina fantastiska kommentarer som är ’mitt i prick’, för dina språkliga tips kring ’less is more’ och ’pang på rödbetan’.
Christina, för din närvaro både rumsligt och bildlikt i arbetet med avhandlingen, för din noggrannhet i skrivandet där inget lämnas åt slumpen.
Marie, för fantastiskt stöd i statistiska spörsmål och för roliga och intressanta diskussioner om statistik och en hel massa annat.
Karin B, för samarbete i projektet, för medförfattarskap, för intressanta och givande diskussioner kring vårt gemensamma ämne.
Gunilla, min examinator, för att du alltid funnits till hands med vägledning och kloka ord.
Terry, för hjälp med insamling av enkäter.
Johan, för medförfattarskap i två studier.
Runda-bords-gänget, för alla ämnesdiskussioner, men också för trevliga after work sessions.
Alla härliga doktorand- och andra kollegor, som har varierat under vägs gång. Jag vill speciellt nämna kamraterna i kursen ’Psykometri inom hälso-vetenskaperna’; Anna-Clara, Elisabeth och Åsa. Tack för allt skoj, alla middagar och fika i samband med kursträffar i Lund och Göteborg. Dessutom ressällskapet till EDCNS konferens i Österrikiska Graz, med sina fantastiska byggnader och sin kulinariska mångfald; Elisabeth och Karin. Tack för trevlig och lärorik samvaro, på konferensen men också till fots i stadens vimmel.
Tack
46
Ingagreta och sedermera Peter, som har hållit ordning på alla dokument som förknippas med den här typen av studier.
Mina kollegor och fikarumskamrater i Örnsköldsvik. Tack för all samvaro både innan och under doktorandtiden, för alla stunder runt fikabordet och alla samtal. Ni har varit min bas och kommer så att förbli.
Jerry, min samåkningskompis, som har lyssnat på mina funderingar till och från jobbet, och som har gjort det möjligt att arbeta på udda tider.
Att genomföra fyra års heltidsstudier kräver också ett rejält mått med tålamod och stöd av andra i ens närhet. Utan det hade den här avhandlingen aldrig kommit till. Jag tänker på mina min familj och mina vänner.
Vänner, det är ovärderligt att ha er att umgås med. Ni finns där i alla livets skiften, även om man själv är “frånvarande”. Ni frågar, uppmuntrar och stöttar, ni gör livet roligt och värdefullt. Jag är så oerhört tacksam och lyckligt lottad som har er – tack för alla positiva tillrop under den här tiden. Nu är det färdigsytt!
Mina svägerskor och svågrar med familjer, mina svärföräldrar. Tack för gemenskap och för ert alltid närvarande stöd i smått och stort.
Mamma Ulla, som alltid har trott på, stöttat och uppmuntrat mig. Tack för ditt ovärderliga stöd under hela mitt liv.
Mina barn; Jenny, Daniel och Linnea. Ni är mitt allt!
Slutligen, min make Sven-Göran. Utan ditt totala stöd hade jag inte klarat av arbetet på samma sätt. Tack för middagar som stått färdiga, men framför allt, tack för att du ger mig utrymmet att göra det jag brinner för.
References
47
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