adherence to venous blood specimen collection practice...

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.

http://www.g-i-n.net/

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


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


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


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


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


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-


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.


18

Study II


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).


19

Study III


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.


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


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’.


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


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


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


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

References

Abrahamson, K., Fox, R., & Doebbeling, B. (2012). Facilitators and Barriers to

Clinical Practice Guideline Use Among Nurses. American Journal Of

Nursing, 112(7), 26-35. doi:10.1097/01.NAJ.0000415957.46932.bf

Adams, A., Soumerai, S. B., Lomas, J., & Ross-Degnan, D. (1999). Evidence of

self-report bias in assessing adherence to guidelines. International

Journal for Quality in Health Care, 11(3), 187-192.

Ahlin, C. (2015). Utveckling av instrument och bedömning av

sjuksköterskestudenters kunskaper och färdigheter att genomföra

venös provtagning och insättning av perifer venkateter. (Licentiate),

Karolinska Institutet, Stockholm.

Ahlin, C., Löfmark, A., Klang-Söderkvist, B., & Johansson, E. (2012).

Development of instruments for assessment of knowledge and skills in

performing venepuncture and inserting peripheral venous catheters.

The journal of vascular access, 14(4), 364-372.

Ament, S. M., de Groot, J. J., Maessen, J. M., Dirksen, C. D., van der Weijden, T.,

& Kleijnen, J. (2015). Sustainability of professionals' adherence to

clinical practice guidelines in medical care: a systematic review. BMJ

Open, 5(12), e008073. doi:10.1136/bmjopen-2015-008073

Andel, C., Davidow, S. L., Hollander, M., & Moreno, D. A. (2012). The economics

of health care quality and medical errors. Journal of health care

finance, 39(1), 39-50.

Asch, S. M., Kerr, E. A., Keesey, J., Adams, J. L., Setodji, C. M., Malik, S., &

McGlynn, E. A. (2006). Who Is at Greatest Risk for Receiving Poor-

Quality Health Care? The New England Journal of Medicine, 354(11),

1147-1156. doi:10.1056/NEJMsa044464

Aspden, P., Corrigan, J., Wolcott, J., & Erickson, S. (2004). Institute of Medicine

(Committee on Data Standards for Patient Safety). Patient safety

achieving a new standard for care: Washington, DC: National

Academies Press.

Attree, M., Cooke, H., & Wakefield, A. (2008). Patient safety in an English pre-

registration nursing curriculum. Nurse Education in Practice, 8(4),

239-248. doi:10.1016/j.nepr.2007.09.003

Baines, R., Langelaan, M., de Bruijne, M., Spreeuwenberg, P., & Wagner, C.

(2015). How effective are patient safety initiatives? A retrospective

patient record review study of changes to patient safety over time. BMJ

Quality & Safety, 24(9), 561-571.

Bandura, A. (1997). Self-Efficacy in Changing Societies: Cambridge University

Press.

Bandura, A. (2006). Guide for constructing self-efficacy scales. Self-efficacy

beliefs of adolescents, 5(307-337).

References

48

Barofsky, I. (1978). Compliance, adherence and the therapeutic alliance: steps in

the development of self-care. Social Science & Medicine,, 12(5A), 369-

376.

Baxter, P. (2007). The CCARE model of clinical supervision: Bridging the

theory–practice gap. Nurse Education in Practice, 7(2), 103-111.

doi:10.1016/j.nepr.2006.06.007

Bisholt, B., Ohlsson, U., Engstrom, A. K., Johansson, A. S., & Gustafsson, M.

(2014). Nursing students' assessment of the learning environment in

different clinical settings. Nurse Education in Practice, 14(3), 304-310.

doi:10.1016/j.nepr.2013.11.005

Bisholt, B. K. (2012). The professional socialization of recently graduated nurses-

-experiences of an introduction program. Nurse Education Today,

32(3), 278-282. doi:10.1016/j.nedt.2011.04.001

Bjørk, I. T., & Kirkevold, M. (2000). From simplicity to complexity: developing a

model of practical skill performance in nursing. Journal Of Clinical

Nursing, 9(4), 620-631.

Bolton-Maggs (Ed), D. P., Watt, A., Thomas, D., & Cohen, H. (2013). The 2012

Annual SHOT Report. Retrieved from http://www.shotuk.org/wp-

content/uploads/SHOT-Annual-Report-20121.pdf

Bolton‐Maggs, P. H., Wood, E. M., & Wiersum‐Osselton, J. C. (2015). Wrong

blood in tube–potential for serious outcomes: can it be prevented?

British journal of haematology, 168(1), 3-13.

Bonini, P., Plebani, M., Ceriotti, F., & Rubboli, F. (2002). Errors in laboratory

medicine. Clinical Chemistry, 48(5), 691-698.

Boström, A.-M., Ehrenberg, A., Gustavsson, J. P., & Wallin, L. (2009).

Registered nurses' application of evidence-based practice: a national

survey. Journal of Evaluation in Clinical Practice, 15(6), 1159-1163.

doi:10.1111/j.1365-2753.2009.01316.x

Brilli, R. J., McClead Jr, R. E., Crandall, W. V., Stoverock, L., Berry, J. C.,

Wheeler, T. A., & Davis, J. T. (2013). A Comprehensive Patient Safety

Program Can Significantly Reduce Preventable Harm, Associated Costs,

and Hospital Mortality. The Journal of pediatrics, 163(6), 1638-1645.

doi:10.1016/j.jpeds.2013.06.031

Brouwers, M. C., Kho, M. E., Browman, G. P., Burgers, J. S., Cluzeau, F., Feder,

G., . . . Hanna, S. E. (2010). AGREE II: advancing guideline

development, reporting and evaluation in health care. Canadian

Medical Association Journal, 182(18), E839-E842.

Browman, G. P., Somerfield, M. R., Lyman, G. H., & Brouwers, M. C. (2015).

When is good, good enough? Methodological pragmatism for

sustainable guideline development. Implementation Science, 10(1), 28.

References

49

Burgers, J. S., Grol, R. P., Zaat, J. O., Spies, T. H., van der Bij, A. K., & Mokkink,

H. G. (2003). Characteristics of effective clinical guidelines for general

practice. British Journal of General Practice, 53(486), 15-19.

Bölenius, K. (2014). Improving venous blood specimen collection practices:

method development and evaluation of an educational intervention

program: utvärdering av ett utbildningsprogram. (PhD Thesis), Umeå

University, Umeå.

Bölenius, K., Brulin, C., Grankvist, K., Lindkvist, M., & Söderberg, J. (2012). A

content validated questionnaire for assessment of self reported venous

blood sampling practices. BMC research notes, 5, 39. doi:10.1186/1756-

0500-5-39

Bölenius, K., Lindkvist, M., Brulin, C., Grankvist, K., Nilsson, K., & Söderberg, J.

(2013). Impact of a large-scale educational intervention program on

venous blood specimen collection practices. BMC Health Services

Research, 13, 463. doi:10.1186/1472-6963-13-463

Bölenius, K., Söderberg, J., Hultdin, J., Lindkvist, M., Brulin, C., & Grankvist, K.

(2013). Minor improvement of venous blood specimen collection

practices in primary health care after a large-scale educational

intervention. Clinical Chemistry and Laboratory Medicine, 51(2), 303-

310. doi:10.1515/cclm-2012-0159

Cabana, M. D., Rand, C. S., Powe, N. R., Wu, A. W., Wilson, M. H., Abboud, P. A.,

& Rubin, H. R. (1999). Why Don't Physicians Follow Clinical Practice

Guidelines?: A Framework for Improvement. Journal of the American

Medical Association, 282(15), 1458 - 1465.

Carter, K. C. (1983). The etiology, concept, and prophylaxis of childbed fever

(Vol. 2): Univ of Wisconsin Press.

Chan, D. S. (2002). Associations between student learning outcomes from their

clinical placement and their perceptions of the social climate of the

clinical learning environment. International Journal of Nursing

Studies, 39(5), 517-524. doi: 10.1016/S0020-7489(01)00057-8

Charleston, R., & Happell, B. (2005). Coping with uncertainty within the

preceptorship experience: the perceptions of nursing students. Journal

of Psychiatric and Mental Health Nursing, 12(3), 303-309.

Cheung, K., Chan, C. K., Chang, M. Y., Chu, P. H., Fung, W. F., Kwan, K. C., . . .

Mak, H. M. (2015). Predictors for compliance of standard precautions

among nursing students. American Journal of Infection Control, 43(7),

729-734. doi:10.1016/j.ajic.2015.03.007

Cloutier, M. M., Hall, C. B., Wakefield, D. B., & Bailit, H. (2005). Use of asthma

guidelines by primary care providers to reduce hospitalizations and

emergency department visits in poor, minority, urban children. The

Journal of pediatrics, 146(5), 591-597.

References

50

CLSI. (2010). Clinical and laboratory standards institute: procedures for the

handling and processing of blood specimens, Approved Guideline6th

edition. 1-56238-650-6 (CLSI document H3-A6).

Cottrell, S., Watson, D., Eyre, T. A., Brunskill, S. J., Dorée, C., & Murphy, M. F.

(2013). Interventions to Reduce Wrong Blood in Tube Errors in

Transfusion: A Systematic Review. Transfusion Medicine Reviews,

27(4), 197-205. doi:10.1016/j.tmrv.2013.08.003

Cruz, J. P., Cruz, C. P., & Al-Otaibi, A. S. D. (2015). Gender differences in hand

hygiene among Saudi nursing students. International Journal of

Infection Control, 11(4).

Cummings, G. G., Estabrooks, C. A., Midodzi, W. K., Wallin, L., & Hayduk, L.

(2007). Influence of organizational characteristics and context on

research utilization. Nursing research, 56(4), 24-39.

doi:10.1097/01.NNR.0000280629.63654.95

Dallner, M. (2000). Validation of the General Nordic Questionnaire

(QPSNordic) for psychological and social factors at work: Nordic

Council of Ministers [Nordiska ministerrådet].

Department of Nursing, Umeå University. (2015).

Department of Veterans Affairs, U. (2016). TRM Glossary. Retrieved from

http://www.va.gov/TRM/TRMGlossaryPage.asp

Desjarlais-deKlerk, K., & Wallace, J. E. (2013). Instrumental and socioemotional

communications in doctor-patient interactions in urban and rural

clinics. BMC Health Services Research, 13(1), 261-268.

doi:10.1186/1472-6963-13-261

Dimitriadou, A., Pizirtzidou, E., & Lavdaniti, M. (2013). The Concept of

Socialization in Nursing Education. International Journal of Caring

Sciences, 6(3), 314.

Donaldson, L., & Philip, P. (2004). Patient safety: a global priority. Bulletin of

the World Health Organization, 82(12), 892-892.

Eccles, M. P., Grimshaw, J. M., Shekelle, P., Schünemann, H. J., & Woolf, S.

(2012). Developing clinical practice guidelines: target audiences,

identifying topics for guidelines, guideline group composition and

functioning and conflicts of interest. Implementation Science, 7(1), 1-8.

Eddy, D. M. (2011). The origins of evidence-based medicine--a personal

perspective. Virtual Mentor, 13(1), 55-60.

doi:10.1001/virtualmentor.2011.13.1.mhst1-1101

El-Rabbany, M., Zaghlol, N., Bhandari, M., & Azarpazhooh, A. (2015).

Prophylactic oral health procedures to prevent hospital-acquired and

ventilator-associated pneumonia: A systematic review. International

Journal of Nursing Studies, 52(1), 452-464.

doi:10.1016/j.ijnurstu.2014.07.010

References

51

Eom, J. S., Lee, M.-S., Chun, H.-K., Choi, H. J., Jung, S.-Y., Kim, Y.-S., . . . Lee, J.

S. (2014). The impact of a ventilator bundle on preventing ventilator-

associated pneumonia: a multicenter study. American Journal of

Infection Control, 42(1), 34-37. doi:10.1016/j.ajic.2013.06.023

Erasmus, V., Daha, T. J., Brug, H., Richardus, J. H., Behrendt, M. D., Vos, M. C.,

& van Beeck, E. F. (2010). Systematic review of studies on compliance

with hand hygiene guidelines in hospital care. Infection Control &

Hospital Epidemiology, 31(03), 283-294. doi:10.1086/650451

Estabrooks, C., Floyd, J., Scott-Findlay, S., O'Leary, K., & Gushta, M. (2003).

Individual determinants of research utilization: a systematic review.

Journal of Advanced Nursing, 43(5), 506 - 520.

Estabrooks, C. A. (1999). The conceptual structure of research utilization.

Research in Nursing & Health, 22(3), 203-216.

Estabrooks, C. A., Thompson, D. S., Lovely, J. J. E., & Hofmeyer, A. (2006). A

guide to knowledge translation theory. Journal of continuing education

in the health professions, 26(1), 25-36. doi:10.1002/chp.48

Felstead, I. S., & Springett, K. (2016). An exploration of role model influence on

adult nursing students' professional development: A phenomenological

research study. Nurse Education Today, 37, 66.

doi:10.1016/j.nedt.2015.11.014

Feng, R. f., & Tsai, Y. f. (2012). Socialisation of new graduate nurses to practising

nurses. Journal Of Clinical Nursing, 21(13‐14), 2064-2071.

doi:10.1111/j.1365-2702.2011.03992.x

Field, M. J., Lohr, K. N., Guidelines, C. C. P., & Medicine, I. (1992). Guidelines

for Clinical Practice: From Development to Use: National Academies

Press.

Forsman, H., Gustavsson, P., Ehrenberg, A., Rudman, A., & Wallin, L. (2009).

Research use in clinical practice – extent and patterns among nurses

one and three years postgraduation. Journal of Advanced Nursing,

65(6), 1195-1206. doi:10.1111/j.1365-2648.2008.04942.x

Forsman, H., Rudman, A., Gustavsson, P., Ehrenberg, A., & Wallin, L. (2012).

Nurses' research utilization two years after graduation--a national

survey of associated individual, organizational, and educational factors.

Implementation Science, 7, 46. doi:10.1186/1748-5908-7-46

Forsman, H., Wallin, L., Gustavsson, P., & Rudman, A. (2012). Nursing students'

intentions to use research as a predictor of use one year post graduation:

A prospective study. International Journal of Nursing Studies, 49(9),

1155-1164. doi:10.1016/j.ijnurstu.2012.04.002

Forsman, R. W. (1996). Why is the laboratory an afterthought for managed care

organizations? Clinical Chemistry, 42(5), 813-816.

References

52

Förberg, U., Wallin, L., Ehrenberg, A., Ygge, B.-M., Johansson, E., & Backheden,

M. (2014). Relationship Between Work Context and Adherence to a

Clinical Practice Guideline for Peripheral Venous Catheters Among

Registered Nurses in Pediatric Care. Worldviews on Evidence-Based

Nursing, 11(4), 227-239. doi:10.1111/wvn.12046

Gardner, C. L. (2015). Adherence: a concept analysis. International journal of

nursing knowledge, 26(2), 96-101. doi:10.1111/2047-3095.12046

Garrouste-Orgeas, M., Philippart, F., Bruel, C., Max, A., Lau, N., & Misset, B.

(2012). Overview of medical errors and adverse events. Annals of

intensive care, 2(1), 2. doi:10.1186/2110-5820-2-2

Graham, R., Mancher, M., Wolman, D. M., Greenfield, S., & Steinberg, E. (2011).

Institute of Medicine report, Clinical practice guielines we can trust.

Washington, DC: National Academies Press.

Graneheim, U., & Lundman, B. (2004). Qualitative content analysis in nursing

research: concepts, procedures and measures to achieve

trustworthiness. Nurse Education Today, 24, 105 - 112.

Green, S. F. (2013). The cost of poor blood specimen quality and errors in

preanalytical processes. Clinical Biochemistry, 46(13–14), 1175-1179.

doi:10.1016/j.clinbiochem.2013.06.001

Grissinger, M. (2014). Oops, Sorry, Wrong Patient!: A Patient Verification

Process is Needed Everywhere, Not Just at the Bedside. Pharmacy and

Therapeutics, 39(8), 535-537.

Grol, R., & Grimshaw, J. (2003). From best evidence to best practice: effective

implementation of change in patients' care. Lancet, 362(9391), 1225-

1230. doi:10.1016/s0140-6736(03)14546-1

Grol, R. P., Bosch, M. C., Hulscher, M. E., Eccles, M. P., & Wensing, M. (2007).

Planning and studying improvement in patient care: the use of

theoretical perspectives. Milbank Quarterly, 85(1), 93-138.

doi:10.1111/j.1468-0009.2007.00478.x

Groot, M., Wouden, J. M., Hell, E. A., & Nieweg, M. B. (2013). Evidence-based

practice for individuals or groups: let’s make a difference. Perspectives

on Medical Education, 2(4), 216-221. doi:10.1007/s40037-013-0071-2

Hallworth, M. J. (2011). The ‘70% claim’: what is the evidence base? Annals of

clinical biochemistry, 48(6), 487-488.

Hammerling, J. A. (2012). A review of medical errors in laboratory diagnostics

and where we are today. Laboratory Medicine, 43(2), 41-44.

Handbook for Healthcare (Producer). Phlebotomy Guidelines. Retrieved from

http://www.vardhandboken.se/Texter/Blodprov-venos-

provtagning/Oversikt/ (In Swedish)

References

53

Haraldseid, C., Friberg, F., & Aase, K. (2016). How can students contribute? A

qualitative study of active student involvement in development of

technological learning material for clinical skills training. BMC nursing,

15, 2. doi:10.1186/s12912-016-0125-y

Harrison, M. B., Légaré, F., Graham, I. D., & Fervers, B. (2010). Adapting clinical

practice guidelines to local context and assessing barriers to their use.

Canadian Medical Association Journal, 182(2), E78-E84.

doi:10.1503/cmaj.081232

Hawkins, R. (2012). Managing the pre- and post-analytical phases of the total

testing process. Annals of laboratory medicine, 32(1), 5-16.

doi:10.3343/alm.2012.32.1.5

Hawkins, R. C. (2011). Specimen labelling: before or after collection? Clinical

Chemistry and Laboratory Medicine, 49(12), 2119-2120.

doi:10.1515/CCLM.2011.737

Haynes, R. B., Taylor, D. W., & Sackett, D. L. (1979). Compliance in health care.

Henderson, A., Cooke, M., Creedy, D. K., & Walker, R. (2012). Nursing students'

perceptions of learning in practice environments: a review. Nurse

Education Today, 32(3), 299-302. doi:10.1016/j.nedt.2011.03.010

Hill, P. M., Mareiniss, D., Murphy, P., Gardner, H., Hsieh, Y.-H., Levy, F., &

Kelen, G. D. (2010). Significant reduction of laboratory specimen

labeling errors by implementation of an electronic ordering system

paired with a bar-code specimen labeling process. Annals of Emergency

Medicine, 56(6), 630-636. doi:10.1016/j.annemergmed.2010.05.028

Hung, D. Y., Leidig, R., & Shelley, D. R. (2014). What’s in a setting?: Influence of

organizational culture on provider adherence to clinical guidelines for

treating tobacco use. Health Care Management Review, 39(2), 154-163

doi:10.1097/HMR.0b013e3182914d11

Ista, E., van der Hoven, B., Kornelisse, R. F., van der Starre, C., Vos, M. C.,

Boersma, E., & Helder, O. K. (2016). Effectiveness of insertion and

maintenance bundles to prevent central-line-associated bloodstream

infections in critically ill patients of all ages: a systematic review and

meta-analysis. The Lancet Infectious Diseases.

Ista, E., van Dijk, M., & van Achterberg, T. (2013). Do implementation strategies

increase adherence to pain assessment in hospitals? A systematic

review. International Journal of Nursing Studies, 50(4), 552-568.

doi:http://dx.doi.org/10.1016/j.ijnurstu.2012.11.003

Jacobs, S. R., Weiner, B. J., & Bunger, A. C. (2014). Context matters: measuring

implementation climate among individuals and groups. Implementation

Science, 9, 46. doi:10.1186/1748-5908-9-46

Jayasekara, R. S. (2012). Focus groups in nursing research: methodological

perspectives. Nursing Outlook, 60(6), 411-416.

doi:10.1016/j.outlook.2012.02.001

References

54

Johnson, T. P., & Wislar, J. S. (2012). Response rates and nonresponse errors in

surveys. JAMA, 307(17), 1805-1806.

Jonsén, E., Melender, H.-L., & Hilli, Y. (2013). Finnish and Swedish nursing

students' experiences of their first clinical practice placement--a

qualitative study. Nurse Education Today, 33(3), 297-302.

doi:10.1016/j.nedt.2012.06.012

Kalra, J. (2004). Medical errors: impact on clinical laboratories and other critical

areas. Clinical Biochemistry, 37(12), 1052-1062.


Kalra, J. (2004). Medical errors: impact on clinical laboratories and other critical

areas. Clinical Biochemistry, 37(12), 1052-1062.


Kaneoka, A., Pisegna, J. M., Miloro, K. V., Lo, M., Saito, H., Riquelme, L. F., . . .

Langmore, S. E. (2015). Prevention of Healthcare-Associated

Pneumonia with Oral Care in Individuals Without Mechanical

Ventilation: A Systematic Review and Meta-Analysis of Randomized

Controlled Trials. Infection Control and Hospital Epidemiology, 36(8),

899-906. doi:10.1017/ice.2015.77

Kaushik, N., & Green, S. (2014). Pre-analytical errors: their impact and how to

minimize them. Medical Laboratory Observer, 46(5), 22, 24, 26.

Kennedy, P. J., Leathley, C. M., & Hughes, C. F. (2010). Clinical practice

variation. The Medical Journal of Australia, 193(8 Suppl), S97-99.

Kenny, A. (2002). Online learning: enhancing nurse education? Journal of

Advanced Nursing, 38(2), 127-135.

Kim, J. K., Dotson, B., Thomas, S., & Nelson, K. C. (2013). Standardized patient

identification and specimen labeling: a retrospective analysis on

improving patient safety. Journal of the American Academy of

Dermatology, 68(1), 53-56. doi:10.1016/j.jaad.2012.06.017

Klompas, M., Branson, R., Eichenwald, E. C., Greene, L. R., Howell, M. D., Lee,

G., . . . Speck, K. (2014). Strategies to prevent ventilator-associated

pneumonia in acute care hospitals: 2014 update. Infection Control &

Hospital Epidemiology, 35(S2), S133-S154.

Kochevar, L. K., & Yano, E. M. (2006). Understanding health care organization

needs and context. Beyond performance gaps. Journal of General

Internal Medicine, 21(S2), S25-S29. doi:10.1111/j.1525-

1497.2006.00359.x

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To err is human::

building a Safer Health System (Vol. 6): National Academies Press.

Krippendorff, K. (2004). Content Analysis: An Introduction to Its Methodology.

London: Sage Publications.

Krueger, R. A., & Casey, M. A. (2014). Focus groups: A practical guide for

applied research. London: Sage publications.

References

55

Lally, P., & Gardner, B. (2013). Promoting habit formation. Health Psychology

Review, 7(sup1), S137-S158.

Larsen, K., & Merlo, J. (2005). Appropriate assessment of neighborhood effects

on individual health: integrating random and fixed effects in multilevel

logistic regression. American Journal of Epidemiology, 161(1), 81-88.

doi:10.1093/aje/kwi017

Larsen, K., Petersen, J. H., Budtz-Jorgensen, E., & Endahl, L. (2000).

Interpreting parameters in the logistic regression model with random

effects. Biometrics, 56(3), 909-914.

Larson, E. L., Early, E., Cloonan, P., Sugrue, S., & Parides, M. (2000). An

organizational climate intervention associated with increased

handwashing and decreased nosocomial infections. Behavioral

Medicine, 26(1), 14-22. doi:10.1080/08964280009595749

Lee, D., Hong, K. S., & Kim, N. Y. (2014). Effects of hospital leadership,

organizational systems, and ESWOS on medical error reduction. Service

Business, 1-19.

Levett-Jones, T., & Lathlean, J. (2009). ‘Don’t rock the boat’: Nursing students’

experiences of conformity and compliance. Nurse Education Today,

29(3), 342-349. doi:10.1016/j.nedt.2008.10.009

Limayem, M., Hirt, S. G., & Cheung, C. (2007). How habit limits the predictive

power of intention: The case of information systems continuance. MIS

Quarterly, 31,705-737.

Lippi, G., Banfi, G., Church, S., Cornes, M., De Carli, G., Grankvist, K., . . .

Laboratory Medicine Working Group for Preanalytical, P. (2015).

Preanalytical quality improvement. In pursuit of harmony, on behalf of

European Federation for Clinical Chemistry and Laboratory Medicine

(EFLM) Working group for Preanalytical Phase (WG-PRE). Clinical

Chemistry and Laboratory Medicine , 53(3), 357-370.

doi:10.1515/cclm-2014-1051

Lippi, G., Blanckaert, N., Bonini, P., Green, S., Kitchen, S., Palicka, V., . . .

Plebani, M. (2009). Causes, consequences, detection, and prevention of

identification errors in laboratory diagnostics. Clinical Chemistry and

Laboratory Medicine, 47(2), 143-153. doi:10.1515/CCLM.2009.045

Lippi, G., & Guidi, G. C. (2007). Risk management in the preanalytical phase of

laboratory testing. Clinical Chemistry and Laboratory Medicine, 45(6),

720-727. doi:10.1515/CCLM.2007.167

Lippi, G., Mattiuzzi, C., & Favaloro, E. J. (2015). Pre-analytical variability and

quality of diagnostic testing. Looking at the moon and gazing beyond the

finger. New Zealand Journal of Medical Laboratory Science, 69(1), 4-8.

Lippi, G., Salvagno, G. L., Montagnana, M., Franchini, M., & Guidi, G. C. (2006).

Phlebotomy issues and quality improvement in results of laboratory

testing. Clinical laboratory, 52(5-6), 217-230.

References

56

Lippi, G., Sonntag, O., & Plebani, M. (2011). Appropriate labelling of blood

collection tubes: a step ahead towards patient's safety. Clinical


doi:10.1515/CCLM.2011.736

Luangasanatip, N., Hongsuwan, M., Limmathurotsakul, D., Lubell, Y., Lee, A. S.,

Harbarth, S., . . . Cooper, B. S. (2015). Comparative efficacy of

interventions to promote hand hygiene in hospital: systematic review

and network meta-analysis. BMJ, 351, h3728. doi:10.1136/bmj.h3728

Lundberg, G. D. (1981). Acting on significant laboratory results. Journal of the

American Medical Association, 245(17), 1762-1763.

Lymer, U. B., Richt, B., & Isaksson, B. (2004). Blood exposure: factors

promoting health care workers' compliance with guidelines in

connection with risk. Jorunal of Clinical Nursing, 13(5), 547-554.

doi:10.1111/j.1365-2702.2004.00897.x

Marschall, J., Mermel, L. A., Fakih, M., Hadaway, L., Kallen, A., O’Grady, N. P., .

. . Maragakis, L. L. (2014). Strategies to prevent central line-associated

bloodstream infections in acute care hospitals: 2014 update. Infection

Control & Hospital Epidemiology, 35(S2), 89-107.

McFadden, K. L., Henagan, S. C., & Gowen, C. R. (2009). The patient safety

chain: Transformational leadership's effect on patient safety culture,

initiatives, and outcomes. Journal of Operations Management, 27(5),

390-404. doi:10.1016/j.jom.2009.01.001

McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A., &

Kerr, E. A. (2003). The Quality of Health Care Delivered to Adults in the

United States. The New England Journal of Medicine, 348(26), 2635-

2645. doi:10.1056/NEJMsa022615

Meijers, J. M. M., Janssen, M. A. P., Cummings, G. G., Wallin, L., Estabrooks, C.

A., & Halfens, R. Y. G. (2006). Assessing the relationships between

contextual factors and research utilization in nursing: systematic

literature review. Journal of Advanced Nursing, 55(5), 622-635.

doi:10.1111/j.1365-2648.2006.03954.x

Melkie, M., Girma, A., & Tsalla, T. (2014). The practice of venous blood

collection among laboratory and non-laboratory professionals working

in Ethiopian Government Hospitals: a comparative study. BMC Health

Services Research, 14, 88. doi:10.1186/1472-6963-14-88

Merlo, J., Chaix, B., Ohlsson, H., Beckman, A., Johnell, K., Hjerpe, P., . . . Larsen,

K. (2006). A brief conceptual tutorial of multilevel analysis in social

epidemiology: using measures of clustering in multilevel logistic

regression to investigate contextual phenomena. Journal of

Epidemiology and Community Health, 60(4), 290-297.

doi:10.1136/jech.2004.029454

References

57

Miller, M. R., Griswold, M., Harris, J. M., 2nd, Yenokyan, G., Huskins, W. C.,

Moss, M., . . . Brilli, R. J. (2010). Decreasing PICU catheter-associated

bloodstream infections: NACHRI's quality transformation efforts.

Pediatrics, 125(2), 206-213. doi:10.1542/peds.2009-1382

Morello, R. T., Lowthian, J. A., Barker, A. L., McGinnes, R., Dunt, D., & Brand, C.

(2013). Strategies for improving patient safety culture in hospitals: a

systematic review. BMJ Quality & Safety, 22(1), 11-18.

doi:10.1136/bmjqs-2011-000582

Morgan, D. L. (1996). Focus groups. Annual Review of Sociology, 22, 129-152.

doi:DOI 10.1146/annurev.soc.22.1.129

Morgan, D. L., & Bottorff, J. L. (2010). Advancing Our Craft: Focus Group

Methods and Practice. Qualitative Health Research, 20(5), 579-581.

doi:10.1177/1049732310364625

Morgan, D. L., & Krueger, R. A. (1998). Planning focus groups (Vol. 2): Sage

Publications.

Morrison, R. S., & Peoples, L. (1999). Using focus group methodology in nursing.

The Journal of Continuing Education in Nursing, 30(2), 62-65.

Muething, S. E., Goudie, A., Schoettker, P. J., Donnelly, L. F., Goodfriend, M. A.,

Bracke, T. M., . . . Kotagal, U. R. (2012). Quality improvement initiative

to reduce serious safety events and improve patient safety culture.

Pediatrics, 130(2), e423-431. doi:10.1542/peds.2011-3566

Niederhauser, A., Lukas, C. V., Parker, V., Ayello, E. A., Zulkowski, K., &

Berlowitz, D. (2012). Comprehensive programs for preventing pressure

ulcers: a review of the literature. Advances in skin & wound care, 25(4),

167-188. doi:10.1097/01.ASW.0000413598.97566.d7

Nielsen, C., Sommer, I., Larsen, K., & Bjørk, I. T. (2013). Model of practical skill

performance as an instrument for supervision and formative

assessment. Nurse Education in Practice, 13(3), 176-180.

doi:10.1016/j.nepr.2012.08.014

Ogilvie, R. I., & Ruedy, J. (1967). Adverse drug reactions during hospitalization.

Canadian Medical Association Journal, 97(24), 1450-1457.

Pérez-Granda, M., Guembe, M., Rincón, C., Muñoz, P., & Bouza, E. (2015).

Effectiveness of a training program in compliance with

recommendations for venous lines care. BMC Infectious Diseases, 15(1),

296. doi:10.1186/s12879-015-1046-1

Píšová, M. (2013). Teacher professional socialisation: Objective determinants.

Orbis scholae, 7(2), 67-80.

Plebani, M. (2006). Errors in clinical laboratories or errors in laboratory

medicine? Clinical Chemical Laboratory Medicine, 44(6), 750-759.

doi:10.1515/CCLM.2006.123

Polit, D. F., & Beck, C. T. (2004). Nursing research: Principles and methods

(Seventh Edition ed.). Philadelphia: Lippincott Williams & Wilkins.

References

58

Public Health Agency of Sweden. (2013). Clean hands. Retrieved from

https://www.folkhalsomyndigheten.se/pagefiles/18543/Rena-hander-

Broschyr-Allt-du-vill-veta-om-handhygien.pdf

Qaseem, A., Forland, F., Macbeth, F., OllenschlÃĪger, G., Phillips, S., & van der

Wees, P. (2012). Guidelines International Network: toward

international standards for clinical practice guidelines. Annals of

internal medicine, 156(7), 525-531. doi:10.7326/0003-4819-156-7-

201204030-00009

Quillen, K., & Murphy, K. (2006). Quality improvement to decrease specimen

mislabeling in transfusion medicine. Archives of Pathology &

Laboratory Medicine Online 130(8), 1196-1198. doi:10.1043/1543-

2165(2006)130[1196:QITDSM]2.0.CO;2

Rabiee, F. (2004). Focus-group interview and data analysis. Proceedings of the

nutrition society, 63(4), 655-660.

Reason, J. (2000). Human error: models and management. British Medical

Journal, 320(7237), 768-770.

Reddy, M., Gill, S. S., & Rochon, P. A. (2006). Preventing pressure ulcers: a

systematic review. JAMA: The journal of the American Medical Association, 296(8), 974-984. doi:10.1001/jama.296.8.974

Reichel, W. (1965). Complications in the Care of Five Hundred Elderly

Hopsitalized Patients Journal of the American Geriatrics Society,

13(11), 973-981.

Robinson, J. H., Callister, L. C., Berry, J. A., & Dearing, K. A. (2008). Patient-

centered care and adherence: definitions and applications to improve

outcomes. Journal of the American Academy of Nurse Practitioners,

20(12), 600-607. doi:10.1111/j.1745-7599.2008.00360.x

Rodriguez, G., & Goldman, N. (1995). An Assessment of Estimation Procedures

for Multilevel Models with Binary Responses. Journal of the Royal

Statistical Society Series a-Statistics in Society, 158, 73-89. doi:Doi

10.2307/2983404

Rudman, A., Omne-Pontén, M., Wallin, L., & Gustavsson, P. J. (2010).

Monitoring the newly qualified nurses in Sweden: the Longitudinal

Analysis of Nursing Education (LANE) study. Human Resources for

Health, 8, 10-10. doi:10.1186/1478-4491-8-10

Sackett, D. L. (2000). Evidence-based medicine (2. ed. ed.). Edinburgh:

Churchill Livingstone.

Salinas, M., López-Garrigós, M., Lillo, R., Gutiérrez, M., Lugo, J., & Leiva-

Salinas, C. (2013). Patient identification errors: the detective in the

laboratory. Clinical Biochemistry, 46(16–17), 1767-1769.


References

59

Scheithauer, S., Haefner, H., Schwanz, T., Lopez-Gonzalez, L., Bank, C., Schulze-

Röbbecke, R., . . . Lemmen, S. W. (2012). Hand hygiene in medical

students: performance, education and knowledge. International

Journal of Hygiene and Environmental Health, 215(5), 536-539.

doi:10.1016/j.ijheh.2012.02.009

Schunemann, H. J., Fretheim, A., Oxman, A. D., & Research, W. H. O. A. C. o. H.

(2006). Improving the use of research evidence in guideline

development: 1. Guidelines for guidelines. Health Research Policy and

Systems, 4, 13. doi:10.1186/1478-4505-4-13

Severinsson, E., & SAND, Å. (2010). Evaluation of the clinical supervision and

professional development of student nurses. Journal of Nursing

Management, 18(6), 669-677. doi:10.1111/j.1365-2834.2010.01146.x

Shaha, M., Wenzel, J., & Hill, E. E. (2011). Planning and conducting focus group

research with nurses. Nurse researcher, 18(2), 77-87.

doi:10.7748/nr2011.01.18.2.77.c8286

Shaneyfelt, T. M., Mayo-Smith, M. F., & Rothwangl, J. (1999). Are guidelines

following guidelines?: The methodological quality of clinical practice

guidelines in the peer-reviewed medical literature. Journal of the

American Medical Association, 281(20), 1900-1905.

Sharif, F., & Masoumi, S. (2005). A qualitative study of nursing student

experiences of clinical practice. BMC nursing, 4(1), 6. doi:10.1186/1472-

6955-4-6

Sharpe, V. A., & Faden, A. I. (1998). Medical Harm: Historical, Conceptual and

Ethical Dimensions of Iatrogenic Illness: Cambridge University Press.

Shinde, M. B., & Mohite, V. R. (2014). A study to assess knowledge, attitude and

practices of five moments of hand hygiene among nursing staff and

students at a tertiary care hospital at Karad. International Journal of

Science and Research, 3(2), 311-321.

Simon-Tuval, T., Neumann, P. J., & Greenberg, D. (2016). Cost-effectiveness of

adherence-enhancing interventions: a systematic review. Expert Review

of Pharmacoeconomics & Outcomes Research, 16(1), 67-84.

doi:10.1586/14737167.2016.1138858

Simonetti, V., Comparcini, D., Flacco, M. E., Di Giovanni, P., & Cicolini, G.

(2015). Nursing students' knowledge and attitude on pressure ulcer

prevention evidence-based guidelines: a multicenter cross-sectional

study. Nurse Education Today, 35(4), 573-579.

doi:10.1016/j.nedt.2014.12.020

Simundic, A.-M., & Lippi, G. (2012). Preanalytical phase–a continuous challenge

for laboratory professionals. Biochemia medica, 22(2), 145-149.

References

60

Simundic, A.-M., Nikolac, N., Church, S., Cornes, M. P., Grankvist, K., Lippi, G., .

. . Sumarac, Z. (2015). Compliance of blood sampling procedures with

the CLSI H3-A6 guidelines: An observational study by the European

Federation of Clinical Chemistry and Laboratory Medicine (EFLM)

working group for the preanalytical phase (WG-PRE). Clinical


doi:10.1515/cclm-2014-1053

Singer, S. J., & Vogus, T. J. (2013). Reducing hospital errors: interventions that

build safety culture. Annual review of public health, 34, 373-396.

doi:10.1146/annurev-publhealth-031912-114439

Sloan, F. A., Bethel, M. A., Lee, P. P., Brown, D. S., & Feinglos, M. N. (2004).

Adherence to guidelines and its effects on hospitalizations with

complications of type 2 diabetes. The review of diabetic studies, 1(1),

29-38. doi:10.1900/RDS.2004.1.29

Smiddy, M. P., O'Connell, R., & Creedon, S. A. (2015). Systematic qualitative

literature review of health care workers' compliance with hand hygiene

guidelines. American Journal of Infection Control, 43(3), 269-274.

Snyder, S. R., Favoretto, A. M., Derzon, J. H., Christenson, R. H., Kahn, S. E.,

Shaw, C. S., . . . Liebow, E. B. (2012). Effectiveness of barcoding for

reducing patient specimen and laboratory testing identification errors: a

Laboratory Medicine Best Practices systematic review and meta-

analysis. Clinical Biochemistry, 45(13–14), 988-998.


Speck, K., Rawat, N., Weiner, N. C., Tujuba, H. G., Farley, D., & Berenholtz, S.

(2016). A systematic approach for developing a ventilator-associated

pneumonia prevention bundle. American Journal of Infection Control.

doi:10.1016/j.ajic.2015.12.020

Squires, J. E., Estabrooks, C. A., O'Rourke, H. M., Gustavsson, P., Newburn-

Cook, C. V., & Wallin, L. (2011). A systematic review of the psychometric

properties of self-report research utilization measures used in

healthcare. Implementation Science, 6(1), 83. doi:Artn 83

10.1186/1748-5908-6-83

Squires, J. E., Hutchinson, A. M., Bostrom, A. M., O'Rourke, H. M., Cobban, S.

J., & Estabrooks, C. A. (2011). To what extent do nurses use research in

clinical practice? A systematic review. Implementation Science, 6(1), 21-

37. doi:10.1186/1748-5908-6-21

Steinberg, E., Greenfield, S., Mancher, M., Wolman, D. M., & Graham, R. (2011).

Clinical practice guidelines we can trust, Washington (DC): National

Academies Press.

Stimson, G. V. (1974). Obeying doctor's orders: a view from the other side. Social

Science & Medicine, 8(2), 97-104.

References

61

Straus, S. E., Tetroe, J., & Graham, I. (2009). Defining knowledge translation.

Canadian Medical Association Journal, 181(3-4), 165-168.

doi:10.1503/cmaj.081229

Strobel, M. (2013). The technology is there: options for preventing lab labeling

and tracking errors. Medical Laboratory Observer, 45(2), 22-22.

Sullivan, N., & Schoelles, K. M. (2013). Preventing In-Facility Pressure Ulcers as

a Patient Safety Strategy A Systematic Review. Annals of internal

medicine, 158(5), 410-+. doi:10.7326/0003-4819-158-5-201303051-

00008

Swedish Board of Health and Welfare. (2015). Lägesrapport inom

patientsäkerhetsområdet 2015.

Söderberg, J., Brulin, C., Grankvist, K., & Wallin, O. (2009). Preanalytical errors

in primary healthcare: a questionnaire study of information search

procedures, test request management and test tube labelling. Clinical


doi:10.1515/CCLM.2009.048

Söderberg, J., Wallin, O., Grankvist, K., & Brulin, C. (2010). Is the test result

correct? A questionnaire study of blood collection practices in primary

health care. Journal Of Evaluation In Clinical Practice, 16(4), 707-711.

doi:10.1111/j.1365-2753.2009.01179.x

Tacconelli, E., Cataldo, M. A., Dancer, S. J., De Angelis, G., Falcone, M., Frank,

U., . . . European Society of Clinical, M. (2014). ESCMID guidelines for

the management of the infection control measures to reduce

transmission of multidrug-resistant Gram-negative bacteria in

hospitalized patients. Clinical Microbiology and Infection, 20, 1-55.

doi:10.1111/1469-0691.12427

Tella, S., Liukka, M., Jamookeeah, D., Smith, N. J., Partanen, P., & Turunen, H.

(2013). What do nursing students learn about patient safety? An

integrative literature review. Journal of Nursing Education, 53(1), 7-13.

The Swedish Society of Nursing. Nursing core competencies. Retrieved from

http://www.swenurse.se/Utanfor-strukturen/karnkompetenser/

Thomas, W. K. (2014). Right Test, Right Time, Right Patient. Critical care

medicine, 42(1), 190-192. doi:10.1097/CCM.0000000000000010

Toner, J. (2009). Small is not too Small Reflections Concerning the Validity of

Very Small Focus Groups (VSFGs). Qualitative Social Work, 8(2), 179-

192.

Travers, C., Martin‐Khan, M., & Lie, D. (2009). Barriers and enablers of health

promotion, prevention and early intervention in primary care: Evidence

to inform the Australian national dementia strategy. Australian Journal

on Ageing, 28(2), 51-57. doi:10.1111/j.1741-6612.2009.00359.x

References

62

Upton, D. J. (1999). How can we achieve evidence‐based practice if we have a

theory–practice gap in nursing today? Journal of Advanced Nursing,

29(3), 549-555.

Us Centers for Disease Control and Prevention, C. (2002). Guideline for Hand

Hygiene in Health-Care Settings. Recommendations of the Healthcare

Infection Control Practices Advisory Committee and the

HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Retrieved

from: http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf.

Wakefield, A., Attree, M., Braidman, I., Carlisle, C., Johnson, M., & Cooke, H.

(2005). Patient safety: do nursing and medical curricula address this

theme? Nurse Education Today, 25(4), 333-340.

Wallin, L. (2009). Knowledge translation and implementation research in

nursing. International Journal of Nursing Studies, 46(4), 576-587.

doi:10.1016/j.ijnurstu.2008.05.006

Wallin, L., Boström, A. M., & Gustavsson, J. P. (2012). Capability Beliefs

Regarding Evidence‐Based Practice are Associated with Application of

EBP and Research Use: Validation of a New Measure. Worldviews on

Evidence‐Based Nursing, 9(3), 139-148.

Wallin, O. (2008). Preanalytical errors in hospitalsImplications for quality

improvement of blood sample collection. (PhD thesis) Umeå universitet.

Wallin, O., Soderberg, J., Van Guelpen, B., Stenlund, H., Grankvist, K., & Brulin,

C. (2008). Preanalytical venous blood sampling practices demand

improvement--a survey of test-request management, test-tube labelling

and information search procedures. Clinica Chimica Acta, 391(1-2), 91-

97. doi:10.1016/j.cca.2008.02.016

Wallin, O., Söderberg, J., Van Guelpen, B., Brulin, C., & Grankvist, K. (2007).

Patient-centred care--preanalytical factors demand attention: a

questionnaire study of venous blood sampling and specimen handling.

Scandinavian Journal of Clinical and Laboratory Investigation, 67(8),

836-847. doi:10.1080/00365510701370675

Wallin, O., Söderberg, J., Van Guelpen, B., Stenlund, H., Grankvist, K., & Brulin,

C. (2010). Blood sample collection and patient identification demand

improvement: a questionnaire study of preanalytical practices in

hospital wards and laboratories. Scandinavian Journal of Caring

Science, 24(3), 581-591. doi:10.1111/j.1471-6712.2009.00753.x

Weidman, J. C., Twale, D. J., & Stein, E. L. (2001). Socialization of Graduate

and Professional Students in Higher Education: A Perilous Passage?

ASHE-ERIC Higher Education Report (0787958360). Retrieved from

http://eric.ed.gov/?id=ED457710

Whitby, M., McLaws, M.-L., & Ross, M. W. (2006). Why healthcare workers

don't wash their hands: a behavioral explanation. Infection Control and

Hospital Epidemiology, 27(5), 484-492. doi:Doi 10.1086/503335

References

63

Wians, F. H. (2009). Clinical laboratory tests: which, why, and what do the

results mean? Laboratory Medicine, 40(2), 105-113.

Wilson, C. (2015). Preventing central venous catheter-related bloodstream

infection. Nursing Standard, 29(19), 37-43.

doi:10.7748/ns.29.19.37.e9271

World Health Organization. (2010). WHO guidelines on drawing blood: best

practices in phlebotomy.

World Health Organization. (2011). Patient Safety Curriculum Guide. Multi-

professional Edition.

World Health Organization. (2016). What is patient safety? Retrieved from

http://www.who.int/patientsafety/about/en/

World Health Organization. (2013). WHO Guidelines on Hand Hygiene in

Health Care. First Global Patient Safety Challenge Clean Care is Safer

Care. 2009.

World Medical Association. (2013). World medical association declaration of

helsinki: Ethical principles for medical research involving human

subjects. JAMA: The Journal of the American Medical Association

310(20), 2191-2194. doi:10.1001/jama.2013.281053

Vrijens, B., De Geest, S., Hughes, D. A., Przemyslaw, K., Demonceau, J., Ruppar,

T., . . . Lewek, P. (2012). A new taxonomy for describing and defining

adherence to medications. British journal of clinical pharmacology,

73(5), 691-705. doi:10.1111/j.1365-2125.2012.04167.x

Zarshenas, L., Sharif, F., Molazem, Z., Khayyer, M., Zare, N., & Ebadi, A. (2014).

Professional socialization in nursing: A qualitative content analysis.

Iranian journal of nursing and midwifery research, 19(4), 432-438.

Zingg, W., Holmes, A., Dettenkofer, M., Goetting, T., Secci, F., Clack, L., . . .

Pittet, D. (2015). Hospital organisation, management, and structure for

prevention of health-care-associated infection: a systematic review and

expert consensus. The Lancet Infectious Diseases, 15(2), 212-224.

Zuckerman, L. M. (2016). Oral Chlorhexidine Use to Prevent Ventilator-

Associated Pneumonia in Adults: Review of the Current Literature.

Dimensions of Critical Care Nursing, 35(1), 25-36.

adherence to venous blood specimen collection practice...

Documents