Egyptian Nursing Journal

ORIGINAL ARTICLE
Year
: 2020  |  Volume : 17  |  Issue : 1  |  Page : 23--35

Effect of customized venipuncture nursing technique on selected responses and insertion difficulty among patients with blood disorders


Safaa M Hassanein, Hala I.A Deif 
 Medical Surgical Nursing, Faculty of Nursing, Cairo University, Cairo, Egypt

Correspondence Address:
Safaa M Hassanein
Medical Surgical Nursing, Faculty of Nursing, Cairo University, Cairo
Egypt

Abstract

Background Peripheral intravenous access is one of the most commonly performed technical nursing procedures in hospitals, and it is mandatory for patients with blood disorders. Obtaining venous access is an essential first step in patient care. Peripheral intravenous success rates, rely heavily on clinician experience and patient physiology. Obtaining peripheral intravenous access may be difficult and cause patient anxiety, discomfort, and pain, and this may cause delays in patient management and employment of additional personnel, leading to lengthening of procedure times. Aim The aim was to evaluate the effect of a customized venipuncture nursing technique (CVNT) on selected responses and insertion difficulty among patients with blood disorders. Design: A quasi-experimental non-equivalent control group design was used. Research hypothesis: H1: The study group that received the CVNT will exhibit improvement in selected responses than the control group that received only routine hospital venipuncture. H2: The study group that received the CVNT will have a significant lower mean insertion difficulty score than the control group that received only routine hospital venipuncture. Patients and methods A total of 60 participants were included in the study (30 for the study group and 30 for the control group). The participants were selected using a simple random sampling technique. Five tools were used to gather data: first, demographic and medical data sheet; second, Beck anxiety inventory; third, numerical pain rating scale; fourth, Likert comfort scale; and fifth, insertion difficulty scale. Results The mean±SD age was 47.7±13.8 and 47.0±14.5 years and BMI was 23.5±1.2 and 23.4±1.2 among the study and control groups, respectively. There was statistical significant difference in needle insertion difficulty (before and after the procedure) among the study group who received CVNT; regarding respiration, pulse, and systolic blood pressure (49.2, 4.2, and 3.4, respectively, with P=0.000). There was a statistical significance difference between the study and the control groups regarding anxiety intensity, pain intensity, comfort, and measure difficulty, as one of the indicators of needle insertion difficulty, total scores, which were 2.9, 8.9, 12.8, and 15.3, respectively, with P value of 0.000. Conclusion Built on the current study findings, the researchers concluded that; CVNT was effective in reducing the pain, anxiety, and difficulty in needle insertion based on the measure difficulty indicator and promoted comfort of such patients during venipuncture. Also it enhanced selected patient parameters such as respiration, pulse, systolic blood pressure, thereby increasing patient comfort. Recommendation Nurses should consider the using of CVNT technique, and be conscious that; there is a need of having evidence-based protocols to care for patients with blood disorders.



How to cite this article:
Hassanein SM, Deif HI. Effect of customized venipuncture nursing technique on selected responses and insertion difficulty among patients with blood disorders.Egypt Nurs J 2020;17:23-35


How to cite this URL:
Hassanein SM, Deif HI. Effect of customized venipuncture nursing technique on selected responses and insertion difficulty among patients with blood disorders. Egypt Nurs J [serial online] 2020 [cited 2020 Nov 29 ];17:23-35
Available from: http://www.enj.eg.net/text.asp?2020/17/1/23/300778


Full Text



 Introduction



Venipuncture, the process of obtaining venous access for blood sampling or intravenous (i.v.) therapy, is the most common clinical procedure performed worldwide, with more than 1.4 billion procedures performed daily in the USA alone. Traditionally, venipuncture has been performed by trained clinicians and phlebotomists, in which a suitable vein is located by both visual and tactile inspection (Leipheimer et al., 2020). Venipuncture refers to the practice of penetrating the vein’s wall with a needle for collection of blood. It is considered as an invasive procedure, which leads to distress, pain, and even unavoidable extreme reactions from the patient’s side (Pan et al., 2019). Moreover, venous blood sampling is an important procedure affecting laboratory results. It consists of several discrete steps, including patient preparation, collection, as well as handling of blood specimens, and each step is prone to errors (Cai et al., 2018). A key objective of venipuncture for the purpose of blood collection is to succeed on the first attempt, with the least possible stress and pain (Sheils et al., 2020).

Common blood disorders include anemia; bleeding disorders include hemophilia and blood clots; and blood cancers include leukemia, lymphoma, and myeloma (Cuker et al., 2018). Actually, blood cell disorder is a condition in which there is a problem with red blood cells, white blood cells, or platelets, which are critical for clot formation. All three cell types form in the bone marrow. Bone marrow is the soft tissue which inside bones, and these cells perform different functions, as red blood cells transport oxygen to the body’s organs and tissues, white blood cells help the body fight infections, while platelets help in blood clotting (Levin, 2019). Blood cell disorders impair the formation and function of one or more of these types of blood cells. One of the critical symptoms experienced by those patients are skin bruises or uncontrolled bleeding with or without injury, as even a small injury can cause severe blood loss (Mayo Clinic, 2017).

Although venipuncture is the most common invasive procedures performed in a hospital, most nurses receive insufficient formal training in this area and constantly seek techniques to enhance their success rates, which reflect to a greater extent on patients comfort and facilitation of insertion (Keleekai et al., 2016). Moreover, they may encounter difficulty that may cause a number of potentially serious patient adverse effects, such as physical pain and nerve injury, as well as regret, and additional labor for the health care personnel (e.g. time and cost). (Ichimura et al., 2020). In several European countries such as the Netherlands, Belgium, Ireland, the UK, and the USA, venous blood samples are collected by a phlebotomist, who has received professional phlebotomy education and training practice (Simundic et al., 2013). However, venipuncture is a common medical procedure that causes distress and anxiety for several patients. The negative long-term consequences, such as needle phobia, may compromise compliance with the venipuncture procedure, as well as with subsequent medical treatment (Lie, 2016). Moreover, Swetharani et al. (2016) added that the higher the frequency of the blood tests, the greater the burden for the nurse as well as the occurrence of discomfort for the patient.

Pain, anxiety, and discomfort always accompany needle insertion for blood specimen. Several studies focus mainly on relieving pain (Katende and Mugabi, 2015). A study conducted by Yamamoto-Hanada et al. (2015) entitled ‘relieving pain and distress during venipuncture’ used lidocaine/prilocaine cream for relieving pain associated with such procedure, and it showed to be effective in reducing pain. However, actually it causes skin dryness, and it is neither available nor reasonable for most clinicians. Other studies focused on applying cold compresses in order to eliminate the occurrence of hematoma during administering the irritant medications or in arteriovenous fistula for patient on hemodialysis. Another study conducted by Redfern et al. (2018) proved that thermo-mechanical stimulation with the buzzy device and ice chips significantly reduced pain in a group of patients with a wide range of ages compared with the control group, but they did not test the effect of pre-procedure anxiety. One more study by Alabdalhai et al. (2017), which focused on the effect of cold therapy on the pain and hematoma on the site of injection, revealed that the cold application can reduce the pain intensity and occurrence of hematoma in patients who receive enoxaparin injection. Apparently, there is no sufficient evidence that could be found to validate that cold compresses act positively on reducing anxiety or discomfort or improving insertion difficulty, as most of these studies acted on reducing the pain associated with either irritant medication or hematoma formation.

On the contrary, scant research studies have focused on studying the effect of applying warm compresses on reducing pain and inducing comfort, such as Fink et al. (2009). The study found that dry heat application decreases the likelihood of multiple i.v. insertion attempts and reduces the insertion time and was comfortable, safe, and economical to use in patients with cancer. They further added that nurses often apply heat to the i.v. insertion site to assist with vein visualization and increase the likelihood of a successful insertion, as cutaneous blood flow increases up to 70% during periods of heating because of an increase in sympathetic vasodilator activity, but the technique has rarely been studied.

Thus, in the current study, the researchers decided to focus on a customized venipuncture nursing technique (CVNT) rather than a single technique, which has been built on evidence to decrease patient anxiety, discomfort, and pain and minimize insertion difficulty to decrease patient suffering. The researchers consider these suffering as multifactorial annoying symptoms, as it is related to several aspects, for example, does not allocate the best anatomical vein position, sometimes choose painful area which rich with nerves, does not warm up the site for easy vein access or applying the tourniquet for a prolonged period of time, in addition to other several technicalities.

Significance of the study

In today’s hospital-based medicinal care, opportunities to reduce complications and improve patient safety and clinical outcomes, without raising the cost of care, are rare. Venipuncture requires professional skills to perform the procedure, in not only doing it correctly but also painlessly; moreover, incompetent implementation of such procedure can lead to patient suffering and jeopardize patient comfort. There are various risks associated with venipuncture, which may include excessive bleeding, feeling light-headed, fainting, nerve damage, hematoma, and infection. Moreover, patients with blood disorders have problems during venipuncture as they might suffer daily from repeated nursing trial to collect blood, and it is obvious that they are exposed to many problems such as pain, anxiety, and discomfort owing to insertion difficulty. These problems have numerous dimensions, as they could be related to insufficient patient preparation before insertion; patient anxiety, which leads to vasoconstriction; the surrounded temperature, which interferes with patients’ vein vasodilatation; the selected body position; and many other related factors. Therefore, important aspects of venipuncture procedures should be reviewed, including the recommended order of taking accurate patient identification and acceptable vein sites,...etc as these aspects can affect the accuracy of the blood test as well as patient’s vital parameters.

A recent researches study conducted by Nilsson et al. (2017) concluded that there is a need to develop evidence-based practice to enhance adherence with practice guidelines and improve patient’s safety related to blood specimen and venipuncture. Indeed, the available research in the subject area of the current study is scarce and is limited to studying the effect of one technique of venipuncture on controlling the unpleasant factors of pain, anxiety, comfort levels, and insertion difficulty. Therefore, the researchers intended to assemble a safe reasonable and more elaborate technique that includes the application of different rationalized technical steps and precautionary actions to test its efficiency in reducing the unpleasant effects of venipuncture. This is done through the initiation of the CVNT, which is based on evidential scientific references, to test its efficiency on decreasing unpleasant factors especially for patients with blood disorders who encountered venipuncture constantly.

Apparently, this research could be counted as one of the nursing research studies investigating the effect of applying a combination of more than one nursing techniques on relieving certain complaints related to venipuncture, where previous studies focused mainly on evaluating the use of only one separate technique such as cooling, warming, distraction, or using of many forms of complementary therapy such as acupressure or a pharmacological line such as analgesic and topical cream to decrease pain, anxiety, and promote comfort, which ease up insertion. Thus, using CVNT deals with various aspects to be considered that may contribute to more competence in implementing venipuncture such as positioning, warm application, and specifying the location of needle insertion, all of which together can reduce patients suffering during the procedure. Furthermore, it could provide a cost-saving benefit in the long term for health care organizations by reducing wasting of supplies owing to repeated failed attempts of venipuncture and by conserving the amount of nursing time and personnel involved in venipuncture insertions.

Operational definitions

Customized venipuncture nursing technique

It is a nursing practice that aims to maintain normal selected vital signs by improving vital signs parameters [blood pressure (BP), respiration, and pulse], reduce anxiety, minimize pain during insertion, and induce comfort as well as minimize needle insertion difficulty by using assembled standard safe methods, which the current researchers classified into three main steps and two main precautions.

Selected responses

Vital signs

BP was measured by sphygmomanometer, pulse by counting the redial pulse rate, and respiration rate through direct patient observation.

Anxiety

It is a feeling of tension, worried thoughts, and physical changes like increase in pulse rate, BP, and respiration and might lead to vasoconstriction as retrieved by Medical Data Sheet and Beck anxiety inventory (BAI).

Pain

It is an unpleasant sensation owing to invasive procedure of the venipuncture counted on a continuum demonstrating severity of pain as a subjective patient experience. It was measured by Pain Numerical Rating Scale.

Comfort

It is a broad concept that denotes relieving of distress, which could be applicable on various levels. In this study, it was applied by measuring comfort related to pain and temperature, by a comfort Likert scale.

Insertion difficulty

It determines the difficulty the patients with blood disorders might encounter through indicators of ‘measure difficulty during inserting needle, prolonged insertion time, and repeated times of insertion’. It was measured by the insertion difficulty scale.

 Patients and methods



Aim

The aim of this study was to evaluate the effect of CVNT on selected responses and insertion difficulty among patients with blood disorders.

Research hypotheses

H1: The study group that received the CVNT will exhibit an improvement in selected responses than the control group that received only routine hospital venipuncture.

H1a: The study group that received the CVN will have significant lower mean vital signs (BP, pulse, and respiration) score than the control group that received only routine hospital venipuncture.

H1b: The study group that received the CVNT will have a significant lower mean anxiety score than the control group that received only routine hospital venipuncture.

H1c: The study group that received the CVNT will have a significant lower mean pain score than the control group that received only routine hospital venipuncture.

H1d: The study group that received the CVNT will have a significant higher mean comfort score than the control group that received only routine hospital venipuncture.

H2: The study group that received the CVNT will have a significant lower mean insertion difficulty score than the control group that received only routine hospital venipuncture.

Research design

A quasi-experimental non-equivalent control group design was used.

Setting

The study was conducted at the medical departments at one of the educational university hospital in Egypt.

Participants

A convenient sample of 60 adult male and female patients was recruited over 3 consecutive months through the year of 2019. Patients who were diagnosed with any blood disorders and fulfilled the inclusion criteria were enrolled in the study. Patients were randomly divided into two groups of 30 patients each, as study and control groups.

Sample criteria

The following were the criteria for selection of the studied participants.

Inclusion criteria

Patients who were undergoing venipuncture procedure, had any blood disorders such as anemia and thalassemia, with an age of 18 years and above were included. Exclusion criteria were unconscious patients, patients with morbid obesity, patients with multiple sclerosis, and those with peripheral neuritis or any other diseases that cause increase in pain and/or discomfort.

Research tools

The tools pertinent to the study were developed after extensive review of literature, evidence-based research studies, and discussion with experts in the health field. Five tools were used as follows:Tool 1 (Demographic and Medical Data Sheet): it consists of two parts: the first part includes patient’s code, age, sex, education, etc., whereas the second part includes the diagnosis, medication, vital signs, etc.Tool 2 (BAI, 1988): it is a self-reported measure of anxiety. It consists of 21 items, with each item counted as follows: 0=no, 1=mild, 2=moderate, and 3=severe. The total tool score was counted as follows: 0–21=low anxiety, score of 22–35=moderate anxiety, and score of 36 and above=severe anxiety. BAI was moderately correlated with the revised Hamilton anxiety rating scale (0.51) and mildly correlated with the Hamilton depression rating scale, so it was valid at this point. Reliability was tested with Cronbach’s α=0.92 (Beck et al., 1988).Tool 3 (pain numerical rating scale): it was used to measure current pain intensity and the least intensity of the pain. Mark (2011), reported that the scale consists of four questions on a continuum, from 0 to 10, where zero means no pain, ratings between 1 and 4 indicate mild pain, ratings between 5 and 6 indicate moderate pain, and ratings of 7–10 indicate severe pain. Thonget al. (2018) have proven the validity of NRS, whereas Castarlenaset al. (2017) tested its reliability and it represented a high agreement as limits of agreement (95% confidence interval: −0.9 and 1.2).Tool 4 (comfort level rating scale): it is based on Brown (2010). The Likert comfort Scale was designed by this study researchers. It measures comfort level focusing on two main scale: discomfort related to temperature and discomfort related to pain. Each one ranged between 0 and 10, where 0 represented no discomfort (optimum comfort), 1–4 indicated mild discomfort, scores of 5 and 6 indicated moderate discomfort, and scores of 7–10 indicated severe discomfort. Validity was established by a panel of experts, and its reliability was examined and tested by the current researchers, as Cronbach’ α=0.91 with perfect scales correlation=0.84.Tool 5 (insertion difficulty scale): it is a tool adapted from Jacobson and Winslow (2005), which consists of three indicators: the first indicator is a ‘measure of difficulty’, which consists of difficulty to puncture and difficulty to thread. Each scale ranges from 0 to 3, where zero=no difficulty, 1=low difficulty, 2=moderate difficulty, and 3=high difficulty. The second indicator is ‘counting insertion time’, starting from needle insertion till termination using stop watch, whereas the third indicator is ‘counted trial number’, as a query question about if the patient had more than one needle insertion’s trial at the same venipuncture procedure. Validity was established by a panel of experts, and its reliability was examined and tested by the current researchers, as Cronbach’ α=0.78 with moderate scales correlation=0.67.

Protection of human rights

Ethical approval was gained from Research Ethics Committee-Faculty of Nursing Cairo University (IRB: 00004025) before the study commenced. Both verbal and written consents were obtained from all participants within the study and the control groups after full explanation to each participant about the nature and the purpose of the study, and the possible benefits of participating in the study were explained to all participants. The collected data were kept confidential. Assurance was given that they can withdraw from the study at any time and also privacy of information would be maintained throughout the study.

Pilot study

Once permission was granted to proceed with the proposed study, a pilot study was carried out before starting data collection on 10 of the targeted patients to test the feasibility, relevance, and practicability of the intervention, as well as to estimate the time needed to collect data. Moreover, a panel of three experts reviewed the utilized tools for its validity, besides the ethical committee reviewers. Findings of the pilot study revealed that the study was feasible and practical to conduct the main study; thus, the sample of the pilot study was included in the current study sample.

Procedure

Once permission to proceed with the current study was obtained, the researchers implemented the study through three phases. In the preparatory phase, the patients who were prescribed by the physician to have venipuncture were informed about the nature of the current study, and their written consent was obtained. Then the researchers used tool 1 to obtain demographic data, such as age and sex and medical assessment (BP, pulse, etc.). Subsequently, the researchers divided the participants randomly into study and control groups. Initially, the researchers assessed the routine hospital venipuncture preparation and technique which they follow; it was found that they use the tourniquet, which sometimes was not applied properly, as they use any other available elastic object such as rubber gloves to allocate the patient vein, also they swab the venipuncture site with alcohol before the procedure. In the implementation phase, the researchers applied the CVNT (as explained within the Technique section) for the study group, whereas for the control group, the venipuncture was applied based on the usual routine hospital preparation and technique. Finally, in the evaluation phase, the researchers evaluated both study and control groups directly after they finished the venipuncture procedure by using tools 2, 3, 4, and 5 to assess patients anxiety, pain, and comfort levels in addition to the insertion difficulty, and also the selected vital signs were reassessed for both study and control group using tool 1.

Customized venipuncture nursing technique used in the study group

The following steps were customized based on the approved techniques of Fink et al. (2009), WHO guidelines on drawing blood: best practices in phlebotomy (2010), UK Biobank (2011), Shropshire Community Health, NHS (2011), Cardif University, Clinical Skills Venipuncture (2015), and Hamad Medical Corporation (2018).Position: the hand must be below the heart level in either positions (sit up-right position or set the hand below the body level if the patient is at a flat position) for 10 min.Temperature:Application of dry heat using a towel (12×24 inches)/(30×60 cm) over the venipuncture area for 7–10 min. Hence, steps 1 and 2 are concurrent.Tighten the standard tourniquet 4–5 finger widths above the venipuncture site.

Precautions

Location of insertion:Avoid bending points such as elbow, wrist, etc.Vein should be in between muscles or flesh.Vein inserted area must be straight.Avoid bruised of fibered area/veins.Swabbing: after swabbing, leave the area for complete dryness at least for 30 s.Anchor the vein by holding the patient’s arm and placing a thumb below the venipuncture site.Tourniquet:Must be flat and elastic.Allocate it for not more than 30 s to 1.30 min maximum to avoid capillary damage and pain.

Statistical analysis

The data were coded and tabulated using a personal computer. Statistical Package for the Social Sciences version 20, by IBM Company USA, was used. Data were presented using descriptive statistics in the form of frequencies and percentages. Inferential tests were utilized such as correlation tests and t-test, in relation to research variables. Statistical significance was set at P value less than or equal to 0.05.

 Results



Statistical findings of the current study are presented in three main sections as follows: section 1 represents participants’ demographic characteristics and their medical data ([Table 1],[Table 2],[Table 3]). Section 2 answers the related hypotheses of H1 (H1.a, H1.b, H1.c, and H1.d) and H2, which were divided into two sub-parts: part A is related to patients’ characteristics and the mean difference of pretest and post-test [BP, ‘systolic and diastolic’ BP, pulse, and respiration] scores among study group that received the CVNT and pretest and post-test (BP, ‘systolic and diastolic’ BP, pulse, and respiration) scores among the control group that received routine hospital venipuncture ([Table 4]), whereas part B is related to patients’ mean differences of anxiety, pain, comfort, and insertion difficulty, which is related to ‘measure difficulty, time, and counted trial of needle insertion,’ scores after venipuncture for the study group that received the CVNT compared with the control group ([Table 5]).{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}

Section 1

It reports the frequency and percentage distribution of baseline variables of patients among study and control groups (n=60)

Based on [Table 1], it was found that 36.7 and 30% in the study and control groups had ages ranged between 50 years and less than 60 years, with mean age of 47.7±13.8 and 47.0±14.5 years, respectively. In addition, 73.3 and 70% were females. 86.7 and 90% was married, 56.7 and 40% can read and write, 73.3 and 60% were housewives, and 56.7 and 40% were living in Giza in the study and control groups, respectively.

Regarding diagnosis, 20% were suffering from thrombocytopenia in each of the study and control groups, whereas 56.7 and 63.3% had grade I obesity, with mean BMI of 23.5±1.2 and 23.4±1.2, in the study and the control groups, respectively. The aforementioned table revealed that there were no statistical significant differences between study and control groups. Before proceeding with needle insertion, χ2 was equal 1.2, with P=0.87; 23.8, with P=0.68; 0.39, with P=0.82; constant difference; and 0.06 with P=0.79, for BP, systolic BP, diastolic BP, pulse, and respiration, respectively. This reflected homogeneity between the study and control groups. However, there was no statistically significant difference when comparing the study and control groups after intervention regarding BP, systolic BP, diastolic BP, pulse, and respiration.

Section 2 (Part A) shows the systolic and diastolic BP, pulse, and respiration mean of difference (before-after) needle insertion among the study group and the control group. Part B focuses on patients’ mean differences in anxiety, pain, discomfort total scores, and insertion difficulty in the form of ‘measure difficulty, counting, time, and counted trial number’ of needle insertion scores after intervention for study group that received the customized nursing technique vs the control group that received only the routine hospital venipuncture preparation.

There was a statistically significant mean difference (before and after needle insertion) among the study group regarding respiration, pulse, and systolic/BP, as it equals 49.2, 4.2, and 3.4, respectively, with P value=0.00, whereas there was no statistically significance mean difference (before and after needle insertion) among the control group regarding respiration, pulse, and systolic/BP.

Section 2 (Part B) represents the patients’ mean differences in anxiety, pain, comfort, and insertion difficulty (related to indicators of measure difficulty, counting time, and counted trial of needle insertion) scores after intervention for study group that received the customized nursing technique compared with the control group that received only the routine hospital venipuncture preparation and technique ([Table 5]).

[Table 5] shows that there was a significant statistical mean difference between study and control groups regarding anxiety, pain, comfort, and venipuncture insertion difficulty (related to measure difficulty) total scores, which equal 2.9, 8.9, 12.8, and 15.3, respectively, at P value=0.000, whereas there was no statistically significant difference between study and control groups regarding venipuncture insertion difficulty (related to counting time in seconds); however, for the control group, 6.7 and 3.3% took 30<45 s and 45≤60 s, respectively, with mean±SD=18.3±9.9, compared with the study group, which did not exceed the timing of 30<45 s, with mean±SD=15.8±6.2. Moreover, there was no statistically significant difference between study and control groups regarding venipuncture insertion difficulty (related to the counted trial of needle insertion), with mean±SD of 15.±6.2 and 18.3±9.9, respectively. However; it was noticed among the control group, that 33.3% of the patients experienced twice trial of needle insertion compared to only 13.3% at the study group.

 Discussion



Venipuncture is one of the main nursing activities. For the safety of patients and nurses, this skill is important to be performed in a proper and responsible way. Thus, the need for a proper technique is essential. A nursing technique that reduces venipuncture-related discomfort and avoids potential complications is generally less costly and can be performed independently by nurses (Jindal et al., 2018). Therefore, it was necessary to develop a safe, cost-effective, and easy nursing technique to minimize suffering and to facilitate the success of needling interventions. Apparently, the current study was conducted to evaluate the use of a CVNT to control several selected factors such as vital signs (BP, pulse, and respiration), anxiety, and pain; induce patient comfort; and decrease insertion difficulty.

The following representation addressed in detail the analysis of the findings in relation to the aim of the current study. No patients discontinued from the study. The key demographic characteristics were similar in both groups and are summarized in [Table 1]. It was crucial to start with section I, which sheds light on the demographic and the medical characteristics for both study and control groups and then discusses the current research hypotheses in section II, to elaborate the significant differences between study and control groups after applying the CVNT on the study group.

Section I: initially, both study and control groups had almost same parameter, with no statistically significant differences in any of the demographic variables (age, sex, etc.) or medical data, which reflected sample’s homogeneity. The current study reported that almost one-third of both study and control groups had an age range of 50 to sixty years old, with mean±SD age of 47.7±13.8 and 47.0±14.5 years, respectively.

In the current study, the highest percentages of both groups were females, and most of them were married. More than half of the study group and almost half of the control group could read and write. The greatest percentages of both groups were housewives. Moreover, it was noticed that around half of the study and the control groups were living in Giza Governorate, and a few of them were living in Beni-Swif or Qaliubeya/Egypt. Pertinent to diagnoses, it is apparent that less than a quarter of the study group had thrombocytopenia, but the rest of them were diagnosed with other blood disorders particularly anemia, bleeding tendency, and systemic lupus erythematosus, which are actually burdening diseases to the patients, who require regular follow-up, including taking multiple daily blood samples, which puts these patients under anxiety, pain, and adverse symptoms. A study conducted by Jeong et al. (2019), consistent with the results of the current study, declared that patients, especially those with abnormal hemostasis (e.g. hemophilia), require frequent venipuncture for coagulation tests.

Apparently, more than half of the both groups had grade I obesity, with mean±SD BMI of 23.5±1.2 and 23.4±1.2 for the study and the control groups, respectively. There is no doubt that any increase in BMI negatively interferes with the proper needle insertion by hindering the visualization of the vein because of the accumulation of the adipose tissue; thus, it was crucial to do such current technique while drawing the blood sample to facilitate it. Moreover, a study by Ichimura et al. (2014) indicated that BMI negatively correlated with venous palpation; thus, the obese patients’ vein was hard to palpate, which was consistent with the current study findings. Moreover, the BMI measurement is relevant significance. However, a contrary result of a study by Homayouni et al. (2019) investigating the use of one technique by applying a local warming on vein diameter showed no relation between neither the variable of sex nor the BMI or the increase in vein diameter.

Section II presents an elaboration on the study findings, leading to validate the acceptance or rejection of the study hypotheses. In fact, vital signs are among the selected responses as an important variable of this study. In this regard, Ghoreyshi et al. (2019) commented that vital signs reflect the patients’ physiological state in various conditions, which constitute valuable markers, adding that they can reproduce valuable issues required for patients care. Before intervention, the current study findings revealed no statistically significant difference between the study and control groups regarding systolic and diastolic BP as well as pulse and respiration. This might reflect homogeneity of both groups. Similarly, after intervention, no statistically significant difference was found between the study and control groups in relation to the same variables, underlying vital signs. In spite of these results, the researchers noticed that it is worth to mention the variation that occurred in the subcategories of vital signs within the study and control groups. Before needle insertion, almost 6% and approximately a quarter percent of the study group presented stage I hypertension and prehypertension, respectively. These values were dramatically decreased after needle insertion using CVNT, as no one was at the prehypertension category but the percentage of normal BP was markedly increased among the majority of the study group. In comparison, in the control group, 6% of them remained at the hypertension stage I category pre-needle and post-needle insertion, with marked constant result of prehypertension category pre and post-needle insertion. Additionally, almost half of the study group had tachypnea which decreased to be only around a quarter of them after needle insertion using CVNT compared with around one-third of the control group who had tachypnea pre-needle and post-needle insertion period, which reflected a positive optimistic result of this study.

A supporting rationale was found in a study by Movahedi et al. (2007) as they explained that the unchanged values of vital signs are referred to the fact that in short painful procedures, it is possible to detect the physiological changes indicated in autonomic arousal, but adaptation rapidly occurs and the autonomic responses return back to normal. For this reason, there are no detection of physiological responses that directly reflect the patients’ condition. Consistent with the current study result is a research conducted by Yasuda et al. (2019), who investigated the venodilation effects of tapping vs massaging for venipuncture; they found that for each venodilation technique, application was not associated with a significant difference in BP or pulse Additionally, BP and pulse did not differ significantly among the three techniques, which are application of tourniquet, application of tourniquet and tapping, and application of tourniquet and massaging the forearm, as assessed before technique applications.

On the contrary, the current researchers attempted to test the differences within the study group pre-post-needle insertion using CVNT and within the control group pre-post-needle insertion as well. A statistically significance mean difference within the study group itself was found when comparing the selected values of patients vital signs before and after performing needle insertion’ regarding pulse, respiration, and systolic BP, whereas there was no statistically significance difference before and after performing the needle insertion within the control group. Moreover, the same findings were evident by Tokizawa et al. (2017) to be congruent with the current study findings, as there was evidence of improvement in both vein diameter and vital signs of the patients (pulse and systolic and diastolic BP) after applying warm compresses before drawing forearm blood sample.

However, dissimilar to the current study result is a study by Yamagami et al. (2017) regarding evaluating the effectiveness of using only two accompanied techniques via tourniquet application after local forearm warming with that of tourniquet application alone in adults. It was evident that there were no significant differences in pulse or BP between the active and passive warming groups, with all recorded values being within published optimal ranges.

Indeed, all these sanguine results could reflect the positive effect of the CVNT on those patients even regarding pulse, systolic BP, and respiratory rate as compared with many other mentioned studies. This finding assents to the researchers to partially accepted sub-hypothesis H1a of the first hypothesis, as there was a significant difference between before/after readings within the study group compared with the result between before/after readings within the control group regarding pulse and systolic BP and respiratory rate, whereas there was no statistically difference regarding the diastolic BP.

Principally, there is no doubt that for any patient who is undergoing any invasive procedural technique, the chief distressing feeling is the needle insertion, which might put them under remarkable pressure. Health care professionals might be unaware of the anxiety that patients could feel during a venipuncture experience. For many patients, especially adults, venipuncture is the first health care procedure they encounter that seems to be somewhat traumatic.

This result showed that, there was a statistically significant mean of difference in the total scores of anxiety, pain, comfort level, and venipuncture insertion difficulty (related to measure difficulty indicator) between study and control group. The study revealed a marked reduction in the level of anxiety and pain among the study group as compared with the control group, yielding a highly significant difference between both groups. Consequently, there is an apparent increase in the comfort level among the study group.

As pain and anxiety are two interrelated factors, a study by Filbet et al. (2017) documents that venipuncture causes pain that brings up anxiety to the patients. The underpinning tactics and the skillful application of warmth, proper positioning, and the precautionary measures of locating the insertion site and tourniquet application included in the CVNT have collectively contributed to such positive results. The researchers considered this finding as a masterpiece of this study, as it brings the attention to the expectation of pain as an unpleasant sensation, and the concomitant feeling of anxiety may drive the patients to avoid the needling for blood sample, even if it is vital to their health condition.

In consistence with this study, Kiger et al. (2014) stated that applying heat for 2–5 min before i.v. site selection by using dry hot packs may be perceived as the simplest or fastest warming method available to demanding staff. Furthermore, the use of dry heat is recommended by the Infusion Nurses Society. Another supporting study by Ahmed and Ali, (2016) found that 100% of their studied patients had no pain when applying a single technique by using a warm towel for up to 10 min before phlebotomy. So, the researchers accepted the sub-hypotheses H1b and H1c of the first hypothesis confidently.

Regarding comfort level, which is actually considered a broad concept of multi-factorial concern, the current study researchers focused on comfort in relation to two factors: firstly to the needle insertion pain, and secondly to the dry towel heat, which constitute a vital item within the CVNT. It was found that there is a highly statistically significant difference between study and control group regarding both factors, as the CVNT had a positive effect among the study patients, and also it is relevant to mention that the majority of the control group had severe level of discomfort compared with the study group, which have a moderate level of discomfort among half of them. Ahmed and Ali (2016) in congruence with the current finding reported that comfortable measure enhances accessibility to the venipuncture, which promotes patient comfort. Therefore, the researchers accepted sub-hypothesis H1d of the first hypothesis.

The combination of cold and vibration gave significant venipuncture pain relief without affecting cannulation success. Interventions were more helpful for those with greater preprocedural fear.

Regarding insertion difficulty, as measured by ‘measure difficulty, counting time of insertion, and counted trial number of insertion’ indicators, the researchers found that the venipuncture insertion difficulty was improved regarding only ‘measure difficulty indicator’ as one of the insertion difficulty factors in the current study, which occurred after applying the CVNT among the study group. Moreover, as based on one of several studies in consistent with the current study, Homayouni et al. (2019) agreed that local warming could be used to improve venous needling in circumstances when vein insertion is difficult. Thus, in many medical centers and before venipuncture procedure, the nurses advise the patient to warm their skin, and in some cases, there are heating devices which directly warm the skin, which is reasonable and easier to use, as in the current study.

Unfortunately, the researchers found that there was no statistically significance difference between study and control groups regarding ‘counting time indicator’, which the researcher used to assess the time of needle insertion while counting the seconds; however, there was some sort of progression regarding the control group, as almost seven percent and three percent took 30<45 s and 45≤60 s, respectively, for time of insertion, with mean±SD=18.3±9.9 compared with the study groups, which did not exceed 45 s with mean±SD=15.8±6.2. Moreover, regrettably, there was no statistically significance difference between study and control groups related to the ‘counted trial number of insertion indicator,’ with mean±SD=15.8±6.2 and 18.3±9.9, respectively, but an optimistic finding was that the study group had around 13% who made twice trials of needle insertion comparing with one-third of the control who had twice trials of needle insertion.

A study conducted by Platt and Osenkarski (2018) found that the number of successful first attempts for venipuncture nearly doubled after the process improvement program they conducted, and the mean number of attempts at needle insertion was reduced by 30%. Another study which agreed with this study finding has reported that the frequency of venipuncture failures depends heavily on the skill and technique of the staff and vasovagal reactions, which are consequential to an array of hemodynamic and psychological changes occurring in the patient. Then, accordingly, the researchers partially accepted the H2, as only there was a statistical significant difference regarding Insertion difficulty/related to ‘measure difficulty indicator’; however, there was no statistical significant difference ‘neither related to insertion time nor related to number of needle insertion’ indicators between study and control groups.

Apparently, Vuk et al. (2015) highlighted that the blood collection staff should invest efforts to create a pleasant, relaxing environment and to distract the patients’ attention from the unpleasant aspects of venipuncture, thereby reducing the prevalence of unpleasant reactions. Thus, hopefully, the current study result might have highlighted the importance of using combined evidence-based technique to delimit any untoward changes in BP, pulse, and respiration to some extent; decrease anxiety and pain; improve comfort level; and minimize insertion difficulty in the light of difficulty measurement.

Conclusion of the study

Patient with blood disorders often face challenges because of their need for frequent i.v. access. The use of CVNT for venipuncture diminishes the likelihood of multiple i.v. insertion attempts and decreases procedure time, as this study is generally concluded that CVNT was effective in controlling selected vital signs related to respiration, pulse, and systolic BP. and controlling insertion difficulty related to measure difficulty indicator, and also reducing the pain, anxiety, and promoting comfort among patients during venipuncture. Nurses should consider using CVNT technique while developing evidence-based protocols to care for patients who require peripheral i.v. insertion. The CVNT is highly recommended because; it is effective, easy to carry out, and inexpensive. Indeed venipuncture is not as difficult as a surgical procedure or differential diagnosis, but, it is certainly a fine art and an integral part of superior nursing health care practice.

Limitation of the study

The present study had few limitations, as the number of conducted studies on the effectiveness of multi-factorial nursing technique to reduce/control patients’ vital signs, pain, comfort, and difficultly of needle insertion was scanty.

Nursing implication of the study

The current study is significant to patient care and clinical practice because it may potentially delineate a successful and straight forward technique to improve the success of i.v. insertion on first attempt. The technique also is cost effectiveness because of the decreased number of i.v. starts, less nursing time, and the need for fewer i.v.-start supplies. Moreover, this nursing technique might contribute to control anxiety, pain, discomfort, pulse, respiration, and systolic BP in addition to measure difficulty. Training nursing staff to master the skill of venipuncture using such an innovative approach of the customized technique would enable them to be more competent in rendering this important action. Providing a copy of the CVNT in the clinical practice areas would be of benefit as a guiding reference. The results of the current study might be counted as one of an advanced assembled proved performance to practice customized venipuncture safely in clinical practice by using combined techniques.

Recommendation of the study

The study should be replicated on larger samples at different settings to validate and generalize the findings.The same technique should be conducted on other targeted groups that could be compared with other interventions.The current CVNT should be used across patients with different age groups and different diagnoses which requires frequent vein penetration or allocation.Nurses’ knowledge and practice of venipuncture technique as one of the health care team members should be assessed.Education of the nurses to use the CVNT is highly recommended, considering this research findings.[43]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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