The main goal of blood transfusion is to treat recipients' underlying disorders and to replace blood loss. Blood transfusion is generally considered safe, but there are risks for adverse effects. It is imperative that the blood transfusion is performed while taking precautions for possible adverse blood transfusion reactions and infectious diseases the donor and recipient may face (Akçay, İncazlı, Kızıl, & Kocabaşoğlu, 2014). To implement the blood transfusion safely, it is very important for health institutions to use national transfusion guidelines and establish blood banks, transfusion laboratories, and blood transfusion protocols (World Health Organization, 2010, 2013). Developing high-quality and safe blood transfusion services can be achieved through collaboration, developing multidisciplinary strategies, and implementing standards based on evidence-based practice. The knowledge and skills of health care professionals are fundamental to developing and strengthening the quality of blood transfusion procedures. A lack of knowledge by health care professionals may lead to an increased risk of mortality and morbidity associated with blood transfusion. For the safety and quality of blood components and transfusion, determining health care professionals' knowledge is necessary for developing educational programs (Hijji, Oweis, & Dabbour, 2012; Vasiliki, 2011; World Health Organization, 2013).
Nurses with evidence-based knowledge on the principles of safe blood transfusion are likely to administer safer blood transfusions and help prevent transfusion-associated morbidities and mortalities. Nurses are required to know each step of a safe blood transfusion procedure thoroughly. Results of studies evaluating nurses' blood transfusion knowledge reveal a need to improve nurses' knowledge, skill, and competence. Their knowledge levels and blood transfusion practices can be assessed using questionnaires and observations. Some studies have shown that nurses did not have sufficient knowledge concerning blood transfusion standards, prevention of possible reactions, and safe blood transfusion practices (Hijji, Parahoo, Hossain, Barr, & Murray, 2010; Lahlimi, Tazi, Sifsalam, Bouchtia, & Mahmal, 2015; Pehlivanoğlu et al., 2011; Rajki, Csóka, Deutsch, & Mészáros, 2015; Saillour-Glénisson et al., 2002). Nurses play an essential role in the blood transfusion process by referring patients pre- and posttransfusion, undertaking patient assessment and blood sampling, and administering the blood transfusion (Vasiliki, 2011). Lack of knowledge may cause nurses to implement unsafe blood transfusion practices or to administer the wrong blood components. The studies regarding nurses' blood transfusion knowledge may guide nurse managers and clinicians to develop regular in-service training to ensure safe blood transfusion administration.
Design and Setting
This descriptive, cross-sectional study aimed to evaluate the knowledge levels of Turkish nurses concerning blood transfusion practices. It was conducted in medical and surgical units and in the intensive care units of two hospitals.
The study population comprised 189 nurses, working in two hospitals, who met the inclusion criteria. A convenience sampling technique was used to form the study sample and aimed for a study population of 189 nurses. Inclusion criteria were as follows: working as a clinical nurse, having completed hospital orientation training, having performed at least one blood transfusion previously, and willing to participate in the research.
All nurses contacted between March 8, 2017, and April 6, 2017, were invited to participate in the study (N = 189). Of the nurses, 184 were recruited to the study. Three nurses could not be contacted as they were on annual leave, and two nurses could not be reached as they were on maternity leave. Of 184 nurses, 13 declined to participate due to lack of time. The sample was developed using a convenience sampling method. A total of 171 nurses who met the inclusion criteria were included in the study; therefore, 90.5% of the target study population had been reached.
Ethical approval was obtained from the ethics committee. The nurses were introduced to the aim of the study, and confidentiality was guaranteed. Written and verbal informed consent was obtained from the participants. Data were collected between March 8, 2017, and April 6, 2017, using the Nurse Characteristics and Knowledge Questionnaire.
The Nurse Characteristics Questionnaire included questions on the sociodemographic characteristics of the nurses (i.e., age, sex, marital status, education level), the hospital unit in which they worked, their length of nursing experience, and their experience regarding blood transfusion. The questionnaire comprised nine questions.
The Knowledge Questionnaire consisted of a total of 40 questions on the nurses' knowledge levels regarding blood transfusion practices. The questionnaire had been developed by the researchers and then revised by nursing academics specialized in medical nursing and, based on their expert opinions, minor changes were made. A pilot test was conducted on a group of nurses (n = 15) working in the medical and surgical units to test understandability and utility of the questionnaire. Following the pilot study, a final version of the questionnaire was issued to the study participants as the pilot study had indicated that the tool was simple to use and apply. The questionnaire included four sections: blood transfusion and blood components, donor selection and principles for safe blood transfusion, blood transfusion reactions and nursing interventions, and prevention and treatment of blood transfusion reactions. The first three sections consisted of 25 multiple choice questions. The last section consisted of 15 true-or-false questions evaluating blood transfusion knowledge levels. In the questionnaire, each correctly answered item scored 1 point and each incorrect answer scored 0 points. The questionnaire scores ranged from 1 to 40 points. Higher scores indicated a higher knowledge level.
Descriptive statistics such as frequencies, arithmetic mean, standard deviation, and percentages were used in data analysis. For statistical analyses, the SPSS® version 16 statistical software was used. The compliance of data with normal distribution was tested through the Kolmogorov-Smirnov test, and, given that the significance value was below .05, nonparametric tests were used in advanced analyses. For two independent variables, the nonparametric Mann-Whitney U test was used, whereas the Kruskal-Wallis test was used for more than two independent variables for comparison with questionnaire scores. The questionnaire scores were compared with personal characteristics, such as age and length of work experience, using Spearman's correlation test.
Blood transfusion is both a life-saving practice and a high-risk invasive procedure. Although blood transfusion supports the clinical condition of the patient, poor practices may occur, resulting in serious adverse reactions. Nurses in transfusion therapy require evidence-based professional knowledge and skills. Improving nurses' blood transfusion knowledge and therapy-related knowledge, and improving their competence to perform transfusion therapy, is likely to improve the therapeutic effects of transfusion therapy and decrease transfusion-related adverse reactions. In the process of ensuring safe blood transfusion, monitoring and safe practices are of great importance.
This study revealed that nurses had a moderate level of blood transfusion knowledge. Similarly, previous studies have revealed that nurses' overall blood transfusion knowledge scores have been poor to moderate in general (Bayraktar & Erdil, 2000; da Silva et al., 2017; Dubey, Sonker, & Chaudhary, 2013; Duarte et al., 2017; Rajki, Csóka, Deutsch, et al., 2015; Rajki, Csoka, & Meszaros, 2015; Tavares, Barichello, De Mattia, & Barbosa, 2015). The nurses' knowledge of transfusion therapy appears to be incomplete, and only approximately half of the nurses undertook the nursing procedures correctly (Rajki, Csóka, Deutsch, et al., 2015). One study reported that nurses' knowledge was moderate (mean knowledge score, 51.3%; Hijji et al., 2012). Knowledge deficits among nurses have been identified in several key aspects of blood transfusion (Hijji, Parahoo, Hussein, & Barr, 2013; Lahlimi et al., 2015). These findings underline the need to improve nurses' blood transfusion knowledge. Clinical training should emphasize indications for blood transfusion, the transfusion of whole blood or blood components, blood storage and transport, and the administrative processes for blood transfusion.
The mean knowledge score regarding blood components revealed that nurses in this study had a moderate level of knowledge. Two other studies (Dubey et al., 2013; Hijji et al., 2012) reported that nurses had poor knowledge of dosage requirements for cryoprecipitate, symptoms of transfusion reactions in unconscious patients, and the storage temperature for cryoprecipitate after thawing, and had been using invalid and potentially harmful methods for thawing blood.
The erythrocyte suspension should start to be transfused within the first 30 minutes postremoval from the refrigerator, and the transfusion should end within 4 hours (World Health Organization, 2010, 2013). In the current study, the nurses' knowledge levels regarding the maximum length of time that could be taken to start transfusing the patient postremoval of blood from the refrigerator were found to be low (35.1%). This is an important finding of the current study that needs to be taken into consideration when developing in-service training. Consistent with our research results, another study reported that only a small percentage of nurses (38.7%) responded correctly to the question regarding the maximum duration to start transfusion after removing the suspension from the refrigerator (Şahin, 2006). Another study reported that the rate of correct answers given by nurses to the same question was 55% (Erkoç, 2010). These study results reveal that nurses do not have sufficient knowledge of the storage conditions of blood and blood components.
Instead of whole blood transfusion, some clinicians may prefer to undertake transfusion of necessary blood components only. In this study, more than half of the nurses answered the Blood Transfusion and Blood Components section questions correctly. In an Iranian study, the nurses were found to have moderate knowledge levels on blood and blood components (66.7%) and blood components transfusion techniques (65.8%; Aslani, Etemadyfar, & Noryan, 2010). Another study demonstrated that 74% of nurses reported that in cases in which the blood scheduled for transfusion was deemed to be cold, murky, different in color, clotted, or contained inside a bag with disrupted integrity, the blood could not be transfused to the patients (Pehlivanoğlu et al., 2011). Many nurses had insufficient knowledge regarding patient preparation prior to blood bag collection and the importance of accurate confirmation of patient identification and how best to ensure this (Hijji et al., 2012). Only one third of nurses (33.3%) in our study correctly answered the question concerning checking the blood bags (“Blood component bags should be checked by one nurse prior to initiation blood transfusion.”). These study results indicate an insufficient knowledge level among the nurses with reference to blood transfusions and blood components.
During a blood transfusion, no medication should be administered via the venous pathways or through the blood sets under any circumstances, and no fluids, except for a normal saline (0.9% NaCl) solution, should be administered (Oxford University Hospitals, 2012). In this study, only three quarters (75.4%) of the study participants were aware that only normal saline (0.9% NaCl) solution could be administered concurrently with a blood transfusion. In Benli's (1996) study, 71.7% of nurses stated that a dextrose (5%) solution could be administered concurrently with transfused blood. Two other studies found that the majority of nurses (> 80%) responded that only normal saline (0.9% NaCl) solution could be transfused simultaneously during blood transfusion (Erkoç, 2010; Şahin, 2006). It is vital to note that normal saline solution is the only fluid or solution that can be transfused simultaneously during whole blood or blood component transfusion.
Compatibility tests are mandatory to prevent blood transfusion reactions due to incorrect blood transfusions and resulting deaths. Performing compatibility tests and administering blood to the correct patient is one of the main principles of blood transfusion (Sarı & Altuntaş, 2007). In the current study, more than half of the nurses (64.9%) incorrectly responded to the question regarding the characteristics of a blood set. Similar to the current study, another study reported that only 66.7% of nurses answered the question regarding the characteristics of a blood set correctly (Benli, 1996). The nurses had good knowledge of the use of standard blood transfusion sets for all blood components (88.7%; Dubey et al., 2013).
It is important to obtain a detailed donor anamnesis and to question the donor with regard to high-risk health behaviors prior to taking blood from the donor under aseptic conditions. The mean score and knowledge percentages regarding donor selection and principles for safe blood transfusion showed that nurses in the current study had a moderate knowledge level. A total of 71.3% of nurses correctly answered questions concerning the characteristics that should be present in the donor, and 80.7% correctly answered that compatibility tests should be performed prior to blood transfusion. Similarly, one study revealed that only three quarters of health care professionals could identify the need for a cross-matching test for compatibility (Kavaklioglu, Dagci, & Oren, 2017). A study undertaken by Hijji et al. (2012) found that nurses had insufficient knowledge of patient preparation and appropriate patient diagnosis (Hijji et al., 2012). The main aim of blood transfusion is to protect the recipient and the donor, which is important to prevent potential transfusion-related infections that may develop in the recipient.
Principles for safe blood transfusion are important for minimizing possible blood transfusion reactions. The current study found that the least correctly answered section involved the blood transfusion reactions and nursing interventions component. The results showed that nurses did not have sufficient knowledge regarding the causes of blood transfusion reactions or the appropriate precautions and interventions required to prevent or manage blood transfusion reactions. Inconsistent with our study results, another study reported that nurses had good knowledge of the signs and symptoms of blood transfusion reactions (79.1%), and monitoring patient vital signs prior to, during, and after blood transfusion (83.4%; Dubey et al., 2013). Another study found that 33% of nurses had limited knowledge of blood transfusion reactions, and 60% were minimally aware of the symptoms of blood transfusion reactions (Pehlivanoğlu et al., 2011). Nurses should be trained to safely perform blood transfusions, and in-service training should be repeated at specific intervals.
The cross-match test is performed to detect the presence of antibodies in the recipient serum against the antigens on the surface of the donor erythrocytes. In this study, the most correctly answered item among the sections was the question “Testing the compatibility of recipient's serum against the donor' red blood cells is carried out by a cross-match test.” This result shows that the nearly all nurses (98.2%) knew about the cross-match test as a compatibility test. In a study by Saillour-Glénisson et al. (2002), nurses were found to have insufficient knowledge on the cross-match test, the pretransfusion appropriateness tests, and posttransfusion reaction development. Similarly, another study found that nurses had poor knowledge especially in regard to the pretransfusion compatibility check (30%), risks in delaying preservation of the blood units (65%), and recognition of adverse transfusion-related reactions following transfusion (40%; Lahlimi et al., 2015). A nurse's knowledge of the cross-match test is important to help prevent acute hemolytic transfusion reactions, which are the most dangerous and deadly transfusion reactions.
The pretransfusion checking procedure should be undertaken at the patient's bedside, with double-checking of the recipient and donor identities; all labels and compatibility tests are also required to undergo double-checking. In the current study, 66.7% of the nurses stated that blood component bags should be checked by only one nurse prior to initiation of the blood transfusion. This result revealed that the majority of nurses did not know that double-checking of the labels on the blood bags, the name of the patient, the protocol number, the blood type, and Rh factor, the date of expiry, the cross-match test, and the compatibility approval written on the blood bag was obligatory. The study results showed that nurses' knowledge was limited regarding the obligatory steps and checks to be undertaken to ensure safe blood transfusion.
Participation in blood transfusion training, the degree level, the number of blood transfusions performed per month, and the length of professional experience were associated with blood transfusion knowledge (Duarte et al., 2017). The current study did not find any statistically significant differences between the Knowledge Questionnaire scores in relation to nurses' education level. Although the difference was not statistically significant, the Knowledge Questionnaire scores of nurses with master's degrees were higher than those with bachelor's degrees or health vocational school graduates. This finding showed that education improves the nurses' safe blood transfusion practices. Similarly, factors associated with blood transfusion knowledge have been identified as including having postgraduate degrees (da Silva et al., 2016). Close monitoring, developing education programs based on nurses' education needs, and more in-service blood transfusion education need to be developed during clinical practice.
This study did not find statistically significant differences between the Knowledge Questionnaire scores of the nurses in relation to the total length of nursing work experience. However, nurses who had worked for more than 6 years obtained the highest knowledge questionnaire scores. This finding suggests that clinical experience improves nurses' knowledge and practice concerning safe blood transfusion. New graduates or inexperienced nurses need more attention to improve their knowledge and require support and education to improve their competence in safe blood transfusion practice. Furthermore, a study conducted involving blood center personnel reported that knowledge among those with more experience was significantly higher (Dubey et al., 2013).
Nurses' knowledge regarding blood transfusion may vary according to the type of work setting. One study found a statistically significant relationship between nurses' knowledge in terms of the work setting and the type of qualifications (Hijji et al., 2013). In the current study, the surgical nurses had a better knowledge concerning donor selection and the principles for safe blood transfusion than nurses who worked in medical units. This result may be associated with the different patient populations and the characteristics of medical and surgical units. One study (da Silva et al., 2016) conducted in hospitalized patients in an oncology unit found that the nurses' average overall knowledge score was 53.6% (in pretransfusion steps, 49.6%; in transfusion steps, 55.7%; and in posttransfusion steps, 63.4%).