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Describe in detail the difference between electric potential and potential energy by giving examples and presenting relevant formulae. 2. Discuss how levitation can be achieved by using super conductors. PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET AN AMAZING DISCOUNT 44 The research design was ethnographic The purpose of this assignment is to identify specific parts of the research process. Some of the answers may require only one sentence, such as in the examples below: The purpose of this study was to investigate the bank teller culture of group normative behavior. (section, paragraph, page number). The research design was ethnographic. Quoting what an author/s exactly said in a research report is acceptable, however quotation marks must be used with the page number where the quote can be found, so as to avoid plagiarism. As you look for the answers to the questions asked about trhe research study but the author/s did not provide the information, then state that it was not provided in the report. Do not make-up something that is not there and look carefully before making the decision that the information is missing. Note: When analyzing a research study report, the abstract should not be used, since specific details contained within the report are not represented in an abstract. 1. ____Problem (1) What was the problem the study was conducted to resolve? The situation was: The problem was: 2. ____Purpose (1) What was the purpose of the study? 3._____ Research Method(1) What was the research method? 4._____ Research Design (1) What was the research design? 5.____ Research Questions (2) What was/were the research question(s)? Note: if the report does not contain a research question, write one that would be applicable for this study 6.____Review of Literature (3) How was the literature review organized in relation to the topics presented and discussed? Were historical sources cited, as well as current ones, published within five years of the study’s publication date to support the need for the study? How many sources were current and how many were historical as presented in the references? 7.___ Sampling and setting (3) What was the sample and what was the non-random sampling technique used to choose the sample from the population? What was the size of the sample and was it adequate for a qualitative study? Provide a rationale. Was data saturation used to determine sample size? In what way was the setting in which data were collected appropriate for this study? 8._____Data Collection (3) What were the qualitative data collection techniques used? Why were the data collection techniques consistent with a qualitative method as compared to a quantitative method? 9. ____Ethics (3) How was confidentiality of the participants protected? How was anonymity of the participants protected? Was informed consent obtained? How? Did the author/s obtain approval from an ethic’s board? 10 ____Credibility (4) What specific methods were used to decrease researcher subjectivity when collecting data? How would these methods increase objectivity? 11____Data Analysis Procedures (4) Were descriptive statistics used and if so, what data were analyzed by which specific descriptive statistic? What were the themes, patterns, and/or categories found as a result of the data analysis? 12.____Limitations (1) What study limitations did the researcher/s identify in the report? 13.___ Recommendations for Future Research (1) What suggestions for further study were identified by the researcher/s? 14. ___Replication (1) Is the description of the study sufficiently clear for replication? Is there information about any of the steps of the research process not provided that would need to be known, in order to replicate the study? 15___ Logical progression and transition of thought, current scholarly sources, correct spelling, punctuation, and grammar, cover page and APA format/style of English usage (3) A Qualitative Study of Phlebotomy Device Selection Downing, Jennifer; Yoder, Linda H ; Kirksey, Kenn M . Medsurg Nursing 20.6 (Nov/Dec 2011): 291-5. Turn on hit highlighting for speaking browsers by selecting the Enter button Abstract (summary) Translate AbstractTranslate Limited research exists comparing Vacutainer versus butterfly phlebotomy devices. The purpose of this study was to examine decision processes staff use when choosing a device. A qualitative, purposive sampling was used and determined a gap between correct device use and reported practice. Applied findings can enhance employee safety. Full Text • Translate Full textTranslate • Turn on search term navigation Headnote Limited research exists comparing Vacutainer® versus butterfly phlebotomy devices. The purpose of this study was to examine decision processes staff use when choosing a device. A qualitative, purposive sampling was used and determined a gap between correct device use and reported practice. Applied findings can enhance employee safety. Under pressure to conciliate skyrocketing health care costs, many hospital administrators decided nearly 20 years ago to decentralize laboratory collection teams. This change in practice resulted in nursing and support staff, such as clinical assistants (CAs), assuming the primary responsibility for blood collection, a practice previously relegated to phlebotomists from a centralized laboratory. For many hospitals, the assumed benefits included a more efficient collection process with increased patient satisfaction scores due to fewer individuals interacting with the patient (Mannion&Nadder, 2007). Critics of this model cited surges in contaminated blood cultures, misidentified samples, increased specimen-rejection rates, conflict between laboratory and nursing staff, and patient dissatisfaction due to multiple venipuncture attempts (Ernst, 2009). Health care providers rely heavily on laboratory results to make patient care decisions, but only limited research has addressed devices used to collect blood (Hefler, Grimm, Leodolter, &Tempfer, 2004). Al – though a variety of devices are available, the butterfly and straight needle with an attached Vacutainer® are the most common methods for obtaining blood (Scales, 2008). Some debate has addressed the efficacy of Vacu – tainer versus butterfly devices in phlebotomy (Hefler et al., 2004). One important facet of this debate largely has been overlooked: the rationale used by hospital staff when selecting a particular device to collect blood. Factors that influence the selection of phlebotomy devices must be identified in order to ensure optimal cost containment, provision of care, and patient satisfaction. Evaluating the rationale for device selection can reveal direct care providers’ experiences, including device safety. Therefore, the purpose of this study was to examine the decision- making process nurses use when choosing a phlebotomy device. Review of Literature An extensive review of the literature revealed no published studies examining the decision process staff nurses use in choosing a Vacutainer or a butterfly device to perform phlebotomy. Studies published from 2000-2010 were reviewed in the following databases: CINAHL, Cochrane, PubMed, Guidelines.gov, and Clinical and Laboratory Stand – ards Institute. Decisions about the efficacy of select phlebotomy devices are a growing concern. Traditional methods of obtaining blood specimens using a straight needle have been thought to result in reliable laboratory specimens due to lower he – molysis rates (Grant, 2003). How – ever, proponents of winged steel instruments have argued “the butterfly collection device is thought to increase the success rate of venipuncture and to decrease patients’ discomfort” (Hefler et al., 2004, p. 935). Hefler and colleagues (2004) conducted a prospective pilot study directly comparing success rates and patient discomfort during phlebotomy collection using a butterfly and Vacutainer. Patients were assigned randomly into groups of 20, stratified by phlebotomists. Twelve phlebotomists performed a total of 1,154 venipunctures. Multiple conditional logistic regression analysis was used to evaluate the device collection success rate, while general linear mixed model analysis was used to evaluate patients’ pain. Researchers found use of the butterfly device increased the chances of a successful venipuncture and the ability to obtain adequate amounts of blood, and also de – creased patients’ pain perception. To date, this is the only study directly comparing the Vacutainer to the butterfly in practice. Therefore, the research question for this study was as follows: What factors influence nurses’ decisions to use a butterfly versus a traditional Vacutainer needle device for phlebotomy collection? Methods A qualitative descriptive methodology was selected for this study. This design was chosen because it is “the method of choice when straight descriptions of phenomena are desired” (Sandelowski, 2000, p. 339). Due to the lack of research about this topic, use of this method also provided the foundation for further exploration of the topic. A purposive sampling technique (Holloway & Wheeler, 2010) was used to select a heterogeneous group of nurses and CAs from three different acute care units in a large metropolitan hospital. The study was approved by the hospital’s institutional review board, and written informed consent was obtained from all participants. Each informant supplied personal demographic data prior to the interview. Demographic Characteristics Eligible participants included registered nurses and CAs who performed phlebotomy on adult pa – tients on a routine basis. Twenty-five interviews were conducted to create a sample of 14 nurses and 11 CAs. Study participants were employed in medical-surgical (n=9), emergency department (ED) (n=8), and postanesthesia care units (PACU) (n=8). See Tables 1 and 2 for summary of demographic data. Data Collection and Analysis Informants were interviewed in a private room near their respective work areas. Participants were asked to identify the type of device they normally used to collect blood specimens and reasons for that choice. Probing and clarification questions followed as needed. Examples of probing questions included the following: What factors influenced your choice to use a particular blood collection device? Are there any patient factors that influenced you to use a Vacutainer versus a butterfly? The researcher digitally recorded each interview and took field notes during each meeting. Digital tapes were transcribed verbatim by a transcriptionist. Registered nurses and CAs were interviewed until data saturation was achieved (n=25). Data saturation is achieved when the interviewers begin to hear consistent answers to the interview questions. At this point, the researcher can be confident further interviews will not reveal any new aspects of the experience being studied (Holloway & Wheeler, 2010). Content analysis was used to determine emerging themes. Each interview was reviewed line by line several times throughout the data collection process. Informants’ perceived experiences were grouped into emerging codes. As analyses continued, similar codes were collapsed into emerging conceptual themes. Analytical memos outlining the decision process for coding were maintained. Once the data were analyzed, member checking was conducted to ensure trustworthiness and themes were validated. Member checking is a qualitative technique that involves meeting with the original study participants or a representative group to review the themes coded from the interviews (Holloway & Wheeler, 2010). Participants were asked if the data were reflective of their experience with obtaining blood specimens. Findings The decentralized phlebotomy experience of hospital staff is complex. Nurses and CAs identified several influencing factors when choosing to use either a butterfly or Vacutainer to collect blood. Many informants described a passionate predilection for their preferred phlebotomy device. I always use the butterfly. The Vacutainer is not even an option. I don’t even think of it. And if there’s none there, I’ll search for a butterfly. [I] will never use the Vacutainer – ever! I will hunt on another floor to get a butterfly before I do a Vacutainer. Staff members often stated their preferences were driven by the demand to collect laboratory specimens in a rapid and reliable manner. Preferences were conceptualized as “choice factors,” or reasons that influence nursing staff decisions to use a particular phlebotomy device. Four choice factor themes were identified: (a) preference for the mechanical features of the butterfly, (b) ability to manually manipulate the butterfly, (c) a patient’s co-morbidities, and (d) vein quality. In addition to the identified themes related to the original research question, an incidental finding highlighting a variety of phlebotomy techniques emerged during the course of the study. Device Preference Nurses and CAs stated a preference for the butterfly when performing phlebotomy (see Table 3). However, nursing practice in the ED and PACU requires starting an intravenous (IV) line first and obtaining blood specimens from that catheter rather than performing separate venipuncture for collecting blood specimens. In this situation, the researchers probed further and asked nurses if an IV was not needed, which device would they choose? All seven informants indicated preference for the butterfly. Choice Factors Mechanical Features Nursing informants expressed a preference for the mechanical features of the butterfly: the wings, extension tubing, push button safety feature, and flash (see Table 4). One informant explained this preference in this way: “[The butterfly], it’s small and easy to handle. The wings on the butterfly allow you to get a good grip on it for advancing and moving around.” Furthermore, many staff members reported the push button on the butterfly was a superior safety feature to the Vacutainer flip cap. This safety device consists of a small button located on the butterfly hub between the needle and extension tubing. After collecting a blood specimen, the nurse activates the push button and a spring withdraws the needle into the hub of the butterfly to create a protected device. One nurse said: Here in the ED, where there’s always a lot of people around, if we have a critical patient, and somebody can bump into you, type thing. I just feel safer with the butterfly or an IV. With the butterfly needle, it’s in there until you eject and the needle goes into the safety part of the needle, so you really don’t have a chance to stick yourself. With the Vacutainer, you pull it out and you have the needle exposed. Nurses also expressed a preference for the butterfly because of the ability to see flash or blood as it enters the extension tubing of the butterfly. Once flash is obtained, a practitioner knows the needle is in a vein and he or she may proceed with sample collection. Manual Manipulation Many informants expressed a preference for the butterfly because it was easier to manipulate. This practice was conceptualized as the ability of the nurse to grip or reposition the phlebotomy device once the needle was inside a patient’s vein. As one medical-surgical nurse stated: I have a hard time with the Vacutainers, because there’s not enough physical room…where if you use a butterfly, you’ve got the little tubing, and I just find it easier to maneuver and put the tubes in. Other informants found the butterfly easier to angle into small veins. One PACU nurse stated: Like our dialysis patients, they have no veins, so mostly you’ll have the smallest, little, tiniest veins, and usually the butterfly works the best for that, the tiny butterfly. Just again for the angle factor, because of the Vacutainer being so round, you can’t get a good angle in. With the butterfly, you can pretty much go right alongside of the skin to get it. Patient Co-Morbidities Many informants listed patient co-morbidities as influencing factors in phlebotomy device selection. These specifically included dehydration, obesity, altered mental status, history of mastectomy, hemodialysis, or advanced age. As one of the CAs described her rationale, “The butterfly would be used like in a case [where] we have a lot of geriatric patients, older people, and people on dialysiswhere their veins are really difficult.” CAs listed patient co-morbidities as the most important factor when choosing a device (see Table 4). As one clinical assistant explained, “If a patient, mostly, like an older patient maybe in their 80s or 90s and I can see that they are hard sticks, I don’t want to stick them twice, so I usually go for the butterfly because it’s easier for them and for me also.” Vein Quality Another recurring factor cited by the nursing staff was patient vein quality. Good vein quality was characterized as vessels that were large, easy to palpate, and simple to visualize. Poor vein quality, or a “difficult stick,” was defined as veins that were small, rolled when palpated, were covered with sclerotic skin, and difficult to visualize. Following is a typical comment reflecting this theme: “If it is an easy vein and an obvious stick, wide enough surface, I’ll use a Vacutainer. If it is a small vein and deep, most likely I’ll use a butterfly.” In contrast to the registered nurses, who cited technical factors such as mechanical preference, the CAs tended to look at the patients when choosing a device. When asked what factors influenced her choice to use a particular phlebotomy device, one CA explained: Simply the patient. You know, just I assume I’m going to use the Vacutainer and straight needle, and look at the patient, look at their veins. If it’s pretty obvious to me that they are very small veins or very fragile veins or, you know, just from looking at the patient and palpating and stuff like that, then if necessary use the butterfly, but I actually find it a lot easier to use the Vacutainer, for the most part. But at the same time, without the butterfly, there are many people that it would do more harm to. If they have very fragile veins, I’m going to end up just putting too much pressure on it, blowing it, and it’ll bruise them. Phlebotomy Techniques In addition to the previous results, a few incidental findings were recognized during the course of the study. Informants reported using a variety of methods to get veins to “pop,” or rise to the surface of the skin for easier visualization. These techniques included wrapping the patient’s arms in warm blankets, applying heat packs to the phlebotomy site, or employing multiple tourniquets. Although a practitioner generally will place one tourniquet on a patient’s arm to help the vein engorge with blood, informants reported placing two or sometimes three tourniquets on a patient’s arm. Practice standards dictate one tourniquet should be applied so it impedes venous return, but does not obstruct arterial flow. The rationale for using a tourniquet is to promote venous filling, while preventing ischemic injury to the limb (Scales, 2008). Incorrect application of a tourniquet or application of multiple tourniquets puts a patient at risk for ischemic limb injury. In addition, a tourniquet left in place for longer than 1 minute can be associated with increased risk of specimen hemolysis (Saleem, Mani, Chadwick, Creanor, &Ayling, 2009). Other identified phlebotomy tech – niques included incorrect activation of the push button safety devices on the butterfly. As one nurse stated: I find the patients will generally complain if I use the retracted device while it’s in their arm, so I pull it out and then hit the button, and I point it away from me, so that it doesn’t spray up into my face. Although concern for patient safety often was considered, incorrect phlebotomy techniques were noted that increased staff risk for accidental needlestick injuries. Discussion Phlebotomy often has been presumed to be a routine nursing procedure in many settings (Scales, 2008). It has been believed widely that nurses receive phlebotomy training in nursing school. This assumption has led to unregulated training, which has resulted in a lack of standardization of blood specimen collection procedures. Inferior phlebotomy technique is a distinct challenge for organizations with decentralized phlebotomy that do not employ properly trained phlebotomists, but instead rely on nursing staff to perform this procedure. During their training, many nurses are not taught correct collection techniques (Appold, 2009). Without standards, many phlebotomy techniques may be used and thus increase the possibility of a needlestick injury. An interesting revelation from the current study was the different approaches nurses and CAs took regarding phlebotomy device selection. Nurses tended to approach blood collection from a technical view, gravitating to the butterfly device with its similarity to an IV insertion device. Conversely, CAs tended to evaluate the patient, considering co-morbidities and vein quality. While it is beyond the scope of this article to hypothesize regarding this difference, it is interesting to note the educational preparation of each group. In the study site, nurses and CAs received very different phlebotomy training. As previously noted, the assumption was that nurses received phlebotomy training in their basic education. When they entered the hospital system, phlebotomy training was reviewed in orientation. The nurses then had to complete two witnessed blood specimen collection episodes to be considered competent. However, as unlicensed personnel, CAs were sent to training at a local community college and had to perform 30 witnessed blood specimen collections to be certified in phlebotomy. Limitations Data were collected from nursing staff members in only one multi-hospital system. Transferability could be limited because all informants were employed by a large hospital network located within an urban setting. Replication of this study in another institution may reveal findings that support or contradict these results because supplied phlebotomy de – vices and network polices may vary among health care organizations. In addition, member checking for this study was conducted several months after the initial interviews were concluded, creating the possibility in – formants’ perceptions may have changed over time. Implications for Practice Findings from this study have raised interesting questions concerning workforce development. A gap was identified between correct use of phlebotomy devices and reported nursing practice. A standard of practice clearly is needed if hospital leaders are to continue using a decentralized phlebotomy approach involving nursing staff in blood specimen collection. Training modalities should be regulated and reinforced. Standardization of training may reduce patient injuries as well as increase workforce safety. Alternately, hospital leaders should consider concentrating this skill to the CAs or returning to a centralized phlebotomy model. Conclusion Although blood specimen collection is a routine procedure performed by nurses, it is incorrect to assume no research is needed in this area. Results of this study demonstrated that choosing a phlebotomy device is a more intricate process than previously presumed. Findings from this qualitative study suggest larger, qualitative and quantitative studies about blood specimen collection training, procedures, and specimen outcomes (e.g., hemolysis and number of repeat collections) should be conducted. Although hospital nursing leaders may desire selection of phlebotomy devices to be somewhat based on cost, none of the informants in this study presented cost as an influencing factor for device selection. Finally, hospital/ nursing policies should be based on the best evidence to support the type of device used, as well as steps in the phlebotomy procedure. References REFERENCES Appold, K. (2009). Solving phlebotomy problems. Journal of Continuing Education Topics and Issues, 11(3), 102-105. Ernst, D.J. (2009). Has decentralized phlebotomy run its course? Medical Laboratory Observer, 41(11), 20, 22. Grant, M.S. (2003). The effect of blood drawing techniques and equipment on the hemolysis of ED laboratory blood samples. Journal of Emergency Nursing, 29(2), 116-121. Hefler, L., Grimm, C., Leodolter, S., &Tempfer, C. (2004). To butterfly or to needle: The pilot phase. Annals of Internal Medicine, 140(11), 935-936. Holloway, I., & Wheeler, S. (2010). Qualitative research in nursing and healthcare (3rd ed.). West Sussex, England: Wiley- Blackwell. Mannion, H., &Nadder, T. (2007). Three alternative structural configurations for phlebotomy: A comparison of effectiveness. Clinical Laboratory Science, 20(4), 210- 214. Saleem, S., Mani, V., Chadwick, M.A., Creanor, S., &Ayling, R.M., (2009). A prospective study of causes of haemolysis during venipuncture: Tourniquet time should be kept to a minimum. Annals of Clinical Biochemistry, 46, 244-246. Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23, 334-340. Scales, K. (2008). A practical guide to veni – puncture and blood sampling. Nursing Standard, 22(29), 29-36. AuthorAffiliation Jennifer Downing, MSN, RN, CCRN, is a Critical Care Nurse, Seton Healthcare Family, Austin, TX Linda H. Yoder, PhD, MBA, RN, AOCN®, FAAN, is Associate Professor, and Director, Nursing Administration and Healthcare Systems Management, The University of Texas at Austin School of Nursing, Austin, TX. Kenn M. Kirksey, PhD, MSN, RN, ACNS-BC, is Senior Nurse Scientist, Seton Healthcare Family, Austin, TX. Acknowledgment: The authors wish to thank Deborah Castro, RN, for her prior contributions to this project. Word count: 3234 Show less Copyright Anthony J. Jannetti, Inc. Nov/Dec 2011
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