From the transcribed data of the three focus group interviews we found patterns and meaning for five themes. The main theme was “Paediatric blood sampling is a challenge for the nurses”, with the subthemes: “Nurses’ feelings of frustration with unsuccessful samplings”, “Nurses believe in team work”, “Venous blood sampling was experienced as the best option”, and “Nurses’ thoughts and needs in regard to developing skills in paediatric blood sampling”. These themes are presented as a narrative, with illustrative quotes describing the participants’ experiences of blood sampling procedure with children.
Main theme: Paediatric blood sampling is a challenge for the nurses
The nurses believed it was more of a challenging process to take blood samples from children than from adults. They viewed the sampling process as more complex and complicated. It was not only the puncture itself which was more difficult, but also the whole situation surrounding it.
“Yes, there’s a huge difference when you’re working on adults but with a child it could be a process that takes a whole morning just to get near them.” (Nurses Group 2)
The nurses felt that they first had to build the children’s confidence to ensure the blood sampling procedure went smoothly. Building confidence was important because the nurses knew the procedure might be repeated several times during the child’s hospital visit. Feeling stressed and wanting to perform high quality care but being unsuccessful was another challenging aspect. The informants were often experienced in adult care, where they felt self-confident, but this changed when they started working in the paediatric hospital.
The participants experienced ethical and moral conflicts related to blood sampling which were challenging, especially when they had to do something against the child’s will. The nurses felt it was inhumane to repeat the blood sampling procedure multiple times. However, the nurses sometimes felt they had no other choice because the sample was key to the diagnosis and proper management of the child.
“How many times is it humane to needle a child? That’s always the ethical question that’s difficult”. (Nurses Group 1)
Working with the whole family was another challenging aspect of the blood sampling procedure. The children’s parents could often interfere and make the nurse’s relationship with the child difficult. For example, the parents could say things that made the nurses feel angry or frustrated.
“No, it’s not really ideal when a parent says: “here comes the stupid nurse to jab you (laughing) and it’ll hurt”. (Nurses Group 2)
Other times the parents wanted to be optimistic for the child, telling them the blood sampling procedure would “go fine with no pain” and that it would be just “one jab”, when the nurses knew this was not true. This made the nurses feel insecure and could lead to lack of confidence and trust between the nurse and child. The nurses often had to deal with the anxiety and fears of both the child and their parents.
The nurses also expressed awareness that children of certain ages or with special needs could present an extra challenge to the procedure. For example, hospitalized children with severe acute or chronic conditions were a category that made the process even harder. The nurses reflected on the fact that the sampling process was time consuming and planning their work could be a challenge. Additionally, the participants felt that moments such as preparations could be challenging but were very important.
“Sometimes when you go in to take samples it all goes really smoothly and that’s good but quite often you have to give yourself time to ensure it goes well, the next time and the time after that”. (Nurses Group 2)
The participants occasionally had poor self-confidence, which could be challenging to cope with. It was easier to help a colleague with a difficult patient than to succeed with their own patients.
Sub theme 1. Nurses’ feelings of frustration with unsuccessful samplings
The nurses experienced frustration around several aspects of unsuccessful blood sampling. Although they might have thought a sampling went well, the hospital lab results recorded in the medical journal reported otherwise, due to pre-analytical errors, such as a clot or haemolysis. The nurses were frustrated that the laboratory never explained what went wrong, merely stating that the sample could not be analysed. Many times the nurses had put all their effort and fighting spirit into the procedure and when the results came back reporting errors, this caused sadness, frustration and anger.
“You get very angry and I called the lab and asked why it was like this and then they had no real answer so then you get really angry.” (Nurses Group 1)
Sometimes the nurses felt that the “machines”, especially the bedside analyses, were working against them. They also perceived that certain blood analyses like the blood gas test, INR coagulation test and amniotic fluid analysis test were difficult to fulfil, which illustrated a lack of knowledge around these aspects. Often the nurses felt they had problems getting too little or too much blood in the collecting micro tubes. The participants thought they had the correct amount and were then perplexed when the laboratory responded by reporting the result to be an “unfilled sample”.
“And then on occasion, when I’ve taken the same sample from a child three times and all three have coagulated each time, and when I really know I turned everything and warmed it up and did everything, that from here on, now there’s something strange – something spooky about it”. (Nurses Group 3)
When the nurses could not believe it was their own mistake, they tried to give other explanations for why sampling was unsuccessful. If not the machines, could it be the quality of materials or even sloppy laboratory staff? The nurses’ ambiguity and uncertainty seemed to nudge them into a blaming culture.
“Sometimes I’ve got the feeling that they just drop the samples and then they (the lab) have the cheek not to report it. Everything went perfectly, and then the haemolysis, you just go what?! Oh no!” (Nurses Group 2)
The nurses thought it was better to send the collected blood samples to the laboratory, even though they were uncertain they had been successful. Often they defended this by expressing concerns for the children in that they did not want them to have too many punctures or suffer from hospital-acquired anaemia. The nurses felt the doctors were unaware of how many blood samples they prescribed or the risks of anaemia, which led the nurses to difficult prioritisations.
“What priorities so we can try to take them if you’ve jabbed (the child) once or twice to get the first samples then you want to chance it and send them, sometimes you can write ‘very difficult patient to needle’ so sometimes I do that…it’s kind of the best we can get”. (Nurses Group 1)
There were occasionally situations when help was needed but not given from elsewhere and communication was poor. The nurses felt frustrated, bringing their concerns for the child in focus.
“Yes, but it feels disappointing. I’m not asking help for my sake – I can push the needle in ten times but it’s for the child’s sake, isn’t it – so you don’t damage the vessels.” (Nurses Group 1)
During the interviews the nurses frequently expressed uncertainty about how to handle the samples or about what and why pre-analytical errors occurred for their specific sampling.
Subtheme 2: Nurses believe in team work
As demanding and complex as the blood sampling can be, the nurses said they felt the presence of facilitators could ease the procedure. They believed a supportive team and good communication would contribute to successful sampling and that having at least two to three colleagues on hand during the procedure was a good idea, helping them to make use of distraction methods and manage the samples effectively.
“…better if there’s more of you, not just for distraction but also so you have someone who can hand you things, stand and turn tubes”. (Nurses Group 3)
The nurses felt that both physical and psychological support from each other were essential for a qualitative sampling procedure. They mentioned that they were able to ask for help and, if necessary, they could spontaneously change blood sampling method or even who was in charge of the needling.
“…but it’s also thanks to having such great back-up and support from our colleagues that no-one ever sighs when you ask for help, they’re very positive and cheerful”. (Nurses Group 1)
During the interviews, the nurses described experiences which showed that they had a deeper understanding of the child’s needs and comfort. They viewed good communication in the team with parents as important and often of benefit in the situation.
“But they (the parents) are really important in it going well. Because if they start getting stressed about things or say stuff that has nothing to do with it or whatever, it can go belly up because of it”. (Nurses Group 2)
The experienced nurses often investigated the child’s condition first and could feel when sampling was unnecessary, prompting them to ask the clinicians to rethink the ordering of blood samples in order to reduce the number of punctures.
Subtheme 3: Venous blood sampling was experienced as the best option
Another subtheme was “Venous blood sampling was experienced as the best option”. The different sampling methods discussed were capillary- and venous blood sampling. During these discussions, the participants interacted and asked each other questions about which method they preferred. Pros and cons were discussed and venous sampling was mainly viewed as the best option by all focus groups. The nurses said venous sampling could benefit the blood flow and increased the chances of capturing good quality blood specimens.
“If you’ve learnt venous it’s easier than capillary, better flow and it increases the chances of getting good samples”. (Nurses Group 1)
One of the participants was positively surprised when she performed a venous puncture on an infant, which led to her suddenly having collected six micro tubes without problem, the tricky part instead being that she had too much blood to handle.
Choosing a method according to the individual child in front of them was described as important. The nurses felt that they had many factors to think about, such as the child’s age and developmental stage. One nurse stated that the choice of sampling method could minimize pain for child.
“It depends on the child. I often think it hurts more if you sample the finger.” (Nurses Group 2).
In regard to capillary sampling, one participant explained it as a minor procedure, while another stated it was seldom used. However, capillary sampling was possibly a better choice if a child had special needs, for example, spasticity. Getting the right amount of blood for the ordered analyses was another aspect discussed in regard to choosing the right method. For the nurses, the fewer punctures they made, the better.
“And then maybe it only takes one needle in the vein instead of three capillary, yes, to get enough blood”. (Nurses Group 3)
Blood sampling is a multifaceted task and the nurses described their skills in planning for the best interests of the child. If the child needed a periphery cannula, the nurses tried to collect blood specimens at the same time from the same cannula. The nurses said that when patients had a new existing cannula, it made things more pleasant for both them and the child, as they could continuously withdraw samples without punctures and pain for the child. It was necessary to plan your procedure accordingly, due to the few available chances nurses have for collecting blood. Another factor the nurses discussed was the limited number of visible and small vessels a small child has.
“ …Not just to have fewer needlings but also because you might not have that many chances to take, in the first instance, venous samples – they’ve kind of got a certain number of vessels that are even possible to try on”. (Nurses Group 2)
Subtheme 4: Nurses’ thoughts and needs regarding skills development in paediatric blood sampling
The last subtheme was “Nurses’ thoughts and needs regarding skills development in paediatric blood sampling”. The nurses described how it felt to lack knowledge of paediatric care and mentioned what they had missed out on during their introduction programs or even university nursing education. Some participants also felt important information had been omitted about the differences between paediatric and adult blood sampling procedures and that university nursing programs had failed to mention this in their training. The nurses felt that learning by doing and by observing colleagues was the main way nurses embraced knowledge. They reflected on their own competence related to blood sampling children, stating that they often tried to “join in” with more experienced colleagues conducting blood sampling procedures to discover “tips and tricks” for their own use. The first focus group stated that, in future, they would like an annual cardiopulmonary resuscitation(CPR) course in sampling techniques.
“Everyone should get trained...just like getting CPR once a year, you can have needle training once a year.” (Nurses Group 1)
Another aspect was that some nurses lacked education concerning preparations and choosing the right blood sampling method, as well as knowledge about the amount of blood that could be taken from the children.
“The thinking around sampling and perhaps a bit more on which ones I can actually take from capillaries and which ones have to be venous, so that’s what I wish I had in my training.” (Nurses Group 3)
Some nurses said that simulation training was a bonus during their paediatric nurse introduction, but that it did not feel like reality and could not simulate real clinical situations they experienced. The nurses were eager to learn more and wanted to improve their skills but did not know how and when it could done.
“It’s hard to practice all situations on a simulation doll or things like that, also that there are things that have to be done in order to improve”. (Nurses Group 2)