(Blood) Drawing on Experience

An interview with Sandra Merkel, Julie Piazza, and Michele Mitchell

Could you please share your backgrounds?
 

Sandra Merkel: I have been a nurse for over 50 years. During that time, a colleague and I developed the FLACC (face, legs, activity, cry, consolability) behavioral pain scale, which is now used worldwide to assess pain in nonverbal children. I became certified in Pain Management Nursing and was also an adjunct instructor at the University of Michigan School of Nursing.  The interdisciplinary team that I co-led with Julie Piazza focused on making needlesticks and other procedures more comfortable for children. Interestingly, our results found that the discomfort, experiences, and solutions were similar for adults.

Julie Piazza: I have been a Certified Child Life Specialist for over 30 years now – serving pediatric inpatients, outpatients, and their families in large academic medical centers. Since moving from a front-line clinical child life role to a project management role with the Office of Patient Experience 10+ years ago, many of the projects I’ve been involved with have focused on reducing patient pain and anxiety; the partnership with Sandra on individualized comfort initiatives for pediatric patients has expanded our reach to adult care areas. I also served as primary investigator for an observational study on comfort measures used by phlebotomists performing pediatric blood draws to fully understand their role and the patient experience.

Michele Mitchell: I enjoyed a 25-year career at Blue Cross Blue Shield of Michigan, where I held various Information System Division positions and ran large healthcare-related projects. After I retired, my passion and desire to give back led me down a new path – patient advocacy. I am a breast cancer survivor and my care at the University of Michigan has been outstanding; naturally, my volunteer work led me straight back to the University’s healthcare system.

I have also been volunteering with the American Society for Clinical Pathology (ASCP) since 2016 and my current passion involves the concept of patients meeting with their pathologist to understand more about their disease. As an ASCP Patient Champion and a member of the society’s Patient Champion Steering committee, it is a great honor to educate and empower patients, move the needle on important issues, and make a real difference in healthcare policy, quality, and safety.

What factors can affect the patient experience during a blood draw?
 

SM: To name a few, the presence of a needle phobia, history of a traumatic blood draw or an uncaring experience, severe bruising from a prior blood draw, a general dislike for needles, and dehydration can all affect the patient experience. A chronic illness that requires frequent blood draws, long wait times in the waiting room, and a recent serious diagnosis or change in illness can also impact fear and anxiety.

JP: Phlebotomist stress can negatively impact the situation. Sometimes, due to the aforementioned patient factors, the stressful situation becomes heightened for the phlebotomist due to timing requirements of collection, patient fears, and parent or caregiver fears for pediatric patients. Addressing the stress experienced from both sides of the draw with intentional partnership efforts engaging the phlebotomist, patient and family and focusing on comfort strategies was the intent of our research.

What role do phlebotomists and technicians play in ensuring patient comfort?
 

SM: They play a major role in patient comfort and success of the blood draw. Good skills can make a blood draw faster, more comfortable, and less stressful.

JP: Phlebotomists are key to a successful experience and future experiences. If we can ensure “comfort competencies” are achieved by phlebotomists, the risk of a negative blood draw experience declines and it supports consistency of experience which can help reduce fear and anxiety – and ultimately enhance the healing environment. The phlebotomist could also get to know the patient and help them become better self-advocates by having an individualized procedure plan to support comfort, relieve stress and anxiety, and reduce unnecessary pain associated with the blood draw.

MM: Phlebotomists and lab professionals are an important part of the multidisciplinary care team. There is no disease diagnosed that didn’t start with some type of blood draw and it often provides valuable information on how the disease is progressing and whether treatment is helping. Therefore, phlebotomy, pathology, and laboratory medicine are critical to every diagnosis and treatment plan. Someday, I hope that laboratory professions become an integral part of the patient-facing multidisciplinary care team because behind every test, specimen, and result is an anxious, sick, and tired person wondering what you are looking for – and they’re waiting for crucial answers. Phlebotomists play a key role in the process because they are on the front line of this care pathway.

How could interactions between patients, patient-facing providers, and the laboratory be improved?
 

SM: I have observed phlebotomists and staff who draw blood, start IVs, and administer injected medications. I have also worked with children and advised adults on how to handle their fear and pain associated with needles, developed educational materials, and participated in changing procedures and workflows. Most phlebotomists are skilled in drawing blood and retrieving specimens; however, many do not take the time to establish a caring experience that makes the interaction a positive experience for the patient. There are five simple steps that healthcare providers can take to build rapport and ease patients into the procedure.

1. Introduce yourself and identify your role.
2. Ask the patient about their needs and expectations.
3. Explain what will happen and work with the patient to outline a plan that includes a specific strategy that incorporates their needs.
4. Proceed with care.
5. Once complete, ask the patient how they thought it went.

JP: The key to enhancing patient interactions is through educating phlebotomists. I have worked alongside phlebotomists for many years, helping to prepare children, parents, and caregivers for the procedure, advocating for comfort positioning, and providing coaching on coping skills that can be used before, during, and following a blood draw. We have worked hard to partner with phlebotomists to improve patient, family, and staff experiences by reducing pain and anxiety and increasing comfort, while being mindful of the timing of collection.

In pediatric practice, it’s also important to understand basic child development relating to new experiences, coping strategies, and comfort measures. Implementing simple techniques such as counting, distraction, and positioning can be key to success of current and future procedures. These can also be adapted for adult care. 

MM: I believe the interaction between patients and patient-facing providers can be improved if you think of the encounter as a total experience for the patient – beginning with the person who checks them in. People with medical trauma or past bad experiences are full of anxiety when they arrive, but a warm, friendly demeanor goes a long way. However, the patient will have the most interaction with the phlebotomist or technician. After a warm greeting, asking the patient about their past experiences and poke preferences and techniques that have previously worked for them would be helpful. The technician should then inform the patient on what the procedure will entail – a key step in preparing the patient and setting expectations. At Michigan Medicine, the process of asking these questions and documenting the responses is formalized into a questionnaire known as a “poke and procedure plan.” As a patient, I can download the information from my portal and take it with me to each appointment. The health system has made the questionnaire and content a permanent part of the patient medical record. It’s helpful to know it’s there for my future procedures.

Tell us more about the “poke and procedure plan” – what factors affect its implementation?
 

SM: A poke and procedure plan is developed with the patient to outline what can be done to provide support and comfort before, during, and after a procedure. Patients are asked about any past procedures or blood draws, how they went, and what worked to help with pain and fear. A plan can be developed for any procedure – from surgery and physical therapy to going to the dentist or getting blood drawn. A blood draw might not be a simple procedure for the patient, but a poke and procedure plan makes it easier to encourage the patient to speak up and request measures that help with their fear and pain. It’s important that phlebotomists and laboratory staff are supported by their work environment to successfully implement these plans.

MM: Education is key for both healthcare professions and patients alike. As a “secret shopper” for the poke and procedure plan at Michigan Medicine, I have found varying degrees of familiarity with the program, so I always take the time to inform staff when I arrive for the procedure or at the blood draw station and ask them if they are aware of the plan. If they are unfamiliar with it, I talk to them about the value of knowing the information it covers ahead of time. I also make sure I have my poke/comfort plan documents readily available for the technicians to access – my hope is while it is a part of the standard medical record, perhaps adding a flag on the patient’s record to act as a visual reminder to staff that they have a plan on file. Alternatively, the plan could be attached to the blood draw order or the flag could be added to the receptionist’s screen during check-in. If the patient needs a vascular access team to assist with the blood draw, it can then be requested ahead of time. Ultimately, it all starts with awareness – if patients or medical staff are unaware of the poke/comfort plan existing in the first place or do not see the value in having one, then the process breaks down.

If a patient doesn’t have a poke and procedure plan, how can phlebotomists make them more comfortable with sampling procedures?
 

SM: Further to those previously mentioned, comfortable waiting and procedure areas, facilitating workflows to reduce wait times, educating staff, and establishing a strategy for decreasing anxiety and pain can help greatly.

JP: The environment is key. Creating a healing environment from the start begins with intentional efforts to support comfort for all partners in the care experience. It is essential to introduce the phlebotomist and their role and let the patient know that we care about their comfort. Additionally, we have added a distraction mural in the waiting area with nature images and a seek and find to support evidence-based research on the impact of improving wellbeing simply by looking at nature and wildlife. 

MM: Listen to what the patient is saying and pay attention to nonverbal cues to create a better experience. It’s also important for healthcare professionals to recognize that, when a patient walks through the door, they may have a history of medical or emotional trauma. Of course, this is also true for the technician, who may have just had a difficult time with a prior patient or is experiencing staff shortages, empathy fatigue, and other work environment stressors that can add to the situation, especially if the current patient expresses concern with the procedure. To ease tension on both sides, technicians can ask the patient a number of rapport-building questions, such as:

• Are there any comfort measures that work for you?
• Do you have a preference or specific vein location that works best?
• Would you prefer a butterfly needle?
• How much information do you want during the poke?
• Are there any distractions that might help you?

If possible, creating a calming environment by dimming lights, adding padding or a warm blanket, repositioning, or asking the patient if they would prefer to lay down can help. Making small talk can offer some relief during the procedure; for children, providing a tablet computer for distraction can be helpful.

If the technician has attempted the poke a couple of times without success, the phlebotomist should ask a colleague or supervisor to take over. Many times, I have been forced to advocate for myself and ask for someone else to try, which puts me in an awkward position; however, if I don’t speak up, I am often left with a large hematoma. It’s not a failure on the phlebotomist’s part to recognize when it’s time to ask for help – I know the technician doesn’t want to cause pain, but some patients may have difficulty advocating for themselves.

What role do laboratory medicine professionals play in supporting and promoting patient- and family-centered care?
 

SM: They have a role in developing departmental philosophies, procedures, policies, work rules, expectations of performance, and respect of colleagues and patients. They must embrace the work they do and do it caringly.

JP: Work competencies such as supporting comfort, communication, and partnership in care need to be addressed during orientation for each new employee and serve as an ongoing mission and vision for the pathology department. Engaging with patient-family advisors as part of service delivery is essential – whether it be an advisory council encompassing the entire pathology service (including phlebotomy) or focus groups with patient-family advisors and staff to create training, education, and tools to ensure ideal patient- and family-centered care. It also goes beyond pathology to the many different service areas on the care continuum that are served by their important work.

MM: Pathologists and lab medicine professionals should be considered an integral part of the interdisciplinary care team. Professionals who agree should speak up to embrace patient-centered care and redefine their role by creating opportunities to engage with patients and family members. Treating each other with dignity and respect, listening to and honoring patient and family perspectives and choices, sharing information, and collaborating on care can all have a positive impact on both patient and employee perspectives.

What education should patients and families receive regarding the role of pathology and laboratory medicine in their care?
 

SM: Basic information on the commitment to collect specimens in a respectful and patient-centered manner and a brief explanation of the need for accurate collection, testing, and results that facilitate healthcare plans. Any interesting or quality facts might also be helpful, such as staff certification, highlighting department successes, and materials highlighting the role of pathologists in their care.

JP: I have found that, with both children and adults, understanding the scientific reasons for collecting blood and the ways it can help determine healthcare needs and treatment often reduces many fears associated with the experience. A simple explanation, such as a flowchart or interactive exhibit about what happens to their blood sample after collection and what lab medicine professionals do behind the scenes, would be an excellent waiting area education resource for all ages.

MM: I don’t think patients understand that everything starts with laboratory medicine. Written/video materials on the patient portal or a poster in the blood draw stations highlighting the importance of phlebotomy could help. Although these fall upon the healthcare provider, patients must also take more responsibility for their own care and for understanding their lab results. Patients need to engage with their prescribed treatment plan, ask questions, and partner in shared decision-making with their providers. The shift toward patient education and partnership is forward-thinking and can move us toward more personalized medicine – transforming the healthcare system from doing things to or for patients and toward partnering with them instead.

Sandra Merkel was the Clinical Nurse Specialist for the Pediatric Pain Service at the University of Michigan Health System and is now retired.

Julie Piazza is a Senior Project Manager, Office of Patient Experience and is a Certified Child Life Specialist at University of Michigan Health.

Michele Mitchell is a Patient Advocate who volunteers her time for the American Society of Clinical Pathologists and the American Cancer Society, and serves as Co-Chair of the University of Michigan Department of Pathology’s Patient and Family Advisory Council, Ann Arbor, Michigan, USA.