Using new research skills: a student nurse, faced with different injection preparation techniques, researches her way out of confusion.

As a year-two nursing student going into a hospital for the first time, I was excited and easily impressionable. I carried with me an expectation that all registered nurses used evidence-based practice and knew the answers to everything. I thought it would be quite unnecessary to use the research skills I had diligently learnt as a student. Surely we only did that to pass our assignments!

How naive I was! Imagine my confusion when I discovered that everyone had a different opinion and way of practice. I thank the staff in ward 7 at Tauranga Hospital who were so very approachable and encouraging, willing to share their practice and indulge my thirst for knowledge. At the same time, they empowered me to use my research skills to satisfy my own burning curiosities.

Having questioned almost every nurse on the ward about how they prepared the patient's skin before giving a clexane injection, I decided it was time to put my new found research skills into practice. I was determined to know why some nurses used alcohol swabs before giving a subcutaneous injection and why some didn't. Was it just personal preference or did someone know something I didn't?

After consulting the Marsden Manual, I discovered that cleansing with an alcohol swab may, in fact, predispose the skin to hardening and does not appear to reduce infections. (1) In fact, a controlled study compared the risk of infections over a six-year period, during which time more than 5000 injections were given to unselected patients without using any form of skin preparation. No single case of local and/or systemic infection was reported. (1) Imagine my confusion when in the next paragraph I read: "The practice at the Royal Marsden Hospital is to continue to dean the skin prior to giving injections." Now I was realty confused!

According to British researcher Barbara Workman, if the nurse maintains a high standard of hand hygiene and asepsis while giving the injection, as well as the patient being physically clean, then skin disinfection is not necessary. (2) If the nurse chooses to use an alcohol swab, then it is important to clean the area for at least 30 seconds and then vital it is allowed to dry for at least 30 seconds, otherwise needle entry will make the site sting, and bacteria are not rendered inactive and could be inoculated into the injection site.

A World Health Organisation (WHO) bulletin published in 2003 states that swabbing clean skin prior to giving an injection is unnecessary. (3) However, if cleaning is necessary, soap and water are sufficient, it says. The WHO's Safe Injection Global Network believes few providers will wait the required contact time before injecting and that unsafe skin preparation protocols may be harmful. (3)

Finding information about evidence-based practice was difficult. I searched the data sheets on both clexane and fragmin via the Ministry of Health's medsafe site (www.medsafe.govt.nz), but neither gave instructions for using alcohol swabs before subcutaneous injections. According to the government drug-funding agency Pharmac, as quoted in a 2004 article, "before you inject, make sure the injection site is clean by either wiping the area with an antiseptic swab or by washing it with soap and water and patting it dry with a clean towel". (4)

In conclusion, my research shows that the use of alcohol swabs is not necessary. However it is vitally important to adhere to rigorous hand hygiene and to ensure the site is not contaminated in any way. If using an alcohol preparation, then it is important to wait the required length of time to reduce the incidence of stinging and inoculation of bacteria at the site.

This article was reviewed by Kai Tiaki Nursing New Zealand's practice article review committee in June 2007.

References

(1) Dougherty, L, & Lister, S. (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (6th ed). United Kingdom: Blackwell Publishing.

(2) Workman, B. (1999) Safe injection techniques. Nursing Standard; 13: 39, 47-53.

(3) Hutin, Y., Hauri, A. & Chiarello, L. et al. (2003) Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections, Bulletin of the World Health Organisation; 81: 7, 491-500. www.scielosp.org/cgi-bin/wxis.exe/iah/. Retrieved 9/02/2007.

(4) Warren, S. (2004) To swab or not to swab? Vision, A Journal of Nursing" 12: 1, 21-22.

Justine Grant is a third-year Waiariki Polytechnic bachelor of nursing student, based at its Tauranga site. She wrote this exemplar when undertaking her second-year practicum placement at Tauranga Hospital.