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A psychological approach to better phlebotomy.

There was a growing sense of frustration in the laboratory of our Veterans Administration Medical Center. A recent nationwide patient survey conducted by the VA had revealed that patients weren't as satisfied with the lab personnel in this 312-bed hospital as they had been in previous years. We were stung to learn that our service ranked below the national average, and we wondered what the reason was.

Several full-time phlebotomists had joined the staff during the previous year, we realized, and were now working on the front lines of patient care. These phlebotomists, and the medical technologists and technicians who shared blood-drawing duties with them, were well-trained and competent, but apparently they needed some coaching in patient relations.

If some staff members had less than perfect bedside manners, it was hardly surprising. Our phlebotomists received excellent technical training, either in a short course at a local community college or on the job at our laboratory. This preparation, however, almost totally neglects the greatest psychological and emotional challenge of the job: performing anxiety-provoking procedures on patients who are often frightened or irritable, while keeping stress to a minimum.

Could this training omission be responsible for tarnishing the laboratory's image--and for the growing job dissatisfaction sensed among phlebotomists themselves? A search through professional literature and medical technology curricula, for advice on the psychological training of laboratory personnel, proved fruitless. The next step was to consult Dr. Marian Peglar, the hospital's training coordinator for psychology service. Together, we decided that everyone in the lab would benefit from a workshop geared to improving patient interaction skills.

Dr. Peglar offered to develop a training program for all staff members who regularly collect blood. For several days, she accompanied two phlebotomists on their rounds to gain a first-hand understanding of the job.

From this observation, she concluded that blood collection called for three primary skills. The first is social skill, or the ability to establish an empathetic rapport with the patient through greeting, introduction, and conversation. The second was technical or sensing skill--the keen observation of veins and skin, and manipulation of the needle. The third was clerical skill, used to identify patients, write out labels, and organize information with precision and accuracy.

These three skills corresponded closely with three major traits--feeling, sensing, and judging--classified by the Myers-Briggs Type Indicator, Dr. Peglar concluded. This standard psychological test, based on the personality type theory of Carl Jung, is widely used to analyze elements of normal personality. We decided to make these three traits the basis of a workshop exploring the psychological side of phlebotomy. Four weekly sessions were planned as short, fast-paced extensions of the regular coffee break.

We began the program with some basic self-analysis. In the first session, the 10 participants took the three-item test shown in Figure I. This very abbreviated version of the Myers-Briggs test measures how individuals perceive their most dominant traits. We reassured participants that there were no right or wrong answers--only an opportunity to examine personal strengths and weaknesses.

This activity worked well aws an ice-breaker. When we summarized the results on the blackboard, the class was surprised to find that most had ranked "feeling" as their strongest trait. So much for the stereotype of the laboratorian as a cold, clinical type!

After describing the three personality dimensions, we related them to the various tasks involved in drawing blood. The test could help indicate which parts of the job come naturally to an individual, and which pose potential problems. Blood collection requires rapid role changes--from social, to technical, to clerical, and back to social--within the space of a few minutes. These quick transitions can create stress even with "easy" patients, we explained. The group responded with a lively discussion concerning the importance of all three traits in doing a good job, and the danger of overemphasizing any one of them.

As an example, we recalled Larry, a former employee who was highly organized and analytical, but who managed to completely ignore the patient's personal needs. Jeanne remembered how she erred in the opposite direction early in her career, becoming so involved with a terminally ill pediatric patient that she was emotionally devastated when the child died. Others expressed concern that they might have overreacted after similar experiences by withdrawing into impersonal coldness.

The group discussed the possibility of developing a balanced attitude that conveys genuine carring, but still preserves a sense of separateness from the patient. By the end of the period, even the initially skeptical participants were involved, and the discussion could easily have continued long past coffee break.

Our second session focused on attitudes and how they influence performance. Too often, we pointed out, phlebotomists state or imply that they will be taking blood, a negative concept that makes patients feel they will be surrendering something vital. Other collectors convey their difficulty with the task, making the patient feel guilty or anxious.

Everyone agreed that tense patients make tense phlebotomists, and vice versa. The phlebotomist's own natural reluctance to inflict pain compounds the problem. "I hate to hurt them." Paula said with distress, demonstrating a deep-seated anxiety that surely affected her patients as well.

The group was eager to find ways of reducing job stress. There are no easy solutions, of course, but we concluded the session by presenting some techniques for stress management and relaxation. Explore alternative attitudes, we suggested. Communicate the idea that you are providing patients with an opportunity to help themselves; by giving blood, they are making an important contribution to their own diagnosis and treatment. When you solicit patients' help and cooperation, they are more likely to view you as a partner, instead of as a nuisance or a dreaded "vampire."

To help participants deal with daily tensions, we offered some brief training in relaxation exercises. These yoga-like refreshers teach us to identify and control stress by imagining ourselves in a peaceful surrounding, then feeling the tension leaving our bodies through toes and fingertips. As the group breathed deeply together, we noticed that our bodies actually felt lighter, and a few individuals reported that their hands and feel felt warmer from improved circulation.

Our third and most boisterous session consisted of role playing with prepared scripts. We developed three blood-drawing scenarios between a laboratory staff member and a patient. In each, the phlebotomist overemphasizes either feeling, sensing, or judging, as shown in the synopses in Figure II.

The role-playing sessions were a hit. Two volunteers acted out each situation. As you can see from one of our scrips in Figure III, we used broad caricature to make the sessions easygoing and lighthearted. In this scene, the technician shows too much attention to observation and technique while ignoring feeling: "Your veins look really small. Let me take a look at your other arm . . . . Hmm. This one looks worse than the first one . . . . Sure hope those veins don't collapse on me." Not surprisingly, there was a lot of laughter, especially when the points that were made struck close to home.

The role playing led to some serious thinking as well. Jim, who had stuck to his guns on the value of a cool professional attitude, played patient to an overly clerical-minded "judging" phlebotomist. "I felt kind of left out," he commented afterward. "I guess I'll think about changing my approach." Several other members of the group mentioned that they planned to do some self-evaluation, and wondered for the first time how their patients viewed them.

Again, we emphasized the necessity of integrating all three traits--feeling, sensing, and judging--to strike a comfortable balance for both phlebotomist and patient. The group became aware of the tension-provoking effect of words like "afraid," "difficult," "hurt," and "trouble," and the reassurance of "give," "helpful," "calm," and "secure." There is no one perfect way to perform a phlebotomy, we reminded them. Each of us has strong points we can capitalize on, and room for growth in areas we have neglected. Participants exchanged practical ideas and hints that had proved helfpul.

The fourth and final workshop meeting focused on applying the group's new attitude awareness to real situations, especially with so-called difficult patients. In several mini-role-playing scenes, group members discussed various responses to typical patient objections and questions, and devised their own rejoinders on the spot.

For example, we talked about the merits and drawbacks of the following responses to a patient who protests. "I'm not going to let you take any more blood":

"Could you tell me why you feel this way?"

"What made you change your mind?"

"I respect your decision, but I really feel that your doctor needs a blood specimen to give you the best possible treatment."

The first response tends to provoke long explanations and emotional reactions. The second, like the first, is also likely to involve a description of problems and complaints that the phlebotomist can't resolve satisfactorily. We decided that the last statement was preferable, since it restated the phlebotomist's intention while stressing the positive role of blood collection as a part of care.

We kept this meeting rather unstructured to allow for some interesting exchanges. Among the cases analyzed was a psychiatric patient whose crude language and negative comments had personally offended and upset one of the phlebotomists. After discussing the situation, the phlebotomist was able to see that the patient's behavior was part of an overall lack of control, and not to be taken personnally.

After the workshop, the group filled out a brief evaluation from to rate how interesting, useful, or stimulating they found the program. On a scale of 1 to 5, we garnered consistent 4s and 5s. There were also some gratifying written comments: "I'd like additional training in stress management; I think everyone would benefit from it." "This workshop made me more aware of what I'm saying to the patient." "All technical staff in the lab should participate--especially the students."

Acting on that last suggestion, we arranged to present a two-hour version of the workshop to medical laboratory technician students at the local community college. The presentation was so well received that we plan to videotape it for the program's future use. We have also presented it as a traveling workshop for the state's medical technology society. It has proved to be popular, attracting 49 people to a recent session in Iowa City.

The results within our own laboratory are subtle but rewarding. "Before the workshop," one technician said, "I asked myself what some psychologist could possibly teach me about my job. I was really surprised at how much I got out of this course." We noticed one of the phlebotomists taking several deep breaths before entering the room of an irascible patient. "It really helps!" she explained.

Throughout the course, we reminded the phlebotomists that they held highly visible positions. In a very real sense, they are the image of the laboratory, and their attitudes and behavior determine what others see and think of the entire laboratory staff. These days, our phlebotomy staff members seem to devote a little more time and attention to patients, and we hiave high hopes that our service will receive better marks on the next VA survey.

For the blood collection staff and students, the added training and group support have bolstered professional pride and stimulated new, more creative approaches to a demanding and often unrewarding job.
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Author:Peglar, Marian; Snider, Jeanne; Gordon, Jaci
Publication:Medical Laboratory Observer
Date:Sep 1, 1984
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