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Julie Piazza et al. It’s Not Just a Needlestick: Exploring Phlebotomists’ Knowledge, Training, And Use of Comfort Measures in Pediatric Care to Improve the Patient Experience. J Appl Lab Med 2019;3:847-56.


Julie Piazza is Senior Project Manager in the Office of Patient Experience at CS Mott Children’s and Von Voigtlander Women’s Hospitals at Michigan Med.


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Randye Kaye:
Hello, and welcome to this edition of “JALM Talk” from The Journal of Applied Laboratory Medicine, a publication of the American Association for Clinical Chemistry. I’m your host, Randye Kaye.

While blood samples are a routine component of laboratory medicine, the process of drawing blood can induce anxiety in patients. In particular, pediatric patients often exhibit fear of pain and needles, and this fear can persist into adulthood and prevent patients from seeking necessary medical care. Often, the training of phlebotomists is focused solely around clinical blood drawing technique and not patient comfort.

A study published in the March 2019 issue of The Journal of Applied Laboratory Medicine describes the results of a survey administered to phlebotomists in order to assess their knowledge and approaches to pediatric blood draws. The study provides practical recommendations for phlebotomist training to improve comfort and reduce anxiety in pediatric patients and their families.

The corresponding author of this study is Julie Piazza, Senior Project Manager in the Office of Patient Experience at CS Mott Children’s and Von Voigtlander Women’s Hospitals at Michigan Med. Welcome, Ms. Piazza.

Julie Piazza:
Thank you. I appreciate the opportunity.

Randye Kaye:
First question. What is the big deal with needlesticks and how can they impact the overall patient experience?

Julie Piazza:
Well, needlesticks really are the most common healthcare experience for all ages and stages. And what I think is most interesting is it’s actually the most talked about healthcare and medical experience in terms of pain by children. They talk about needlestick pain more so than post-op surgical pain. And that was in the literature and it was really something that we really founded our study on.

Because it’s a repeated experience and common to so many, it’s really relatable. And what we found is that that experience, which is often a first one for children in terms of any kind of healthcare experience that they have, carries on to our lives as adults and actually anxiety can begin in very early stages of development, and then carry on through other medical encounters as the child matures and gets older and becomes an adult.

And then, if it’s not handled, it really can impact an overall patient experience as an adult. So, anxiety grows from a needlestick procedure—it’s really, as I mentioned, often the first invasive procedure that someone will have—and it’s also painful to watch for many when they have a negative experience; often that parent can contribute then to a child’s experience.

So, that’s where we found in pediatrics, that it’s really a family affair and it’s definitely something that we wanted to address.

Randye Kaye:
Absolutely. I think anybody listening has had a personal experience or witnessed an experience like this. So, just tell me a little bit about the survey that you conducted. Who was surveyed, what types of questions were they asked?

Julie Piazza:
So, one of the things that we found in our setting was that from varied clinical backgrounds, whether it be nursing, phlebotomy, child life, even patients and families, we kept on having challenges with the needlestick procedures and it really caused us to dive deeper into what was really an issue on the front line, especially for the phlebotomist.

So, while we were all interfacing and engaging with this, we felt like the phlebotomists were really on that front line very often, and we didn’t know a lot about their experience. And there really was a very big gap in the knowledge in terms of their experience in supporting and training and education related to comfort initiatives. Which in some disciplines, like my background as a child life specialist, I had much more training and education related to providing and supporting comfort, and preparing children and families for procedures like this.

So, in the survey, what we looked for in the questions that we asked were to general phlebotomists. We were asking about their experience, their perspective. We were curious about their day-to-day experience performing blood draws, especially on what their level of stress was related to these experiences. What were the comfort techniques that they were currently using in their practice, and their training and background; how did they become a phlebotomist; what was their educational background? We were curious about how long their training was.

And also, we wanted to find out from some free-answer questions, their self-report, on what were some of the challenges or barriers to their work, and what did they feel most confident about and maybe prepared to handle, versus things that were really hard for them on a day-to-day basis.

Randye Kaye:
Wow! That’s very important. I think the needlestick fear can keep people away from the doctor sometimes and away from treatment that they might need.

So, based on the results of this survey, what did you find, what training is lacking, what else is needed to best equip these front line providers?

Julie Piazza:
From our survey results, we really found that most phlebotomists had varied backgrounds. They came into the field from various points and that was something that we had an inkling of.

I think often a phlebotomy role, it can be an entry level to further medical training. It’s something that we’ve found over the years in our settings and others that this could be a gateway to another profession. But often, there are people who remain in the field, and we were also curious why that happens or what were some things that they were drawn to about the field.

So, what we had was a variance from -- most of our phlebotomists that we surveyed had associate’s degrees, more often than a four-year degree, although we did have some. And they also pretty much, by and large, lacked training in child development specifically and how to address pain and anxiety more specifically. Their training was really focused on technique of the actual procedure, how to find the vein, versus how to approach the patient with anxiety and maybe help them prepare for a procedure that would have some pain associated with it.

So, the survey really indicated that most phlebotomists while citing that anxiety of parents and children was a barrier and stressful and part of their daily work, it was most often not addressed in their training or learned on the job, and often by trial and error to really see what might be possible. And they also commented on using more close at hand resources or things like singing, which we thought was a great technique, but that was something that was sort of unexpected rather having a targeted distraction or a coping technique that they could practice and utilize in their clinical work with children and families.

So, what we found was, based on their experience, we found that they were going to the things that were just more close at hand versus really seeking out another professional maybe to help. Although they might seek out a colleague, we have trained child life specialists within our hospital setting that were being called upon, but not nearly as often, and that was a resource that up until the research study was unfolding that the phlebotomists themselves were really lacking.

Their manager might have known or a supervisor might have known about the resource of the child life specialists that they could call on to support that work, but we found that actual dedicated training, focusing on comfort, was really lacking in their relationship and work with the children.

We also found that the importance of quickly building a relationship of trust proceeding with a positive supportive patient experience from the start and throughout the encounter was new to them in some regards. They were focused again in their training, on the procedure, the technical aspect, and less on more of the environment of care and what they could do to help with that. And that’s been a really wonderful thing to realize and to be able for them to know that it can be the simplest of things like introductions, what is your role and what will you be doing, that often provide that comfort of care, that trust building that can go on for future experiences.

It’s a humanizing experience that helps them to really understand that trust is crucial in the patient and provider experience, and also for the patient to really get that comfort to know, “Oh, we’re in this together.” It’s a message of caring and compassion.

Randye Kaye:
And it goes a long way. A lot of people have spoken about the lack of—or maybe a change, but in the past, the lack of bedside manner training in medical schools. But it’s so important for the front line providers before you even see the doctor to have that change.

Julie Piazza:
Right. And I would venture to say that even though we talked about the variance and backgrounds of people going into the field, I think it’s wonderful when we do have physicians that are now in training, who have had an experience as a phlebotomist. Because that is a really challenging way and to be able to learn through some of these skills and experiences of having things that are invasive, things that are hard that you’re actually involved with building trust and learning some of those techniques. So, I’m excited for the work that we’ve done and the work that can come out of this too in the future.

Randye Kaye:
Wonderful. So, you’ve got some recommendations going forward. Maybe you can specify those and then tell me how you’ll monitor the impact of that because it is of continued importance to monitor that. So, tell me a little bit about the recommendations, how and why you will monitor the impact of them?

Julie Piazza:
The recommendations we have realized through this, the survey and the process of doing the research, is really that practice is amazing and important, and you need to practice things when they go well as well as things when they don’t go so well. And one of the things that we are recommending is how can we—and we are integrating distraction and comfort positions and best words into training with phlebotomists to help them to have some resources to able to mitigate some of this anxiety that is just a natural part of their environment and their work. And also, to provide some really “at the elbow” support, more training, and coaching for support on what went well and how can we improve this.

We’re also recommending modeling those experiences by a child life specialist, a certified child life specialist that has training and development, knows how to introduce and use some best words and techniques and really get down on that child’s level or up the child’s level if they’re an older teen. Just how to support some of those initiatives and really partner together to support training. Because sometimes, it does take that extra effort to be able to mitigate some anxiety or some anxiety that’s built up over time.

And what we were finding was that the phlebotomist might bring another provider in and that would take more time and more resources in from their team and not necessarily have the outcome that was beneficial for the patient or for the provider and increase stress all around. So, I think having those impacts and additions to the training with a background in child development and knowing those ages and stages, and really understanding why a child might be afraid and maybe what to be expected at that particular level of development will be important.

We also have brought in some parents and patients to be able to share and demonstrate and let the staff know. We have patient advisers in our institution that provide lots of feedback and great insights to how can we make a patient experience a better one, and how can we support along the way and really partner together to be able to increase understanding and improve care across the continuum. So, that has been truly very valuable to be able to do some training videos and to partner with child life.

How we will monitor and make sure that those impacts and the changes that we are making are going to make a difference, are many fold. I mean, we utilized the Press Ganey in our institution as a survey to help us to understand involving personal issues. There’s a personal issues index, which actually looks at the emotional care and includes pain control, and it also includes response to concern from participation in the treatment decision. And that information shared by the parent, the caregiver, and the pediatric setting has been really valuable to help us improve that work.

We’re also looking at how well do you feel your child’s pain was controlled or managed in those questions from the Press Ganey are very important to us as well.

We also find that our phlebotomy area has incorporated some satisfaction surveys of their own in looking at how was that patient experience, did you feel welcome in your care, did you feel that your child was provided some comfort during their experience? Did the staff introduce themselves? That was a basic one in the beginning because that was something that we found was very much -- not that it wasn’t ever thought about, but it was something that we really hadn’t called to attention as much in the training.

And what we found is such as a huge turnaround and improvement just by simply highlighting, “Let’s introduce ourselves and support that patient experience right from the start.” And we also, within, I mentioned our office of patient experience here at Michigan Medicine, and what we found is that, inspired by that office along with the IOM, which is the Innovation of Medicine Organization, there has been a process called, “Breaking the rules for better care,” to consider what’s an area or maybe one question that you could make an improvement on. And so, we are involved in this in our institution that helps us to gain information and access to the patient voice and as well as the staff voice. Because it’s definitely for the staff to comment on what they can make an improvement on as well. And it’s important to know that we’re partnering together on this work.

And for the staff development, just to make sure that that’s really working well, we have, of course continued to measure our staff by their engagement and in their feelings of engagement and the care. So, we have a program, “Vital Voices of Staff”, which provides annual feedback in terms of letting us know how engaged the staff are in their particular areas and departments.

And by educating and partnering together, we have found that staff feel their voices matter, and they’re seeing each and every day that their commitment, their dedication or contributions are leading to more satisfied patient and staff experiences. They’re also observing and reporting less pain and less anxiety.

Another big factor to this is we’ve learned about the training and the services, and the education. And so, we’ve embedded a child life specialist to specifically work with phlebotomists and in the blood draw area. And that partnership, and that elbow-to-elbow coaching, and that prioritization of the care so that the child life specialist can then see and they’re seeking out that phlebotomists are seeking out to a child life specialist to help support a patient who may be very high on the anxiety scale.

And then they’re nervous, they’re a little timid about having this blood draw, but the child life specialist has been able to coach the phlebotomist to learn some techniques they can utilize. They can position that patient, they can support, they can ask for individual preferences. Even simple things like, “Does a child want to look away or watch?”

And we have a program called, “The Poke Plan Procedure Program” here that is an individualized comfort measure to help find out ahead of time what’s going to work best for that child, for that family member, to be able to support as well as for going forward, “How can we learn from this experience. If it didn’t go so well today, how can we learn from it for future?” And build that coping strategy and skill in the children and in the families. And ultimately, the staff learn some things as well for making those situations going forward better.

Randye Kaye:
Okay. Wow! Sounds like you’ve come up with a lot of findings and a lot of important recommendations. One final question: if others want to engage in team-based research to improve patient care and comfort, do you have any advice for them?

Julie Piazza:
Yeah. So, I think for one thing, team-based research is so rewarding. First of all, I have learned so much from the team. I mean, I’m a child life specialist by training, so I didn’t fully understand or have that background with phlebotomists. I’ve learned so much from them as partners and also working with nursing, working with our psychology department, our behavioral pediatrics. We were all struggling with an issue and came together surrounding what can we do to help makes this an improved situation and how can we work together on it. And I think that was what was so key to look at.

And I would advise others to leverage some of the data points and areas that you’re seeking to improve at your institution and look for ways that you can collaborate on a clinical research outcome, whether it’s patient safety or quality of care, or the environment of care, or the patient experience overall. These are all areas that collectively we need to consider to improve and enhance the healthcare experience.

And, I think, right now, what seems to be very timely is looking at self-advocacy, how to help patients and families, and also ourselves, to be advocate for what is needed to improve, if there are some ways that we can advocate for—“I do have an opinion about that or I have a choice about that.” And help to teach that at an early age for the child to be able to learn: I can ask that I want to sit up versus laying down. I can ask that I would like to hold my parent’s hand or I can ask for some of these distraction techniques to make a difference. That will improve our skill as patients in a system and learn how to work through some of those relationship building opportunities.

And then, also pain management and non-pharmacological means of addressing pain are really key. And what we’ve seen when it is unmitigated anxiety, is higher levels of stress and higher levels of patients coming forth and saying, “I’m not going to be able to do this without some medication ahead of time.” And that’s really challenging and unfortunate, and we want to be able to help people learn ways that they can cope and have a positive experience in a way that they feel supported and partnered with, that they feel that their voice matters and the choice matters.

I would just say that it really starts with just an idea, just to keep open to opportunities for interdisciplinary partnerships and ways that you can look to seek what fuels your passion and what fuels the energy, and what can make a difference at your respective location.

Randye Kaye:
Wonderful. Well, you brought up a lot of fascinating points all across the board and I thank you so much for joining us today.

Julie Piazza:
Well, thank you. It’s been a pleasure.

Randye Kaye:
That was Julie Piazza from CS Mott Children’s and Von Voigtlander Women’s Hospitals, describing her article, “It’s Not Just a Needlestick: Exploring Phlebotomists’ Knowledge, Training, And Use of Comfort Measures in Pediatric Care to Improve the Patient Experience,” from the March 2019 issue of JALM. Hey, thanks for tuning in to this episode of “JALM Talk.” See you next time and don’t forget to submit something for us to talk about!