Sacred Cow University: Revealing the Evidence about Intramuscular Injections by Pediatric Nurses in a Tertiary Care Pediatric Hospital.

Every year Society of Pediatric Nurses (SPN) members compete for and are rewarded national and regional grants to support their clinical inquiry efforts. The support to raise and probe clinical questions is an important way to advance the practice and science of pediatric nursing. The following project was funded by the 2015 SPN Research and Evidence-Based Grant. Recipients are encouraged to share their clinical inquiry work with the membership through the journal. As novice authors, they are provided with mentoring assistance by the SPN Department editor. The authors provide a clear description of how the initial evidence-based practice process progressed to the next equally important step of changing practice. This project reminds nurses that it is important to challenge accepted practice, ask questions, and read current nursing literature. Practice change endeavors are most powerful and effective when clinical nurses initiate questions and search for ways to improve care. As nurses enter into the practice of their chosen profession, they begin to implement knowledge and skills learned in their basic nursing programs. They are encouraged to continue learning throughout their careers and to question why they do what they do and the way in which they do it. In so doing, they seek to improve the quality of nursing care. When questions surface, there are processes available to systematically collect and analyze information to determine the best nursing practice. The Iowa Model of Evidence-Based Practice to Promote Quality Care (Tilter et al., 2001Tilter M.G. Kleiber C. Steelman V.J. Rakel B.A. Budreau G. Everett L.Q. Goode C.J. The Iowa model of evidence-based practice to promote quality care.Critical Care Nursing Clinics of North America. 2001; 13: 497-509Abstract Full Text PDF PubMed Google Scholar) is one method used to guide nurses toward answers to their questions, leading to the understanding and adoption of quality nursing practices. The steps of the Iowa Model include: 0) cultivating a spirit of inquiry, 1) asking clinical questions in PICOT (population, intervention, comparison, outcomes, time) format, 2) searching for the best evidence, 3) critically appraising the evidence, 4) integrating the evidence, 5) evaluating the outcomes, and 6) disseminating the results (Melnyk et al., 2010Melnyk B.M. Fineout-Overholt E. Stillwell S.B. Williamson K.M. Evidence based practice: Step by step: The seven steps of evidence-based practice.The American Journal of Nursing. 2010; 110: 51-53https://doi.org/10.1097/01.NAJ.0000366056.06605.d2Crossref PubMed Scopus (183) Google Scholar). During a “sacred cow” initiative at a pediatric hospital, employees were encouraged to be mindful of their practice and question why they do what they do. One nurse asked the question, “Should nurses aspirate when administering an intramuscular (IM) injection?” The Innovative Practice Council (IPC), a multi-disciplinary group of healthcare providers responsible for educating all healthcare providers about the Evidence Based Practice (EBP) process, took the lead in searching for an answer to this simple question. The council quickly developed a hospital-wide EBP project inspired by the “sacred cow” question. A pre-education survey of the nurses' current practice at this pediatric hospital revealed that 55% reported they aspirate with IM injections, while 45% reported they did not aspirate. The lack of uniformity in the basic nursing skill of performing IM injections was further exacerbated by the absence of a clear hospital policy. The lack of a consistent method of administering IM injections at this institution provided an excellent opportunity to educate healthcare providers on the EBP process, implement EBP changes and evaluate the changes. Initial queries revealed that nurses administer injections based on the method learned in nursing school resulting in some nurses who aspirate and some who do not aspirate prior to administering an IM medication. Having confirmed the legitimacy of the original ‘scared cow’ question, the IPC formulated the PICOT question to begin the process of learning and implementing current best practice for administering IM injections. To guide the study, the following PICOT question was developed asking, “In pediatric nurses at Le Bonheur Children's Hospital, how does education on administering IM injections compared to current practice affect injection practices?” Articles were reviewed from the last 10 years to critically appraise the literature regarding aspiration when administering IM injections. The literature review was performed utilizing multiple databases including, CINAHL, Medline, EMBASE, Cochrane, PubMed, JoAnna Briggs Institute, and Google Scholar using the following search terms: intramuscular injections, aspiration, technique, safety, and adverse reactions. IM injections are performed by nurses on a regular basis in a variety of inpatient and outpatient settings. Performing injections is a skill usually taught early in a nurse's first educational program. When giving IM injections, nurses make the following decisions: selecting the correct site, selecting correct needle length and gauge, injecting up to the hub of the needle and deciding whether to aspirate or not (Greenway, 2014Greenway K. Rituals in nursing: Intramuscular injections.Journal of Clinical Nursing. 2014; 23: 3583-3588https://doi.org/10.1111/jocn.12627Crossref PubMed Scopus (14) Google Scholar). The age of the patient and type of medication injected also influences decisions concerning IM injections. Medications are better absorbed if given in the muscle. Vaccine studies state fewer side effects such as bruising and fever occur when injections are administered into the muscle while increasing vaccine titers (Centers for Disease Control and Prevention, 2011Centers for Disease Control and Prevention. (2011). General recommendations on immunizations: Recommendations of the advisory committee on immunization practices (ACIP). Morbidity and Mortality Weekly report. 60(RR02), 1-60. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htmGoogle Scholar). Specific medications require the nurse to aspirate for 5 to 10 s to create negative pressure (Crawford and Johnson, 2012Crawford C.L. Johnson J.A. To aspirate or not: An integrative review of the evidence.Nursing. 2012; 42: 20-25https://doi.org/10.1097/01.NURSE.0000411417.91161.87Crossref PubMed Scopus (12) Google Scholar). If aspiration is performed incorrectly, then blood may not be visualized in the syringe indicating that a blood vessel was penetrated. Due to the risk for systemic reactions, various authors advise clinicians that aspiration is indicated when administering Penicillin, Lidocaine, and allergy medications (Crawford and Johnson, 2012Crawford C.L. Johnson J.A. To aspirate or not: An integrative review of the evidence.Nursing. 2012; 42: 20-25https://doi.org/10.1097/01.NURSE.0000411417.91161.87Crossref PubMed Scopus (12) Google Scholar; Hensel and Springmyer, 2011Hensel D. Springmyer J. Do perinatal nurses still check for blood return when administering the hepatitis B vaccine?.Journal of Obstetric, Gynecologic & Neonatal Nursing. 2011; 40: 589-594https://doi.org/10.1111/j.1552-6909.2011.01277.xAbstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar). A review of literature regarding the practice of IM injections revealed multiple education points. Some articles focused on techniques to reduce pain during injections (Rishovd, 2014Rishovd A. Pediatric intramuscular injection: Guidelines for best practice.The American Journal of Maternal/Child Nursing. 2014; 39: 107-112https://doi.org/10.1097/NMC.0000000000000009Crossref PubMed Scopus (5) Google Scholar; Taddio et al., 2009Taddio A. Ilersich A.L. Ipp M. Kikuta A. Shah V. Physical interventions and injection techniques for reducing injection pain during routine childhood immunizations: Systematic review of randomized controlled trials and quasi-randomized controlled trials.Clinical Therapeutics. 2009; 31 (Supplement 2): S48-S76https://doi.org/10.1016/j.clinthera.2009.07.024Abstract Full Text PDF PubMed Scopus (115) Google Scholar), other articles looked at techniques and adverse reactions (Cook and Murtagh, 2005Cook I.F. Murtagh J. Optimal technique for intramuscular injection of infants and toddlers: A randomized trial.Medical Journal of Australia. 2005; 183: 60-63https://doi.org/10.5694/j.1326-5377.2005.tb06922.xCrossref PubMed Scopus (23) Google Scholar), and some investigated aspiration techniques and identification of correct sites (Crawford and Johnson, 2012Crawford C.L. Johnson J.A. To aspirate or not: An integrative review of the evidence.Nursing. 2012; 42: 20-25https://doi.org/10.1097/01.NURSE.0000411417.91161.87Crossref PubMed Scopus (12) Google Scholar; Hensel and Springmyer, 2011Hensel D. Springmyer J. Do perinatal nurses still check for blood return when administering the hepatitis B vaccine?.Journal of Obstetric, Gynecologic & Neonatal Nursing. 2011; 40: 589-594https://doi.org/10.1111/j.1552-6909.2011.01277.xAbstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar; Rodger and King, 2008Rodger M.A. King L. Drawing up and administer intramuscular injections: A review of the literature.Journal of Advanced Nursing. 2008; 31: 574-582https://doi.org/10.1046/j.1365-2648.2000.01312.xCrossref Scopus (94) Google Scholar). Aspiration is discouraged by the World Health Organization, Advisory Committee on Immunization Practices, American Academy of Pediatrics and the American Academy of Family Physicians (Centers for Disease Control and Prevention, 2012Centers for Disease Control and Prevention. (2012). Vaccine recommendations and guidelines of the ACIP. Retrieved from https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html.Google Scholar; Rishovd, 2014Rishovd A. Pediatric intramuscular injection: Guidelines for best practice.The American Journal of Maternal/Child Nursing. 2014; 39: 107-112https://doi.org/10.1097/NMC.0000000000000009Crossref PubMed Scopus (5) Google Scholar). Not only is aspiration discouraged, evidence showed that it is rarely done correctly and that it increased discomfort at the injection site. Hensel and Springmyer, 2011Hensel D. Springmyer J. Do perinatal nurses still check for blood return when administering the hepatitis B vaccine?.Journal of Obstetric, Gynecologic & Neonatal Nursing. 2011; 40: 589-594https://doi.org/10.1111/j.1552-6909.2011.01277.xAbstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar found that only 3% of nurses aspirated for the correct amount of time of 5–10 s. In an integrative review on the evidence regarding aspiration, Crawford and Johnson, 2012Crawford C.L. Johnson J.A. To aspirate or not: An integrative review of the evidence.Nursing. 2012; 42: 20-25https://doi.org/10.1097/01.NURSE.0000411417.91161.87Crossref PubMed Scopus (12) Google Scholar found no data to support aspiration for the injection of vaccines and immunizations. They found that current injection practices vary throughout healthcare settings. Variation in injection techniques also were found in a 2001 survey of 500 nurses (Chiodini, 2001Chiodini J. Best practice in vaccine administration.Nursing Standard. 2001; 16: 35-38https://doi.org/10.7748/ns2001.10.16.7.35.c3109Crossref PubMed Scopus (8) Google Scholar). Along with finding that current evidence discouraged aspiration, additional aspects of IM injections may be incorrect such as needle gauge, needle length and injection site. Crawford and Johnson, 2012Crawford C.L. Johnson J.A. To aspirate or not: An integrative review of the evidence.Nursing. 2012; 42: 20-25https://doi.org/10.1097/01.NURSE.0000411417.91161.87Crossref PubMed Scopus (12) Google Scholar found that the most common complications of injections were from incorrect technique and inappropriate selection of site, needle size, and needle gauge. According to the Centers for Disease Control and Prevention (CDC), there are anatomically no large blood vessels present at the recommended injection sites (2011). In a review of literature from 2002 to 2013, Greenway, 2014Greenway K. Rituals in nursing: Intramuscular injections.Journal of Clinical Nursing. 2014; 23: 3583-3588https://doi.org/10.1111/jocn.12627Crossref PubMed Scopus (14) Google Scholar found that injection techniques were often a ritualized practice and noted that changing from aspiration to non-aspiration was the hardest to alter as it was so ingrained in practice. Similarly, in a descriptive study of 72 nurses, 99% reported learning to aspirate in nursing school and 69% identified this initial training as the most influential factor on their decision whether to aspirate or not (Hensel and Springmyer, 2011Hensel D. Springmyer J. Do perinatal nurses still check for blood return when administering the hepatitis B vaccine?.Journal of Obstetric, Gynecologic & Neonatal Nursing. 2011; 40: 589-594https://doi.org/10.1111/j.1552-6909.2011.01277.xAbstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar). Lack of knowledge regarding current recommendations was found to be the major barrier in practice change making re-education necessary. Furthermore, administering IM injections properly is faster when not aspirating which produces less pain during the injection (Crawford and Johnson, 2012Crawford C.L. Johnson J.A. To aspirate or not: An integrative review of the evidence.Nursing. 2012; 42: 20-25https://doi.org/10.1097/01.NURSE.0000411417.91161.87Crossref PubMed Scopus (12) Google Scholar; Rishovd, 2014Rishovd A. Pediatric intramuscular injection: Guidelines for best practice.The American Journal of Maternal/Child Nursing. 2014; 39: 107-112https://doi.org/10.1097/NMC.0000000000000009Crossref PubMed Scopus (5) Google Scholar). Results from an extensive literature review related to pain following IM injection, Crawford and Johnson, 2012Crawford C.L. Johnson J.A. To aspirate or not: An integrative review of the evidence.Nursing. 2012; 42: 20-25https://doi.org/10.1097/01.NURSE.0000411417.91161.87Crossref PubMed Scopus (12) Google Scholar and Xue et al., 2014Xue Y. Campbell J. Carroll M. Intramuscular injection: Aspiration. Adelaide: The Joanna Briggs Institute.http://joannabriggs.orgDate: 2014Google Scholar found that most nurses do not aspirate correctly for the process to be beneficial. Another study revealed nurses underestimate the needle length thinking it will decrease pain, but it actually causes more pain (Rodger and King, 2008Rodger M.A. King L. Drawing up and administer intramuscular injections: A review of the literature.Journal of Advanced Nursing. 2008; 31: 574-582https://doi.org/10.1046/j.1365-2648.2000.01312.xCrossref Scopus (94) Google Scholar). There are fewer nerve fibers in the muscle than in the subcutaneous tissue; therefore, after penetrating the subcutaneous tissue and entering the muscle, the pain is generally less as the medication is administered. Cook and Murtagh, 2005Cook I.F. Murtagh J. Optimal technique for intramuscular injection of infants and toddlers: A randomized trial.Medical Journal of Australia. 2005; 183: 60-63https://doi.org/10.5694/j.1326-5377.2005.tb06922.xCrossref PubMed Scopus (23) Google Scholar were unable to find any reported cases of sciatic nerve injury following IM injections. Other vaccine studies indicate giving the injection intramuscularly decreases pain (Immunization Action Coalition, 2017Immunization Action Coalition. (2017). Administering vaccines. Retrieved from http://www.immunize.org/askexperts/administering-vaccines.aspGoogle Scholar). While the original question focused on aspiration, the literature review documented that choosing the correct site, needle gauge, and needle size were also critical factors in the correct administration of an IM injection. Incorporating evidence into the education plan about what practices reduce pain during IM injection, how to correctly choose needle gauge and site for the delivery of medication, as well as knowing if aspiration is indicated, enables the nurse to provide safe, effective evidence-based care that is individualized to the patient. Based on evidence found in the literature, the EBP team understood that aspiration is not necessary before most IM injections; however, they knew there would be challenges related to re-education and making a practice change of a ritualized practice. The Innovation Practice Council chose Lippitt's change theory to guide the process of using evidence to implement a practice/policy change. The theory's phases mirror the nursing process and thus provide a useful guide for affecting change. Lippitt's theory consists of seven phases: three related to assessment, (1) assessment of the problem, (2) assessment of the need for change, (3) assessment of the change agent's resources to implement change; two related to planning, (4) identification of the change objective, (5) formulation of the change agent's role; one directed at implementation (6) introduction and sustainability of change; and one for evaluation, (7) evaluation of change (Mitchell, 2013Mitchell G. Selecting the best theory to implement planned change.Nursing Management. 2013; 20: 32-37Crossref PubMed Scopus (58) Google Scholar). Together the IOWA model and Lippitt's change theory provided the framework for this project. Institutional Review Board (IRB) approval was obtained by the University of Tennessee Health Science Center prior to the implementation of this project. The project was funded by the 2015 Society of Pediatric Nurses (SPN) Research and Evidence-Based Grant. The population included 626 out of 900 (70%) pediatric staff nurses from Le Bonheur Children's Hospital. Over a three month time period, attendees participated in one of multiple, non-mandated education sessions provided via a mobile classroom in various locations throughout the hospital. Although these sessions were not mandatory, leadership valued the outcomes of this study, therefore, attendance was highly encouraged. The educational approach included face to face education by educators attending staff meetings, performing walking rounds and having education blitzes during various shift changes. Evidence based practice on IM injection technique, appropriate injection sites, needle length, and needle gauge was provided. A back to school theme titled “Sacred Cow University” traveled to the various inpatient and outpatient units to provide a mobile classroom setting (Fig. 1, available online) with sessions being offered multiple times weekly. A pre-test was administered to each nurse to determine current practice. These 30 minute education sessions provided opportunities for demonstration and return demonstration of injections with and without aspiration. In order to change ritualistic behavior of aspirating prior to an IM injection, educators demonstrated the difference of aspirating versus not aspirating. Attendees then performed return demonstration in a simulated setting to retrain their brain on a new behavior while learning the evidence on aspiration techniques with the purpose of overcoming cognitive dissonance. To reinforce the education, each nurse received a “badge buddy” (Fig. 2, available online) to attach to their identification badge with a diagram of common IM injection sites and the approximate needle length and gauge based on the age and size of the patient. Nurses were also provided a handout with the current literature on best practice with regard to aspiration techniques, the information on the “badge buddy” and references to support the practice change. After the initial education, a demonstration on the appropriate administration of an injection was performed (Fig. 3, available online). Each nurse then worked through various scenarios to choose the appropriate gauge needle and length as well as injection site and performed a return demonstration. Upon completion of the mobile classroom education, each nurse received a syringe shaped pen to symbolize the IM injection information they learned. A post-test administered via an online learning management system assessed the knowledge retained by the nurses three months after the education event. Data was analyzed using descriptive statistics. Fifty-five percent of all nurses that participated in the pre-test and education indicated that they aspirated when giving IM injections. Almost 18% indicated they had seen blood during aspiration. Prior to education, nurses with a Bachelor of Science in Nursing (BSN) degree, who attended undergraduate school since 2010 and are younger than 30 were more likely to administer IM injections without aspirating (Table 1, available online). Overall, 66% (74 out of 112) of nurses that participated in the re-education class and completed the three-month post-test had changed practice. A more in-depth analysis of the numbers, however, revealed that nurses continued to practice as initially taught. Thirty-four percent (38 out of 112) continued to aspirate when giving IM injections. Nurses 20–30 years old were less likely to aspirate after the education with 20% (8 out of 40) who continued to aspirate while 41% (7 out of 17) of nurses aged 51–60 years and 100% (4 out of 4) of nurses 61–70 years of age continued to aspirate when administering IM injections. Nurses with an Associate Degree in Nursing (ADN) and a BSN were less likely to aspirate after re-education 30% (7 out of 23) and 31% (22 out of 70) respectively, while 64% (7 out of 11) of nurses that graduated from a diploma school continued to aspirate after re-education. Only 14% (1 out of 7) of master's-degree prepared nurses continued to aspirate after re-education. These results revealed that younger nurses and those with more advanced degrees are more likely to change their practice. The purpose of the EBP project was to examine practices related to aspirating before giving intramuscular (IM) injections by pediatric nurses. Along with surveying the nurses on their current practices, a core group of IPC members educated the nursing staff on the EBP process while concurrently informing them about best practice evidence for administering IM injections.