Early implementation of appropriate treatments reduces mortality of sepsis, but before starting antibiotherapy, drawing blood culture is essential to identify the source of sepsis and to adapt treatment. Suboptimal practices result in blood culture contamination from patient's skin at the venepuncture site. As blood culture is the standard method to diagnose a bacteraemia, appropriate training of nursing students can promote good clinical practice.
This study aims to evaluate the teaching and the training of French nursing students on blood culture execution and related hygiene practices.
The study design was a cross-sectional audit based on an electronic questionnaire sent to the 10,000 French nursing students over a 4 months period.
One thousand and thirty-six nursing students filled out the survey, representing around 10% of the French nursing students. At nursing school, 30% of the nursing students declared to have received theoretical and practical training on blood culture. During their internship, 45% declared no training on it. Among blood culture execution recommendations, peripheral stick and first aerobic were well known among 88% and 83% of the nursing students, respectively. Similarly, the practice of washing hands and cleaning the venepuncture site prior to blood culture execution were known among 96% and 94% of nursing students. In contrast, the practice of wearing gloves (80%) and facial mask (15%) is relatively lower.
There are discrepancies between the knowledge of nursing students and good practice recommendations for blood culture execution and related hygiene practices. Strengthening the teaching practices will likely improve students' knowledge base, reduce blood culture contamination and improve quality of care.
Evaluation, Good practice, Nursing students, Training
Sepsis a major public health problem, with an estimated incidence of 300 per 100,000 inhabitants [1,2]. Sepsis is involved in one-third to one-half of all in-hospital deaths  with a mortality rate reaching 30% [1,2,4,5]. The outcome of septic patients relies on the early identification and rapid implementation of appropriate treatments, especially hemodynamic optimization and antibiotics administration, named bundle of cares [3,6] whose efficacy to reduce mortality is proven [6-12]. Most of the time, sepsis results from a bacteraemia .
Blood cultures are the standard method for the diagnosis of bacteraemia. A blood culture consists of taking a predefined volume of blood in order to identify the germ(s) responsible of the bacteraemia. The "sepsis-3" conference underlined that the quality of blood culture is at the utmost importance to first allow the identification of the origin of sepsis and second to adapt antibiotic treatment based on lab results . To reach this goal, recommendations for blood culture drawing practices have been performed but vary between countries [15-18].
However, bad practices are involved in blood culture contamination with an approximate rate of 3% in the US . Blood culture contamination results in unnecessary and insensible antibiotic use, increased length of hospital stay and increased healthcare costs [20,21]. Patient's skin at the venepuncture site is often the source of blood culture contamination . In order to reduce blood culture contamination rates, the efficacy of good practice recommendations, pre-packaged antisepsis kits, dedicated phlebotomy teams as frequent and easily accessible training have been observed [23,24].
However, teaching, training and practices of blood culture drawing varies among countries [15-18]. For example, in France, blood cultures are mainly taken by nurses. Therefore, in order to promote good clinical practices and reduce consequences of false positive blood culture, enhancing appropriate initial teaching and training of nursing students appears to be essential.
The aim of this study is to evaluate the teaching and the training received by French nursing students at school and hospital on blood culture execution and related hygiene practices.
French blood culture guidelines, lastly updated in 2015 , underline that in case of sepsis, blood culture, aerobic and anaerobic, should be performed immediately, and before any antibiotic administration . The French and international guidelines recommend sampling a unique peripheral sample, first aerobic bottle and second anaerobic bottle, in order to optimize the sensitivity for the detection of microorganism [15,26]. In France, a nurse can perform blood culture without any supervision in accordance with the ward protocols.
Two theoretical lessons concerning blood culture execution are dispensed: 1 during the first year and 1 during the second year . The practical teaching is dispensed during the internship during one of the 3 years of the initial training for French nursing students.
A cross-sectional study aiming to evaluate the teaching and the training received by French nursing students on blood culture execution and related hygiene practices based on a survey was performed. The survey was based on a questionnaire (Annex 1) sent out to all French nursing schools between October 2017 and January 2018.
The questionnaire was established by a nurse after discussion between two nurses and two staff physicians leading to a consensus on its contents. The questionnaire encompassed 22 short answer questions and multiple-choice questions exploring the theoretical and practical aspects of teaching and training received by nursing students on hygiene practices concerning blood culture practice. The external validity was evaluated with 10 nurse students fulfilling the questionnaire to ensure understanding and clarity of issues.
Student participation was voluntary. In the electronic-mail it was specified that "the participation is totally voluntary, and the participants can withdraw from the study anytime without giving any reason". According to the French law, the study was exempted by Human Subjects Committee review considering that the study as a voluntary audit.
All responses were collected electronically via Google Form©.
Quantitative data are expressed as mean ± standard deviation (SD). Qualitative variables are expressed as frequency with percentage.
One thousand and thirty-six nursing students filled out the survey representing a response rate of 10% of the 10,000 French nursing students. Of these, 90% were female. The mean age was 24 ± 6 years. Among the responders, 48% were third year, 38% second year and 14% first year nursing students.
These students did an internship in medicine, surgery or obstetric ward (81%), geriatric ward (76%), psychiatry ward (70%), intensive care unit (19%) and in the emergency department (10%).
At nursing school, only 57% of the nursing students declared to have received theoretical training on blood culture execution. During their internship, 87% received practical training only and 30% theoretical and practical training. Of them, 95% thought that improvement on training could allow better care: 66% prefer a theoretical and practical training at nursing school whereas 42% prefer that the training should be performed during the internship.
Moreover, 28% declared to have no knowledge of recommendations on blood culture handling and 12% declared a lack of blood culture protocol during the internship.
Unique sample is considered as the gold standard by 27% of nurse students.
Main results are summarized in Table 1.
Table 1: A summary of survey results. View Table 1
In this study, we observed discrepancies between good practice recommendations and declared knowledges, theoretical and practical, for blood culture practices among nursing students. Thus, opportunities exist to improve blood culture related practices for nursing students to reduce blood culture contamination, improve quality of care and reduce hospital length of stay and related health care costs.
Despite international and national good practice recommendations for blood culture execution [15,17,18,30], we observed major differences in what the students knew regarding blood culture practices. The recommendations about "peripheral stick" and "first aerobic blood culture execution" are relatively well known in contrast to other recommendations: Single-sampling, cleaning the blood culture bottle tops, blood volume sampled and wearing a facial mask. Single-sampling is not considered as the gold by most of the student despite evidence in favour this last one. Single-sampling reduces the incidence of contamination [31-33] and improve the diagnosis performance of blood culture [32,34]. Adequate volume sampling is the most important parameter for the detection of bloodstream infection, thus a minimal of 8-10 mL of blood is required . The contamination rate is lower when samples are drawn by peripheral venipuncture [26,35]. To avoid contamination, cleaning the top of blood culture bottle is therefore recommended [15,26]. The WHO guidelines on drawing blood contain the best practices for health worker particularly hygiene practices .
The discrepancies observed between recommendations and the declaration of nursing students in this study may explain the persistent contamination rate of 3% observed in France as in other countries [19,37]. The herein results are consistent with other studies [35,38].
We plan to use the results of this survey to underline the necessity to reinforce the teaching of good healthcare practices during in-class as well as in-hospital training of nursing students in France. It is essential for nursing students to have a sound knowledge base of good healthcare practices which is the first step in reducing blood culture contamination. It is hoped that this will eventually lead to an improvement in infectious agent identification and a reduction of inappropriate antibiotics administration.
Some limitations in our study deserve consideration. First, it is a declarative survey about practices and not an observational study of daily practices. Second, part of the results observed here may result from poor teaching practices at hospitals for the nursing staff. Third, the sample is not equally dispatched between the 3 years. There is a low percentage of first-year nursing students, that could artificially enhanced results. Fourth, since the recommendations were updated in 2015, it is possible that not all nursing schools updated their program which could have negatively impacted the results. Fifth, our results are not directly transposable to other countries because teaching and training programs are not the same than in France.
However, strengthening the teaching and the training of nurse students is an easy way to improve knowledge and skills in order to enhance blood culture practice and quality of care.
The knowledge base of nursing students does not correspond with good practice recommendations for blood culture execution. Strengthening the teaching practices at nursing schools and the training during the internship would probably help to improve knowledge base and reduce blood culture contamination. At the end, this may also contribute to improve quality of care and reduce health care related costs.
Authors appreciate the English revision made by Ms Pakeezah Saadat health research methodology candidate, Mc Master University Hamilton, Ontario Canada.