Blackwell Publishing IncMalden, USATRFTransfusion0041-11322006 American Association of Blood BanksAugust 200646813941401Original ArticlePHLEBOTOMIST INTERPERSONAL SKILLSTEWART ET AL.

BLOOD DONORS AND BLOOD COLLECTION

Phlebotomist interpersonal skill predicts a reduction in reactions

among volunteer blood donors

Kendra Ray Stewart, Christopher R. France, Aaron W. Rader, and Jesse C. Stewart

S
evere and potentially dangerous shortages in the
BACKGROUND: Adverse reactions in response to blood blood supply are common. A survey of 7 of the 11
donation negatively affect the likelihood of donor return. largest metropolitan areas in the United States
In this study, the interpersonal skill of phlebotomists was shows that these areas have an inadequate blood
examined as a potential predictor of both donor reactions supply for their communities and, as a result, must import
and returns for future donation. blood from other areas of the country.1 This problem is
STUDY DESIGN AND METHODS: Participants were 82 exacerbated during the summer months and winter holi-
phlebotomists who completed the Social Skills Inventory, days when many donors are on vacation, and it becomes
a global measure of interpersonal skill. Scores on this difficult or impossible for other regions to compensate
measure were used to predict the likelihood of donor for shortages. Consequently, continuous recruitment and
reaction (rated by phlebotomists) and return for future retention of donors is essential to maintain the nation’s
donation in two samples of volunteer blood donors blood supply and to ensure our ability to meet future
associated with these phlebotomists. Use of two samples needs.
permitted examination of phlebotomist interpersonal skill Given the importance of donor retention, many
as a predictor of donor reactions and returns both before investigators have turned their focus to factors that may
and after the phlebotomists were aware of the influence the decision to return for future donations.
interpersonal skills assessment. Existing research suggests that a blood donor’s assessment
RESULTS: Results of multilevel logistic regression of his or her overall donation experience plays a crucial
analyses demonstrated that a one-standard-deviation role in this decision.2,3 For example, Thomson and
increase in Social Skills Inventory score was associated colleagues3 found that donors’ perceptions of their phys-
with a significant reduction in the likelihood of donor ical well-being in response to donation and their percep-
reaction in the first sample (odds ratio [OR], 0.86; 95%
confidence interval [CI], 0.76-0.96) and with a marginally
significant reduction in the likelihood of donor reaction in
ABBREVIATION: ICC = intraclass correlation coefficient.
the second sample (OR, 0.90; 95% CI, 0.79-1.02). Social
Skills Inventory scores were not related to returns for From the University of Pittsburgh Cancer Institute, Pittsburgh,
future donation in either sample. Pennsylvania; the Department of Psychology, Ohio University,
CONCLUSIONS: This study provides the first empirical Athens, Ohio; Central Ohio Region Blood Services, American Red
evidence that phlebotomist interpersonal skill predicts the Cross, Columbus, Ohio; and the Department of Psychiatry,
experience of reactions among volunteer blood donors. A University of Pittsburgh School of Medicine, Pittsburgh,
focus on the interpersonal skill of phlebotomists may Pennsylvania.
therefore provide an additional avenue for improving Address reprint requests to: Christopher R. France, PhD,
donors’ physical well-being and satisfaction, thereby Department of Psychology, Ohio University, 245 Porter Hall,
enhancing donor retention. Athens, OH 45701; e-mail: France@ohio.edu.
At the time this research was conducted, K.R.S. was affiliated
with the graduate program of the Department of Psychology at
Ohio University.This research was supported by a Competitive
Research Grant from the Department of Psychology at Ohio
University; and by the National Institutes of Health Training
Grant HL07560.
Received for publication October 23, 2005; revision received
January 9, 2006, and accepted January 9, 2006.
doi: 10.1111/j.1537-2995.2006.00908.x
TRANSFUSION 2006;46:1394-1401.

1394 TRANSFUSION Volume 46, August 2006


tions of treatment by blood center staff were two of the
strongest predictors of intent to provide a future donation.
Consistent with these findings, recent evidence demon-
strates that the experience of reactions such as faintness,
dizziness, and nausea during donation has a significant
detrimental effect on likelihood of subsequent donation.4,5
One factor that could enhance donor retention by
influencing both donors’ physical well-being and their per-
ceptions of treatment by blood center staff is phlebotomist
interpersonal skill. Although no studies have directly eval-
uated this possibility, phlebotomist interpersonal skill has
long been viewed as a potentially important predictor of
reactions among donors.6-8 Additional indirect support for
this notion is provided by previous studies of the interper-
sonal skills of medical providers. Specifically, it has been
found that physicians’ use of patient-centered communi-
cation (e.g., allowing the patient to dominate the conver-
sation, utilizing reassurance techniques, or exploring the
patient’s feelings and expectations) is associated both with
better patient health outcomes9,10 and with better ratings
of patient satisfaction.11 Although the comparison to blood
donation is far from perfect, these findings do suggest that
the interpersonal skills of a medical provider can affect
both physical well-being and patient satisfaction.
To directly examine whether phlebotomist interper-
sonal skill is predictive of donor reactions or returns for
future donation, we conducted the first empirical investi-
gation of these potential relationships in a sample of
American Red Cross phlebotomists and two associated
samples of volunteer blood donors. We hypothesized that
phlebotomist interpersonal skill would be negatively
associated with the likelihood of donors experiencing a
reaction to blood donation, as interpersonally skilled
phlebotomists may help prevent donor reactions because
they are more adept at early detection of donor distress
and are capable of offering comfort, reassurance, or dis-
traction as needed. Such interventions might in turn
increase donor physical well-being, satisfaction with
blood collection staff, and willingness to return in the
future. Accordingly, we also hypothesized that phle-
botomist interpersonal skill would be positively associ-
ated with the likelihood of donors returning for a future
donation.
MATERIALS AND METHODS
Participants
Participants were 82 phlebotomists from the Central Ohio
Blood Services Region of the American Red Cross. To allow
for analysis of retrospective data, only phlebotomists who
had been employed in the region for at least 8 months
were recruited. Eleven phlebotomists were excluded from
analyses because they had not drawn blood from at least
20 donors during each of the two donor data collection
periods, and one phlebotomist was excluded because her
PHLEBOTOMIST INTERPERSONAL SKILL
pattern of responses on the interpersonal skills measure
was determined to be invalid. The final sample (n = 70)
had a mean age of 40.1 years (standard deviation [SD],
11.8 years) and a mean phlebotomy experience level of
98.6 months (SD, 81.7 months). The sample was mostly
female (76%) and Caucasian (73%). Phlebotomists held
either an RN or LPN degree (24%) or had received specific
phlebotomy training only. Participants provided written
informed consent to all procedures and received $10 for
completing the assessments. This study was approved by
the institutional review boards of Ohio University and the
American Red Cross.
Measures and procedure
Phlebotomists were recruited for this study at quarterly
meetings held by each collection territory of the American
Red Cross Blood Services, Central Ohio Region. Those who
chose to participate first completed a brief demographics
questionnaire assessing age (years), sex (0 = male,
1 = female), race (0 = Caucasian, 1 = non-Caucasian),
experience (months), and training (0 = RN/LPN, 1 = other
training). Race was coded as a dichotomous variable due
to the relatively small percentage of non-Caucasian phle-
botomists (27%) in the final sample. Additionally, phle-
botomist training was dichotomized to compare
phlebotomists with nursing backgrounds to those who
had received other phlebotomy training (e.g., by partici-
pating in a medical assistant or American Red Cross edu-
cational program). After completing the demographics
questionnaire, participants were administered the Social
Skills Inventory, which is a 90-item instrument divided
into six subscales (Emotional Expressivity, Emotional Sen-
sitivity, Emotional Control, Social Expressivity, Social Sen-
sitivity, and Social Control).12 This measure was selected
because it quantifies both verbal and nonverbal skills
across the domains of sending, receiving, and controlling
communications with others. Furthermore, it has been
used previously as a measure of nursing job performance13
and was therefore deemed to be relevant to the goals of
the present study. Each item of the Social Skills Inventory
is rated on a 1 (“Not at all like me”) to 5 (“Exactly like me”)
Likert scale. The sum of the six subscale scores yields the
total score, a global measure of social skill ranging from 90
to 450. Internal consistency for the Social Skills Inventory
is high for both men and women (α = 0.84 and α = 0.80,
respectively), and the test-retest reliability at a 2-week
interval is 0.94.12 Additionally, Riggio12 reports that the
Social Skills Inventory demonstrates convergent and dis-
criminant validity, as it is correlated in the expected direc-
tions with other measures pertaining to interpersonal
communication and personality. In the present study,
Social Skills Inventory scores (mean, 290.2; SD, 29.9) were
converted to z-scores so that a 1-unit change in this vari-
able corresponded to a change of 1 SD.
Volume 46, August 2006 TRANSFUSION 1395
STEWART ET AL.
Assessment of
Donor Data Donor Returns for
Collection 1 Data Collection 1
-7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5
Months
Donor Data Assessment of
Collection 2 Donor Returns for
Data Collection 2
Fig. 1. Timeline of donor data collection and assessment of
donor returns for the retrospective (Data Collection 1) and pro-
spective (Data Collection 2) analyses. The Social Skills Inven-
tory was administered to phlebotomists at Time 0.
Using the Donor Management Information System,
the official database of the American Red Cross, data were
retrieved for all allogeneic donors associated with each
phlebotomist during a 30-day period occurring 6 months
before the phlebotomist’s enrollment in the study (Data
Collection 1) and during a 30-day period immediately
after phlebotomist enrollment (Data Collection 2). This
retrospective and prospective design (see Fig. 1) allowed
us to examine phlebotomist interpersonal skill as a pre-
dictor of donor reactions and returns both before the
phlebotomists were aware of the interpersonal skills
assessment and after the phlebotomists had knowledge of
this assessment. After excluding donors with missing data
on any of the variables, 8669 donors remained in Data
Collection 1 and 7628 donors remained in Data Collection
2. As can be seen in Table 1, variables obtained from the
donor database included age (years), sex (0 = male,
1 = female), race (0 = Caucasian, 1 = non-Caucasian), and
first-time donor status (0 = experienced, 1 = novice). Race
was dichotomized because of the small percentage of
non-Caucasian donors in Data Collection 1 (8.9%) and in
Data Collection 2 (8.3%).
The following four outcome variables were also
derived from the donor database: donor reactions for Data
Collection 1, donor reactions for Data Collection 2, 12-
month returns for Data Collection 1, and 6-month returns
for Data Collection 2 (see Table 1). During the time period
of the study, phlebotomists coded donor reactions as
either absent, light, moderate, or severe, with a standard
American Red Cross classification system. In the present
analyses, however, donor reaction was treated as a dicho-
tomous variable (0 = no reaction, 1 = reaction) for both
data collection periods, due to the extreme rarity of mod-
erate and severe reactions (≤0.1%). As a measure of donor
retention, donors included in Data Collection 1 were
tracked during the 6 months before phlebotomist enroll-
ment and during the 6 months after enrollment (see
Fig. 1), which permitted evaluation of returns across a 12-
month period. As is also shown in Fig. 1, donors included
1396 TRANSFUSION Volume 46, August 2006
TABLE 1. Characteristics of donors*
Data Collection 1 Data Collection 2
Variable (n = 8669) (n = 7628)
Female 4236 (48.9) 3856 (50.6)
Non-Caucasian 774 (8.9) 630 (8.3)
6 7 First-time donor status 1336 (15.4) 969 (12.7)
Donor reactions 471 (5.4) 368 (4.8)
Returns for future 6408 (73.9)† 4626 (60.9)‡
donation
Age (years)§ 40.8 (15.7) 40.8 (13.9)
* Data are reported as number (%).
† Returns assessed 12 months after initial study donation.
‡ Returns assessed 6 months after initial study donation.
§ Data are reported as mean (SD).
in Data Collection 2 were tracked during the 6 months
after phlebotomist enrollment; thus, return data for the
second donor sample were available only for this period.
For both data collection periods, return for future dona-
tion was treated as a dichotomous variable (0 = no return,
1 = return), with donors coded as returning if they gave
blood or attempted to give blood one or more times after
the initial study donation.
Statistical analysis
To determine whether phlebotomist interpersonal skill
predicts the likelihood of donor reaction or return for
future donation, a series of multilevel logistic regression
analyses was performed with donors at Level 1 and phle-
botomists at Level 2. Multilevel logistic regression analysis
was selected because donors were nested within phlebot-
omists and because the four outcome variables were
dichotomous. These analyses were conducted with HLM
software, version 6.0, with parameters estimated by
restricted penalized quasi-likelihood.
Consistent with recent recommendations regarding
multilevel model specification,14 the following procedure
was used to examine phlebotomist interpersonal skill as
a predictor of each of the four outcome variables (donor
reactions for Data Collection 1, donor reactions for Data
Collection 2, 12-month returns for Data Collection 1, and
6-month returns for Data Collection 2). First, an empty
model was created that included only the random inter-
cept (i.e., no predictor variables). Results from this analy-
sis were used to compute the intraclass correlation
coefficient (ICC) for the empty model, which provided an
estimate of the proportion of total variance in the out-
come variable at the phlebotomist level. The ICC was cal-
culated as
ICC = VP/(VP + π2/3),
where VP is the variance between phlebotomists (i.e., the
phlebotomist-level variance, which is equal to the inter-

cept variance component), and π2/3 is the variance within
phlebotomists.14
Second, a base model consisting of important donor
and phlebotomist variables was created. Each donor vari-
able (age, sex, race, and first-time donor status) was first
entered into a separate model containing only the ran-
dom intercept. Donor variables that were significant in
their individual model were retained for inclusion in the
base model. For each significant donor variable, the test
of the random slope was examined. If this test was non-
significant in the variable’s individual model, only the
fixed effect for the variable was included in the base
model; if this test was significant, both fixed and random
effects were included. After the donor-level elements of
the base model were identified, each phlebotomist vari-
able (age, sex, race, experience, and training) was then
entered into a separate model containing the random
intercept and the selected donor variables. Phlebotomist
variables that were significant in their individual model
were retained for inclusion in the base model. It should
be noted that, in the individual models and the base
model, continuous donor and phlebotomist variables
were centered about the grand mean and dichotomous
variables were uncentered. Results from this analysis
were used to compute the residual ICC for the base
model. In addition, the proportion of phlebotomist-level
variance explained by the variables in the base model was
calculated with the equation
VEXPLAINED = [(VP0 − VP1)/VP0] × 100,
where VP0 is the phlebotomist-level variance for the empty
model and VP1 is the phlebotomist-level variance for the
base model.15,16
Third, a full model was created by entering Social
Skills Inventory total score (grand mean centered) into the
base model. Results from this analysis were first used to
compute the residual ICC for the full model and the
proportion of phlebotomist-level variance explained by
the variables in the full model (VEXPLAINED = [(VP0 − VP2)/
VP0] × 100, where VP0 is the phlebotomist-level variance for
the empty model and VP2 is the phlebotomist-level vari-
ance for the full model). The proportion of phlebotomist-
level variance accounted for by the Social Skills Inventory
total score beyond that explained by the variables in the
base model was then calculated by subtracting VEXPLAINED
for the base model from VEXPLAINED for the full model. To
determine whether the various subscales of the Social
Skills Inventory were predictive of donor reactions or
returns, follow-up analyses were conducted when the
Social Skills Inventory total score was a significant or mar-
ginally significant predictor of the outcome variable. In
these instances, the full model analysis was repeated uti-
lizing each of the six subscale scores in place of the Social
Skills Inventory total score. Furthermore, to explore
whether any donor characteristics moderate the relation-
PHLEBOTOMIST INTERPERSONAL SKILL
ships between phlebotomist interpersonal skill and the
likelihood of donor reaction or return, cross-level interac-
tions between each donor variable (age, sex, race, and
first-time donor status) and Social Skills Inventory total
score were entered one at a time into the full model. For
these analyses, both fixed and random effects for each
donor variable were included in the models. Because none
of the cross-level interactions were significant, these
results are not reported.
RESULTS
Donor reactions
Data Collection 1. In the first donor sample, phlebot-
omist interpersonal skill was negatively associated with
the likelihood of donors experiencing a reaction to blood
donation. The ICC for the empty model was 0.033, indi-
cating that 3.3 percent of the total variance in reactions
was at the phlebotomist level (see the top panel of
Table 2). All of the donor variables—age, sex, race, and
first-time donor status—were significant predictors of the
likelihood of donor reaction and therefore were included
in the base model. Specifically, younger individuals,
women, Caucasians, and first-time donors were each
more likely to experience a reaction. Of the phlebotomist
variables, only age was a significant predictor in the pres-
ence of the selected donor variables, as the likelihood
of donor reaction increased with phlebotomist age. Col-
lectively, the variables in the base model explained
57.9 percent of the phlebotomist-level variance in reac-
tions (i.e., 1.9% of the original 3.3% of the total variance in
reactions that was at the phlebotomist level). The full
model analysis revealed that Social Skills Inventory total
score was a significant predictor of the likelihood of donor
reaction in the presence of the variables in the base model.
The odds ratio (OR) for Social Skills Inventory total score
was 0.86, indicating that a 1-SD increase in the Social Skill
Inventory total score was associated with a 14 percent
reduction in the likelihood of donor reaction. To further
illustrate this relationship, mean reaction rates (not
adjusted for the selected donor and phlebotomist vari-
ables) were calculated after classifying phlebotomists into
quartiles based on their Social Skills Inventory total score.
The mean reaction rate was 6.6 percent for phlebotomists
in the first (lower) quartile, 6.1 percent for those in the
second quartile, 4.5 percent for those in the third quartile,
and 4.5 percent for those in the fourth (upper) quartile.
Social Skills Inventory total score accounted for an addi-
tional 17.5 percent of the phlebotomist-level variance in
reactions beyond that explained by the selected donor and
phlebotomist variables. Follow-up analyses with Social
Skills Inventory subscale scores revealed that Emotional
Sensitivity was a significant predictor of the likelihood of
donor reaction (OR, 0.87; 95% CI, 0.78-0.98; p < 0.05). Fur-
thermore, Social Expressivity (OR, 0.89; 95% CI, 0.79-1.01;
Volume 46, August 2006 TRANSFUSION 1397
STEWART ET AL.

TABLE 2. Multilevel logistic regression analyses predicting the likelihood of donor reaction
Phlebotomist-level Explained phlebotomist-
Model/Variable OR 95% CI variance (SD) ICC level variance (%)
Data Collection 1
Empty model 0.114 (0.337) 0.033 Reference
Base model* 0.048 (0.218) 0.014 57.9
Donor age 0.95† 0.94-0.96
Donor sex 1.55† 1.27-1.89
Donor race 0.37† 0.25-0.56
First-time donor status 2.96† 2.37-3.69
Phlebotomist age 1.02† 1.01-1.03
Full model 0.028 (0.167) 0.008 75.4
Social Skills Inventory score 0.86‡ 0.76-0.96
Data Collection 2
Empty model 0.204 (0.452) 0.058 Reference
Base model* 0.058 (0.240) 0.017 71.6
Donor age 0.96† 0.95-0.97
Donor sex 1.54† 1.23-1.93
First-time donor status 2.90† 2.27-3.71
Full model 0.043 (0.206) 0.013 78.9
Social Skills Inventory score 0.90§ 0.79-1.02
* For all of the selected donor variables, only the fixed effect was included in the base model.
† p < 0.01.
‡ p < 0.05.
§ p = 0.10.

p = 0.07) and Social Sensitivity (OR, 0.89; 95% CI, 0.79-
1.01; p = 0.06) were marginally significant predictors of the
likelihood of donor reaction. None of the other subscales
were significant predictors.
Data Collection 2. Similar results were obtained in
analyses predicting the likelihood of reaction in the sec-
ond donor sample. As can be seen in the bottom panel of
Table 2, 5.8 percent of the total variance in reactions was
at the phlebotomist level. The donor variables that were
significant predictors of the likelihood of reaction were
age, sex, and first-time donor status; each of these vari-
ables was related to reactions in the same direction as in
Data Collection 1. Because none of the phlebotomist vari-
ables was significant predictors in the presence of the
selected donor variables, none was included in the base
model. Together, the variables in the base model
explained 71.6 percent of the phlebotomist-level variance
in reactions. Social Skills Inventory total score was a mar-
ginally significant predictor of the likelihood of donor
reaction (p = 0.10). The OR of 0.90 indicates that a 1-SD
increase in Social Skills Inventory total score was associ-
ated with a 10 percent reduction in the likelihood of donor
reaction. The unadjusted mean reaction rates were 5.4,
5.8, 4.2, and 3.6 percent for phlebotomists in the first, sec-
ond, third, and fourth quartiles, respectively. Social Skills
Inventory total score accounted for an additional
7.3 percent of the phlebotomist-level variance beyond
that explained by the selected donor variables. In contrast
to the findings from Data Collection 1, none of the Social
Skills Inventory subscale scores were predictive of the like-
lihood of donor reaction.
Returns for future donation
Data Collection 1. In contrast to donor reactions,
analysis of data from the first donor sample indicated that
phlebotomist interpersonal skill was not related to the
likelihood of donors returning within 12 months of their
initial blood donation for a subsequent donation. Of the
total variance in 12-month returns, 3.8 percent was at the
phlebotomist level (see the top panel of Table 3). Donor
age, sex, race, and first-time donor status were each sig-
nificant predictors of the likelihood of 12-month return in
their individual models; older individuals, men, Cauca-
sians, and experienced donors were more likely to return
for another blood donation. In the presence of the
selected donor variables, phlebotomist race and training
were also significant predictors in their individual models,
as the likelihood of 12-month return was greater for Cau-
casian phlebotomists and phlebotomists with nursing
backgrounds. When all of the selected donor and phlebot-
omist variables were simultaneously entered in the base
model, however, donor sex became nonsignificant, and
phlebotomist training became marginally significant. As a
set, the variables in the base model explained 70.8 percent
of the phlebotomist-level variance in 12-month returns.
The full model analysis revealed that, in the presence of
the variables in the base model, Social Skills Inventory
total score was not associated with the likelihood of 12-
month return.
Data Collection 2. In the second donor sample,
comparable results were obtained in analyses predicting
the likelihood of donors returning within 6 months for

1398 TRANSFUSION Volume 46, August 2006

 PHLEBOTOMIST INTERPERSONAL SKILL

TABLE 3. Multilevel logistic regression analyses predicting the likelihood of return for future donation
Phlebotomist-level Explained phlebotomist-
Model/Variable OR 95% CI variance (SD) ICC level variance (%)
Data Collection 1
Empty model 0.130 (0.360) 0.038 Reference
Base model 0.038 (0.195) 0.011 70.8
Donor age* 1.04† 1.04-1.05
Donor sex‡ 1.02 0.92-1.14
Donor race 0.64† 0.54-0.76
First-time donor status 0.31† 0.27-0.35
Phlebotomist race 0.84§ 0.71-0.98
Phlebotomist training|| 0.85¶ 0.70-1.03
Full model — — —
Social Skills Inventory score 1.03 0.96-1.11
Data Collection 2
Empty model 0.185 (0.431) 0.053 Reference
Base model 0.115 (0.339) 0.034 37.8
Donor age 1.02† 1.02-1.02
Donor sex 0.83† 0.76-0.92
Donor race 0.69† 0.58-0.83
First-time donor status 0.36† 0.31-0.41
Phlebotomist age 1.01† 1.00-1.02
Full model — — —
Social Skills Inventory score 0.99 0.89-1.09
* Both fixed and random effects for this variable were included in the model.
† p < 0.01.
‡ Donor sex was a significant predictor in its individual model (OR, 0.86; 95% CI, 0.77-0.96; p < 0.01) but became nonsignificant when the
selected variables were simultaneously entered in the base model.
§ p < 0.05.
|| Phlebotomist training was a significant predictor in its individual model (OR, 0.81; 95% CI; 0.67-0.98, p < 0.05) but became marginally
significant when the selected variables were simultaneously entered in the base model.
¶ p < 0.10.

another donation. As is shown in the lower panel of
Table 3, 5.3 percent of the total variance in 6-month
returns was at the phlebotomist level. All of the donor
variables were significant predictors of the likelihood of
6-month return and were related to returns in the same
direction as in Data Collection 1. In addition, phleboto-
mist age was positively associated with likelihood of
6-month return. The variables in the base model
explained 37.8 percent of the phlebotomist-level vari-
ance in 6-month returns. Social Skill Inventory total
score was not associated with the likelihood of 6-month
return.
DISCUSSION
Our hypothesis that phlebotomist interpersonal skill
would be negatively associated with the likelihood of
donors experiencing a reaction to blood donation was
supported. After adjustment for important donor and
phlebotomist variables, a 1-SD increase in Social Skills
Inventory total score was associated with a 14 percent
reduction in likelihood of donor reaction in Data Collec-
tion 1 and with a 10 percent reduction in Data Collection
2. Three of the Social Skills Inventory subscales were sig-
nificant or marginally significant predictors of donor reac-
tions in Data Collection 1, but these results were not
supported by the subscale analyses for Data Collection 2.
Although phlebotomist variables have not been empiri-
cally studied in the existing blood donation literature, the
findings of this study are consistent both with previously
observed relationships between physician interpersonal
skills and patient health outcomes9,10 and with the sugges-
tion by Ogata and coworkers7 that “outgoing” and inter-
personally skilled phlebotomists may have a lower rate of
donor reactions among the donors that they assist. Future
studies are needed to examine the mechanism through
which phlebotomist interpersonal skill may translate into
fewer donor reactions. We speculate that phlebotomists
who are interpersonally skilled may have a salutary effect
on donors in part because they are more likely to attend
to and interpret the nonverbal cues of others, thus allow-
ing them to respond to signs of an impending reaction and
to intervene preventatively rather than after a reaction has
actually occurred. Additionally, phlebotomists possessing
characteristics such as attentiveness and responsiveness
may not only intervene intentionally to prevent reactions,
but may also indirectly reduce reactions by providing a
reassuring and warm presence, establishing a bond with
the donor, engaging the donor in a friendly and affiliative
interaction, distracting the donor from the blood dona-
tion procedure, and/or creating an impression of profes-
sional competency. Due to the correlational nature of the

Volume 46, August 2006 TRANSFUSION 1399

STEWART ET AL.
relationships observed in this study, however, it must also
be considered that the inverse relationship between phle-
botomist interpersonal skill and the likelihood of donor
reactions may occur because phlebotomists with high
interpersonal skill may be less likely to report reactions
among the donors that they assist. For example, inter-
personally skilled phlebotomists might minimize the
severity of or underreport the occurrence of donor reac-
tions because they desire to be favorably evaluated by
supervisors.
Interestingly, we did not observe a relationship
between phlebotomist interpersonal skill and the likeli-
hood of return for future donation in either data collection
period. This finding is surprising, given that phlebotomist
interpersonal skill was related to donor reactions, and
reactions have previously been found to be predictive of
donor nonreturn.4,5 There are several potential explana-
tions for these null findings. First, assuming that the
relationship between phlebotomist characteristics and
returns for future donation is primarily mediated by donor
reactions, it is possible that the Social Skills Inventory is
not sufficiently related to reactions to have a significant
influence on returns. In addition, although phlebotomist
interpersonal skill may enhance the overall donation
experience, a host of factors (e.g., perceived inconve-
nience, apathy, and changes in medical eligibility) ulti-
mately contribute to donor return behavior.
In addition to suggesting that phlebotomist interper-
sonal skill is related to the likelihood of donors experienc-
ing a reaction, our findings also indicate that donor
characteristics are more important than phlebotomist
characteristics in predicting both donor reactions and
returns for future donation. Across the multilevel models,
only 3 to 6 percent of the total variance in donor reac-
tions and returns was at the phlebotomist level, indicat-
ing that most of the variance in these outcomes was at
the donor level—or perhaps at an unexamined level in
the hierarchy, such as site of donation. Further, donor
characteristics were consistently and strongly predictive
of the likelihood of both reactions and returns. These
findings are in line with previous studies that have found
donor age and first-time donor status to be predictive
of donor reactions17,18 and with other studies that have
reported a relationship between donor sex and reac-
tions.2,8,19,20 Our findings from Data Collection 1 are also
in agreement with those of Newman and colleagues,21
which suggest that reactions occur at a lower rate among
African American versus Caucasian donors. Although
donor characteristics were found to be most important
in the prediction of returns for future donation, certain
phlebotomist characteristics were also predictive. For
example, donors from the first data collection period
were more likely to return if their phlebotomist was
trained as a nurse. If this outcome can be confirmed in
other donor samples, it would suggest that additional
1400 TRANSFUSION Volume 46, August 2006
research should be devoted to examining the technical
and interpersonal characteristics of such phlebotomists
that might enhance donor return.
Some important limitations of this study should be
noted. First, the Social Skills Inventory is a self-report
measure of interpersonal abilities, and as a self-report
measure, it is subject to response bias. For example,
social desirability may have affected the way in which
phlebotomists portrayed themselves on this instrument,
although concern about evaluation by employers was
probably not a factor, as it was explained both verbally
and in written format to the participants that supervisors
and other employees of the American Red Cross would
not have access to their responses. In addition, phleboto-
mists were aware that donor reactions would be moni-
tored for 30 days after enrollment in the study, and this
knowledge may have affected phlebotomist-donor inter-
actions during Data Collection 2. This limitation, how-
ever, does not pertain to Data Collection 1, wherein the
strongest relationship between phlebotomist interper-
sonal skill and the likelihood of donor reaction was
observed.
In summary, results of the present study indicate that
phlebotomist interpersonal skill is associated with a
reduction in the likelihood of donors experiencing a reac-
tion to blood donation. These findings suggest that in
addition to the obvious importance of phlebotomist tech-
nical skill, phlebotomist interpersonal skill may also con-
tribute to the overall donation experience for volunteer
blood donors.
REFERENCES
1. Newman BH. Adjusting our management of female blood
donors: the key to an adequate blood supply. Transfusion
2004;44:591-6.
2. Piliavin JA, Callero PL. Giving blood: the development of an
altruistic identity. Baltimore: Johns Hopkins University
Press; 1991.
3. Thomson RA, Bethel J, Lo AY, et al. Retention of “safe” blood
donors. The Retrovirus Epidemiology Donor Study.
Transfusion 1998;38:359-67.
4. France CR, Rader A, Carlson B. Donors who react may not
come back: analysis of repeat donation as a function of
phlebotomist ratings of vasovagal reactions. Transfus Apher
Sci 2005;33:99-106.
5. France CR, France JL, Roussos M, Ditto B. Mild reactions to
blood donation predict a decreased likelihood of donor
return. Transfus Apher Sci 2004;30:17-22.
6. Moloney WC, Lonnergan LR, McClintock JK. Syncope in
blood donors. N Engl J Med 1946;234:114-8.
7. Ogata H, Iinuma N, Nagashima K, Akabane T. Vasovagal
reactions in blood donors. Transfusion 1980;20:679-83.
8. Williams GE. Syncopal reactions in blood donors: an
investigation of 222 cases. Br Med J 1942;1:783-6.

9. Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J.
Influence of context effects on health outcomes: a
systematic review. Lancet 2001;357:757-62.
10. Stewart M, Brown JB, Donner A, et al. The impact of patient-
centered care on outcomes. J Fam Pract 2000;49:796-804.
11. Bertakis KD, Roter D, Putnam SM. The relationship of
physician medical interview style to patient satisfaction.
J Fam Pract 1991;32:175-81.
12. Riggio RE. Manual for the social skills inventory. Palo Alto
(CA): Consulting Psychologists Press; 1989.
13. Riggio RE, Taylor SJ. Personality and communication skills
as predictors of hospice nurse performance. J Bus Psychol
2000;15:351-9.
14. Snijders TA, Bosker RJ. Multilevel analysis: an introduction
to basic and advanced multilevel modeling. Thousand Oaks
(CA): Sage Publications; 1999.
15. Bryk AS, Raudenbush SW. Hierarchical linear models:
applications and data analysis methods. Newbury Park (CA):
Sage Publications; 1992.
PHLEBOTOMIST INTERPERSONAL SKILL
16. Merlo J, Lynch JW, Yang M, et al. Effect of neighborhood
social participation on individual use of hormone
replacement therapy and antihypertensive medication:
a multilevel analysis. Am J Epidemiol 2003;157:774-83.
17. Kasprisin DO, Glynn SH, Taylor F, Miller KA. Moderate
and severe reactions in blood donors. Transfusion
1992;32:23-6.
18. Trouern-Trend JJ, Cable RG, Badon SJ, Newman BH,
Popovsky MA. A case-controlled multicenter study of
vasovagal reactions in blood donors. influence of sex, age,
donation status, weight, blood pressure, and pulse.
Transfusion 1999;39:316-20.
19. Greenbury CL. An analysis of the incidence of “fainting” in
5,897 unselected blood donors. Br Med J 1942;1:253-5.
20. McVay PA, Andrews A, Kaplan EB, et al. Donation reactions
among autologous donors. Transfusion 1990;30:249-52.
21. Newman BH, Siegfried BA, Buchanan LA. Donor reactions
among African-American and Caucasian first-time whole-
blood donors. Transfusion 2005;45:1398-9.
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