Chapter II  

                       Review of Literature

REVIEW OF LITRATURE
Knowledge is growing rapidly. It gets doubled in a very short span of time. Scholars,
Researchers and writers go on adding knowledge through their studies and writings. A researcher
who is not fully conversant with what has gone before has little chance of making a worthwhile
contributions. He / She has to survey the available literature relating to his / her field of study
and related areas and keep themselves updated.19

This chapter deals with review of literature which helps to gain an insight into various aspects of
the problem under study, its objectives, appropriate research design, methods, instruments
measures and techniques of data collection that may prove useful in the proposed project.

The review of literature provides a basis for future investigations, justifies the need for
replication, throws light on the feasibility of the study to another. It also helps to establish a
comprehensive body of scientific knowledge in a professional discipline from which valid
pertinent theories may be developed.20

In the present study, the research investigator has carried out different types of literature review
at different stages of his research process and presented under the following headings:
1.    Studies supporting the  knowledge and practice of Blood transfusion
2.    Studies supporting to indications of Blood transfusion
3.    Studies supporting to complications of Blood transfusion
4.    Studies supporting to Self instructional module

1.  Studies supporting the knowledge and practice of Blood transfusion

   A questionnaire study on assessment of knowledge in blood transfusion of medical staff in 14

state-run hospitals. Study purpose was to asses the knowledge in blood transfusion of medical
staff. The findings of this shows that 694 questionnaires were analyzed (rate of return 15%). The
rate of correct answers (RCA) ranged from 14 to 89%, according to the questions. The RCA
ranged from 47-78% for 7 of the 9 essential safety questions and 82% and 83% for the two
questions concerning the interpretation of incompatible final bedside controls: there were 9% of
Wrong answers, which validated an incompatible blood transfusion. The mean weighed score
were higher for those that regularly prescribe them occasionally. There were no significant
differences between hospitals. Study concludes that, this study has confirmed that medical staff
has deficiencies in their knowledge of blood transfusion, deficiencies which are acknowledged
by medical staff. 21

A questionnaire study on evaluation of a teaching pack designed for nursing students to acquire
the essential knowledge for competent practice in blood transfusion administration. Study
objectives include to assess students knowledge of the process for transfusion of blood
component pre-and post-teaching and evaluate the effectiveness of the teaching pack. The
information was gathered by using a questionnaire. The study concludes that the educational
strategies implemented will be explained and evident that applying structured learning
programmes in the undergraduate nursing curriculum can improve students knowledge
presented. 22

A questionnaire survey study on should nurses prescribe blood components? Study objective was
to explore the feasibility of nurses prescribing blood components. Using a convenience snowball
sample, a UK-wide questionnaire survey study was undertaken to identify transfusion practices
and canvass the opinions of nurses and doctors. Study result was total of 179 (59%) of 302
respondents were supportive of nurses prescribing blood components, saying it would have a
positive effect time more effectively. The remaining 123(41%) respondents had reservations
about time and resource constraints and worries about undermining medical care and
responsibility. Study concluded that development of non-medical prescribing to allow nurses to
prescribe blood components has the potential to deliver a more patient-centered quality services.
23

A questionnaire based survey study on implication of nurses in blood transfusion safety at

Gustave-Roussy institute, France. The purpose of this was to asses the knowledge and practice
among nurses in transfusion safety. The study revealed that a significant improvement was
observed in knowledge of good practices between the first and second survey [p=10(-4)].
However, the multivariate analysis showed that the impact of Training was heterogeneous.
Pre-transfusion protocol checks have improved significantly (p=0.05) as well as pre-transfusion
bedside compatibility test interpretation of ABO compatibility (p=0.07).Study concluded that
implementation of good practices has significantly improved but it is essential to continue and
adopt the training.24

         A cross sectional study on paramedical staff knowledge and practice related to the blood
transfusion safety. Study objectives include to describe the paramedical staff’s knowledge and
practice regarding blood transfusion safety and to identify factors that are related to them. The
information was gathered by using a questionnaire. The result of this study was only 215% of the
interviewed persons have had a score less than 30 (scale range from 0 to 100). Study concludes
that the importance of strategies improving the quality and the safety of blood  transfusion, i.e.,
the continuous medical education, implementing a blood transfusion information system and the
use of transfusion practice guidelines. .25

A questionnaire based survey study on factors associated with nurse’s poor knowledge and
practice of transfusion safety procedures in Aquitaine, France. Study purpose was to describe
knowledge, attitudes, and reported practice of blood transfusion on nurses .The study include
sample about 1090 nurses. Result of this study show (1) the bedside blood compatibility test
proportion of responses (PR) with potential life threat between 12.7 and 35.5% (2)
Pre-transfusion compatibility check when receiving blood units (PR=34. 5%). (3) Delay
between screening of red cell antibodies and transfusion (PR=20.5%): (4) delay in preservation
of blood units in the ward (PR=33.4%) (5) Recognition of abnormal reactions after transfusion
(PR=47.1%). Study concludes that low training and transfusion activity were key determinants
of poor transfusion-related practice. 26

An evaluative study on transfusion practice and attitudes among 199 young physicians, working
in two university hospitals in Tunisia. Results indicate that physician’s knowledge about blood
transfusion is insufficient to guarantee quality of this medical act. In terms of attitudes and
practices, physicians are not really always implicated in the different stages of blood transfusion
process. Intervention is limited to prescription and blood transfusion record card writing.
Transfusion itself and monitoring were, in particular, delegated to nurses. So transfusion
incidents were under-declared. Transfusion medicine must occupy important place in physicians
curriculum. Studies concluded that, at hospital level, quality insurance process, based on audit,
have to be implemented to obtain transfusion good practices, in a domain here risks are
unfortunately not yet totally circumscribed.27

A descriptive study on blood transfusion knowledge and practice among nurses in Turkey. The
objectives includes identify blood transfusion practice and knowledge of 100 nurses from 3
hospitals in Ankara, Turkey. With the interview method they collected data of nurses. The result
of this study was, out of total 100 score, none of the participating nurses achieved a score of
100, and only a few had scores higher than 50. Although a positive correlation existed between
the nurses knowledge and practice scores, the correlation coefficient was insignificant. Study
concludes that insufficient knowledge about transfusion, reflected in undesirable practice.28

2.  Studies supporting to Blood transfusion indications

  Case control study on Blood transfusion, anesthesia, surgery and risk of non-Hodgkin
lymphoma (NHL) in a population. Study evaluated these factors with NHL risk in a
population-based study of 759 cases and 589 frequency-matched controls. Inclusion of
transfusion and surgery or transfusion and anesthesia in the same model did not attenuate these
associations. Blood transfusions were associated with NHL risk, but appear to be a marker for
underlying medical conditions. Multiple surgical procedures and/or repeated administration of
anesthesia have not been previously reported to be associated with risk of NHL and these
exposures warrant further evaluation.29

A prospective study on Blood transfusion in critically injured patients .  The present study
evaluated patterns of red blood cell transfusions and risk factors for transfusions at various stages
of admission in trauma patients. Study design was  Prospective, observational study of
transfusion practices in patients (n = 120) admitted to a single Level 1 academic trauma centre.  
Study concluded that  Trauma patients are heavily transfused with allogeneic blood throughout
the course of their hospital stay and transfusions are administered at relatively high
pre-transfusion haemoglobin levels (mean of 9 g/dL). Transfusion of >4 units of blood is an
independent risk factor for SIRS. Strategies to limit blood transfusions should be investigated in
this population.30

A descriptive study on erythropoietin use and cost in hematologic   patients in Spain. Study aims
were to assess the effectiveness of erythropoietin use in hematologic patients and to analyze the
extent to which recommendations are applied as provided by Spanish prescribing information.
Study includes results of Thirty –six patients (37% males). In the group of patients with multiple
myeloma and lymphomas, effectiveness was 57%, while in the myelodysplastic syndrome group
it was 45-64% (depending on criteria used ) adjustment to erythroid response at 4 and 8 weeks,
and dosage titration when needed. Study concluded that there is a high percentage of therapy
failures and inconsistency between erythropoietin use recommendations and clinical practice.31

Survey study on Transfusion practice in the critically ill. Anemia in the critically ill patient
population is common. This anemia of critical illness is a distinct clinical entity characterized by
blunted erythropoietin production and abnormalities in iron metabolism identical to what is
commonly referred to as the anemia of chronic disease. The study found that critically ill patients
receive an extraordinarily large number of blood transfusions. Between 40% and 50% of all
patients admitted to intensive care units receive at least one red blood cell unit, and the average is
close to five red blood cell units during their intensive care unit stay. Study concluded that
practice strategies should be directed toward a reduction of blood loss and a decrease in the
transfusion threshold in critically ill patients.32

Evaluative study on The rh enigma: problems encountered in St. John's Medical College
Hospital,  Bangalore. The Rh system is a complex blood group system. The variety of antisera
with variable reactivity that are available, compounds the problems encountered in Rh typing in
routing practice and accounts for the inter laboratory variation in reporting. Correct interpretation
of Rh is essential for safe transfusion and protecting infants from hemolytic disease of the
newborn due to anti D. Our aim is to project the problems faced by us in Rh typing at SJMCH
The Rh typing of all donor and patient samples received over a period of 18 months was
analyzed. We found Rh positivity of 94.25 percent & Rh negativity of 5.75 percent with 0.15
percent incidence of weak D. In 2 cases with red cell antibody coating the Rh could not be
interpreted. As 1 in 1000 persons is faced with conflicting reports of his Rh type, we conclude
that a critical review and uniform standards are necessary to avoid discrepancy and have
consistent reporting.33

Survey study on  Homologous blood transfusion: do we have any alternatives? in  Military
Hospital (CTC), Pune. Homologous blood transfusion, despite numerous and serious transfusion
associated hazards, is an important treatment modality. Transmission of infectious agents like
HIV, hepatitis viruses, malaria, etc is a distinct possibility notwithstanding careful screening of
the blood. Pre deposit autologous blood transfusion (PABT) and per operative acute
normovolemic haemodilution (ANH) are two comparatively safer, simpler and practical
alternatives. Unfortunately, their potential remains unexploited. Earnest motivation efforts at
PABT and ANH have paid handsome dividends in our hospital. These have now become very
popular amongst surgeons as well as the patients. These techniques can be easily adapted at all
hospitals to reduce the demand for homologous blood transfusion. ANH can be safely practiced
even in hospitals without a blood bank.34                                        

3. Studies supporting to complications of Blood transfusion

Descriptive study on age of Transfused Blood & Risk of Complications after Surgery In this
study, nearly 3,000 patients undergoing open-heart surgery were evaluated after being transfused
with almost 9,000 units of blood that had been stored for 14 days or less.  The complications and
death rates for this group of patients were then compared to a similar group of almost 11,000
open-heart surgery patients who had received “older” blood, which had been collected and stored
for more than 14 days.  On average, blood given to the first group of patients was about 11 days
old, while the blood transfused into the second group of patients was, on average, about 20 days
old, and these patients were also more likely to suffer severe infections than the patients who
received “newer” blood (4.0% vs. 2.8%, respectively).  Similarly, the risk of kidney failure,
which is associated with a high risk of death in critically ill patients, was also significantly higher
in patients receiving “older” blood (2.7% vs. 1.6% in patients receiving “newer” blood,
respectively).  35

Interview study on Transfusion-associated transmission of West Nile virus – Arizona . A case of

West Nile virus (WNV) encephalitis associated with transfusion of blood that did not react when
tested for WNV by minipool (MP) nucleic acid testing (NAT) is described.  An investigation was
initiated to determine the source of this infection. Study includes the patient's family members
were interviewed to identify risk factors for WNV infection. Study results was  the patient's
family denied recent mosquito exposure. Study concluded that  WNV RNA detection by
individual donation NAT demonstrates viremic blood escaping MP-NAT and supports
transfusion-related WNV transmission. 36

Survey study on Estimated risk of HIV transmission by blood transfusion in Kenya. The study
aim was  to promote awareness of blood safety issues in this country with a mature HIV
epidemic, and to identify methods to reduce the risk of HIV transmission by blood transfusion in
Kenya. Study includes the prevalence of HIV among blood donors was 6.4% (120 of 1877) and
varied by hospital (range 2-20%). HIV test results were available for 1290 donor-recipient pairs.
Of these, 26 HIV-positive donations were given to HIV-negative patients. We estimate that 2.0%
of transfusions transmitted HIV problems in the hospitals that contributed to transfusion risk
included inconsistent refrigeration, data entry errors, equipment failure, and lack of a
quality-assurance programme. Study concludes that  a high proportion of blood transfusions
transmitted HIV in this high-prevalence area of Africa, primarily because of erroneous
laboratory practices. On the basis of these results, the Kenya Ministry of Health introduced a
number of practical and inexpensive interventions to improve national blood safety. 37

Survey study on Transfusion-transmitted infectious diseases in Argentina, 1995 through 1997. 

Study found that the proportion of donors screened for HIV increased from 84.52 percent in
1995 to 97.97 percent in 1997; in the same period, serologic screening for HbsAg increased from
83.71 percent to 98.48 percent; that for HCV from 69. 92 percent to 97.83 percent; and that for
syphilis from 87.94 percent to 98.71 percent. The overall prevalence of HIV per year varied from
2.42 to 3.36 per 1,000 donors; that of HBV, from 5.80 to 9.76 per 1,000; of HCV, from 7.39 to
16.61 per 1,000; and of syphilis, from 5.25 to 7.65 per 1,000. The overall index of the spread of
infectious viral disease through blood transfusion decreased from 47. 74 per 10,000 donations in
1995 to 4.75 per 10,000 in 1997.. Study concluded that  the status of the blood supply in
Argentina improved steadily from 1995 to 1997, as shown by the increase in screening
coverage.38

4. Studies supporting to Self Instructional Module (SIM).

Comparative study on Experienced registered nurses'
satisfaction with using self-learning modules versus traditional
lecture/discussion to achieve competency goals during hospital
orientation. Staff development educators are challenged with
various levels of experience and learning styles among newly
hired registered nurses in a hospital orientation group. This
diversity forces the educator to use various teaching strategies to
meet the learning needs of the group. This study investigated the
experienced registered nurses' satisfaction with using
self-learning modules versus traditional lecture/discussion
methods during the nursing orientation process. The results
revealed that experienced nurses prefer the more traditional
method of learning by l Impact of self--instructional module for
the nurses on nursing--management of the patients having chest
tube drainage lecture/discussion. 39

Questionnaire study on evaluation of a teaching pack designed for nursing students to acquire the
essential knowledge for competent practice in blood transfusion administration. Study objectives
include to assess students knowledge of the process for transfusion blood component pre-and
post-teaching and evaluate the effectiveness of the teaching pack. The information was gathered
by using a questionnaire. The study concludes that the educational strategies implemented will
be explained and evidence that applying structured learning programmes in the undergraduate
nursing curriculum can improve students knowledge presented. 40         

Randomized control study on Impact of self-assessment questions and learning styles in

Web-based learning: Study aim was  to determine the effect of self-assessment questions on
learners' knowledge and format preference in a Web-based course, and investigate associations
between learning styles and outcomes. The study concluded that  Instructional methods that
actively engage learners improve learning outcomes. These findings hold implications for both
Web-based learning and "traditional" educational activities. Future research, in both Web-based
learning and other teaching modalities, should focus on further defining the effectiveness of
selected instructional methods in specific learning contexts. 41

Quasi –experimental study on Impact of self--instructional module for the nurses on

nursing--management of the patients having chest tube drainage. By adopting quasi-
experimental study systematically & randomly selected 100 staff nurses working in Nehru
Hospital, PGIMER, Chandigarh were included in the study. A knowledge assessment
questionnaire consisting of 25 multiple choice questions was developed based on SIM, got
checked by experts for its content validity and was tested using test-retest and split - half method
to ensure its reliability. Study includes  the maximum knowledge scores found in age group of
20-25 years during pre-test and post-test (12.84 and 20.03) respectively. The study concludes that
the information given through SIM proved beneficial in improving the knowledge and skill of
100 study subjects as written information in the form of ready reference i.e. SIM available with
the subjects could provide reinforcement in their day to day clinical knowledge and skill, which
eventually improved the quality of care. 42

Comparative study on 77 nursing students in which two teaching methods were compared: The
first: the traditional method included a self-study module, a brief lecture and demonstration by an
instructor and hands-on experience using a plastic manikin and a real 12-lead ECG machine in
the learning laboratory. The second method covered the same content using an interactive,
multimedia CD-Rom embedded with virtual reality and supplemented with a self-study module.
There were no significant (p<0.05) baseline difference in pre-test scores between the two groups.
They found both groups were found to be satisfied with their instructional method. 43

Questionnaire study on using a self learning module to teach nurses about caring for hospitalized
children with tracheotomies. The purpose of this study was to determine the effectiveness of
self-learning module (SLM) to teach nurses about caring for hospitalized children with
tracheotomies. Data analysis using an independent samples ‘t’ test showed that statistically
significant learning occurred after completion of the SLM (p=0.0.14, n=85). These findings can
influence the way staff education is provided, giving the nurse educator an alternative,
cost-effective, and time saving method of presenting information.44

Computer based study on Development of an experimental paradigm in which to examine

human learning using two computer-based formats. Computer-based self-instructional programs
are frequently promoted as means to augment or replace the traditional anatomy curricula taught
in medical schools. For this study, students will be prospectively randomized into two groups,
each group learning the lung anatomy lesson using one of the computer-based formats described.
Immediate knowledge retention will be measured by asking students to complete the assessment
instrument immediately after completing their learning module. The results of the pilot study will
be used to refine and improve the design of the remainder of studies planned in this experimental
series. 45

Evaluative study on Efficacy of a geriatric oral health CD as a learning tool.. A study reported
here tested the efficacy of this educational tool for improving student knowledge of geriatric oral
care. A convenience sampling procedure was used. Sample size calculation revealed that fifty-six
subjects were required to meet clinical and statistical criteria. When stratified on the basis of
viewing the CD-ROM, the subgroup of thirty-eight students who reported not actually reviewing
the CD-ROM had no change in their knowledge scores, while the subgroup of twenty-nine
students who reported reviewing the CD had a significant improvement in test scores (p<0.001).
Use of a self-instructional e-learning tool in geriatric oral health is effective among those
students who choose to employ such tools.46

Evaluative study on the effectiveness of a self-instructional module in increasing the nurses’

acquisition knowledge of regarding genetics. The study materials were mailed to 262 registered
nurses involved in screening egg donors at 177 reproductive health centers in the United States.
One hundred of these 262 eligible nurses completed a pre-test (38% return rate). It was found
that there was a significant increase of 20.8% in participant’s mean knowledge score on the
post-test (M=89.0%, SD=8%, range=67%, 100%) as compared with the pre-test (M=69%,
SD=!@%, range=42% and 92%), based on paired t-test analysis (t=11.74, p<0.0001). That
shows that knowledge of genetics through self-instructional module for registered nurses was
effective in increasing the level of knowledge of basic human genetic concepts and further risk
assessment too.47
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