INTRODUCTION:

Patient safety is one of the main objectives for all health care systems and it is a key step in ensuring a good quality of care. There are many health care processes to be analyzed in order to improve patient safety, but medication management should be highlighted because of its complexity and many steps involved from prescription to administration. Administration of medicine is one of the greatest responsibilities of a nurse.¹

The huge volume of injections being given worldwide – an estimated 16 billion injections per year are administered in the developing and transitional countries alone. There are four main considerations regarding injections: the route, site, techniques and equipment.²

Intravenous medication administration occurs when a needle is inserted into a vein and medication is administered directly into the blood stream through the needle. Intravenous injection technique is considerably more complicated and more dangerous than other type of injection.³

Another route of drug administration is intramuscular injection. According to WHO, Intramuscular injection is an administration of medications parenterally through a skin puncture by a syringe and a needle deep into a large muscle of the body, providing rapid systemic action and absorbing relatively large doses; from 1ml in the deltoid site to 5ml elsewhere in adults.⁴

OBJECTIVES:

· To assess the practices regarding injection administration among staff nurses.

· To associate the findings with selected socio demographic variables.

· To analyse the findings with current injection administration guidelines.

· To develop an informational booklet regarding injection administration.

MATERIAL AND METHOD:

A quantitative research approach was adopted for the study with analytical research design to achieve the objectives of the study. Non probability convenient sampling technique was used to draw sample of 100staff nurses working in a 205 bedded private hospital of district Mohali who fulfilled inclusion criteria. Practices of staff nurses regarding intramuscular and intravenous injection administration were assessed by observational checklist.

Inclusion Criteria:

Staff nurses who were:

· available at time of study

· willing to participate in the study

Exclusion Criteria:

· Area where researcher was not present at the time of injection administration because of overlapping of timing of injection administration.

FINDINGS:

Table 1 shows the socio demographic variables of staff nurses. 100 staff nurses were observed for intramuscular and intravenous injection administration. Majority of staff nurses were between 22-25years of age i.e. 53%, followed by 43% between age of 26-29 years. Gender distribution of samples revealed that majority of samples i.e. 94% were females. With respect to educational qualification; 43% staff nurses did General Nurse and Midwifery whereas, 40% and 16% did Basic B.Sc. nursing and Post Basic B.Sc. nursing respectively. In this study, majority of the staff nurses were working in general ward i.e. 54%, whereas, 25% and 13% were working in intensive care unit and emergency ward respectively. Majority of staff nurses i.e. 45% were having 2-4 years’ experience and 40% were having 0-2 year experience. Out of 100 staff nurses, no one has attended educational program related to injection administration.

Table 1: Frequency and percentage distribution of socio demographic variables of staff nurses N=100

S. No.	Socio Demographic Variables	Frequency (f)	Percentage (%)
1	Age (in years)
	22-25	53	53.0
	26-29	43	43.0
	30-33	4	4.0
2	Gender
	Male	6	6.0
	Female	94	94.0
3	Education qualification
	General Nursing and Midwifery	43	43.0
	Basic B.Sc. Nursing	40	40.0
	Post Basic B.Sc. Nursing	16	16.0
	M.Sc. Nursing	1	1.0
4	Area of work
	General ward	54		54.0
	Emergency ward	13		13.0
	Intensive Care Unit	25		25.0
	Out Patient Department	8		8.0
5	Work experience(in years)
	0-2	40	40.0
	2-4	45	45.0
	4-6	10	10.0
	≥ 6	5	5.0
6	Attended educational program related to injection administration
	Yes	0	0
	No	100	100.0

Practices during intramuscular injection:

Most of the staff nurses i.e. 73.3% did not gather sterile gauze. No one gathered ampoule and kidney tray. 86.7% staff nurses performed hand hygiene with sanitizer but no one performed with soap and water. Glovers were worn by 70 % staff nurses. Out of 14 staff nurses who withdrew medication from ampoule, no one used ampoule filer. 100 % staff nurses withdrew medication by aseptic technique and verified the patient before giving injection. 100 % staff nurses pulled back plunger for checking blood return, injected the medication slowly, withdraw the needle before releasing skin and applied pressure at injection site after giving injection. 93.3% cleaned the injection site with alcohol swab. 40 % changed the needle for administering intramuscular injection after withdrawal of medication.100 % staff nurses discarded used articles according to hospital policy, documented the procedure and checked patient for immediate adverse reaction. 86.7% did hand washing after procedure.

Overall level of practice for each staff nurse was depicted (poor, fair, good) using the total practice score obtained by each of them.

Table 2: Overall level of practice regarding intramuscular injection administration among staff nurses N=30

Overall level of practice (Total Practice score)	Frequency (f)	Percentage (%)
Poor (0-16)	0	0
Fair (17-33)	2	6.7
Good (34-50)	28	93.3
Median (Min.-Max.)	40.00 (33-44)
Mean ± SD	39.43±2.775

Table 2 depicts the distribution of level of practice among staff nurses who administered intramuscular injection. In this study, majority of the staff nurses 28 (93.3%) fall into a category of good practice score, 2 (6.7%) of them had fair practices. None of them fall into category of poor practices.

Practices during intravenous injection:

44% staff nurses gathered injection tray and only 4.3% gathered alcohol wipe. 24.3% and 12.9% gathered sterile gauze and gloves respectively. No one gathered ampoule filer and kidney tray. 68.6% staff nurses performed hand hygiene with sanitizer but no one performed with soap and water. 12.9%worn gloves.100% prepared medication at bed side. Out of 6 staff nurses who prepared medication from vial containing liquid, 4 injected air into the vial before withdrawing medication and no one cleaned top of vial with alcohol wipe.29 staff nurses out of 30, who prepared medication from vial containing powder have drawn diluent aseptically and 16 staff nurses mixed medication by rolling vial in palm. Out of 34 staff nurses who prepared medication from ampoule, 31 tapped stem of ampoule to ensure medication moves from neck of ampoule but no one used ampoule filer. 91.4% withdrew medication aseptically. 100 % staff nurses verified patient, injected medication slowly, ensured whole medication has been administered, discarded the used articles according to hospital policy, documented the procedure and checked patient for immediate adverse reaction. Intravenous line is flushed with normal saline by 52.9 % staff nurses before administering medication and 44.3 % after administering the medication. 65.7% staff nurses did hand washing after the procedure.

Overall level of practice for each staff nurse was depicted (poor, fair, good) using the total practice score obtained by each of them.

Table 3: Overall level of practice regarding intravenous injection administration among staff nurses N=70

Overall level of practice (Total practice score)	Frequency (f)	(%)
Poor (0-16)	0	0
Fair (17-33)	34	48.6
Good (34-50)	36	51.4
Median (Min.-Max.)	34.00 (28-39)
Mean ± SD	33.63±2.616

Table 3 depicts the distribution of total practice score among staff nurses who administered intravenous injection. In this study, majority of the staff nurses 36(51.4%) fall into a category of good practice. 34(48.6%) of them had fair practices. None of them fall into category of poor practices.

Table 4: Association of practices regarding intramuscular injection administration among staff nurses with selected socio demographic variables N=30

S. No.	Socio demographic variables		Frequency	Level of practices					χ2, df, p-value
			Frequency	Fair n₁=2			Good n₂=28
			f	f₁		%	f₂	%
1	Age (in years)
	22-25		17	2		11.8	15	88.2	1.639,^NS 1, 0.201
	26-29		13	0		0	13	100.0
	30-33		0	0		0	0	0
2	Gender
	Male		3	0		0	3	100.0	.000,^NS 1, 1.000
	Female		27	2		7.4	25	92.6	.000,^NS 1, 1.000
3	Education qualification
	General Nursing and Midwifery	11		1		9.1	10	90.9	4.675,^NS 3, .197
	Basic B.Sc. Nursing	15		0		0	15	100.0
	Post Basic B.Sc. Nursing	3		1		33.3	2	66.7
	M.Sc. Nursing	1		0		0	1	100.0
4	Area of work
	General ward	6			1	16.7	5	83.3	2.545,^NS 3, 0.467
	Emergency ward	8			1	12.5	7	87.5
	Intensive care unit	8			0	0	8	100.0
	Out Patient unit	8			0	0	8	100.0
5	Work experience (in years)
	0-2	10			2	20.0	8	80.0	4.286,^NS 3, 0.232
	2-4	16			0	0	16	100.0
	4-6	3			0	0	3	100.0
	≥6	1			0	0	1	100.0

^NSNon significant

*significant p<0.05

Table 5: Association of practices regarding intravenous injection administration among staff nurses with selected socio demographic variables N=70

S. No.	Socio-demographic variables	Level of practices						χ2, df, p-value
		Frequency		Fair n₁=34		Good n₂=36
		f		f₁	%	f₂	%
1	Age in years
	22-25	36		22	61.1	14	38.9	4.858,^NS 2,.088
	26-29	30		11	36.7	19	63.3
	30-33	4		1	25.0	3	75.0
2	Gender
	Male		3	1	33.3	2	66.7	.000,^NS 1, 1.000
	Female		67	33	49.3	34	50.7	.000,^NS 1, 1.000
3	Education qualification
	General nursing midwifery		32	19	59.4	13	40.6	3.354,^NS 2,.187
	Basic B.Sc. Nursing		25	11	44.0	14	56.0
	Post Basic B.Sc. Nursing		13	4	30.8	9	69.2
	M.Sc. Nursing		0	0	0	0	0
4	Area of work
	General ward		48	28	58.0	20	41.7	6.246,^NS 2, 0.044
	Emergency ward		5	2	40.0	3	60.0
	Intensive care unit		17	4	23.5	13	76.5
	Out-patient department		0	0	0	0	0
5	Work experience (in years)
	0-2		30	20	66.7	10	33.3	7.257,^NS 3, 0.064
	2-4		29	11	37.9	18	62.1
	4-6		7	2	28.6	5	71.4
	≥6		4	1	25.0	3	75.0

^NSNon significant

*significant p<0.05

Table 6: Number of literature referred according to levels of evidences.

LEVEL	EVIDENCE TYPE	NUMBER OF LITERATURE REFERRED
I	Systematic Reviews (Integrative/Meta-analyses/Clinical Practice Guidelines based on Systematic reviews	11
II	Single experimental study(RCTs)	2
III	Quasi-experimental studies	1
IV	Non-experimental studies	4
V	Care report/program evaluation/narrative literature reviews	25

Table7: Number of evidences found against each item of pre procedure steps in observational checklist

`	PRE PROCEDURE STEPS FOR INJECTION ADMINISTRATION	NUMBER OF EVIDENCES FOUND
1.	Check before preparation of medication
i.	Right patient	25*
ii.	Right drug	25*
iii.	Right time	25*
iv.	Right dose	25*
v.	Right route	25*
2.	Gather articles:-
i.	Injection tray	11*
ii.	Disposable syringe and needle of appropriate size	26*
iii.	Medicine vial/ampoule	24*
iv.	Ampoule filer	10*
v.	Alcohol wipe	23*
vi.	Sterile gauge	21*
vii.	Gloves	21*
viii.	Kidney tray	7
3.	Perform hand hygiene
i.	With soap and water	27*
ii.	With plain water	0
iii.	With sanitizer	4*
4.	Wear gloves	15*
5.	Prepare the medication at bedside	4
5.1	Prepare the medication from vial containing liquid
i.	Clean the top of vial with an alcohol wipe in one stroke	14*
ii.	Remove the needle cap using sterile technique	17*
iii.	Pull air into the syringe equal to the amount of the medicine needed	16*
iv.	Inject air into the vial’s air space, holding on to the plunger.	16*
5.2	Prepare the medication from vial containing a powder
i.	Remove cap cover of vial and diluent aseptically	15
ii.	Draw up diluents into syringe using sterile technique	14
iii.	Inject diluent through center of rubber seal of vial	14
iv.	Mix medication by rolling vial in palms, not by shaking	11
5.3	Prepare the medication from ampoule
i.	Tap stem of ampoule lightly to ensure that medication moves from neck of ampoule	18*
ii.	Keep a sterile gauze on one side of the stem and make a mark on the glass with a filer	12*
iii.	Break the stem using slight pressure with gauge	18*
iv.	Insert needle into ampoule without touching needle tip to rim of ampoule	18*
6.	Withdraw medicine using aseptic technique	19*
7.	Verify the client’s identity	21*
8.	Provide privacy either by screen or curtain	21*
9.	Explain the procedure to patient	21*

*Level I evidence (strongest type of evidence) included

Table 8: Number of evidences found against each item of intra- procedure steps of intramuscular and intravenous injection in observational checklist

S. No.	INTRA-PROCEDURE STEPS OF INTRAMUSCULAR INJECTION ADMINISTRATION	NUMBER OF EVIDENCES FOUND
1	Uncover and locate the site (ventrogluteal muscle, dorsogluteal muscle, vastuslateralis muscle or deltoid muscle) where medication is to be injected	25*
2	Clean the site with an antiseptic swab using a circular motion, starting from center and moving outward about 5cm in one stroke	20*
3	Instruct the patient to relax the muscle by deep breathing	8
4	Replace the needle used for medicine with drawl with an unused needle	9*
5	Hold the muscle of the injection site between thumb and index fingers of one hand in case of thin patient whereas stretch the skin in patient who is obese	20*
6	Insert the needle swiftly at an angle of 90 degree	23*
7	Pull back on plunger and check for blood appearance	25*
7.1	If no blood appears, inject slowly	23*
8	Withdraw needle before releasing the skin	19*
9	Apply pressure at the injection site	21*
S. NO.	INTRA-PROCEDURE STEPS OF INTRAVENOUS INJECTION ADMINISTRATION
1	Assess the intravenous site for complications like thrombophlebitis, haematoma and excessive pain etc.	18*
2	Clean injection port with antiseptic swab.	11*
3	Attach syringe filled with normal saline to injection port	13
4	Pull back on syringe plunger for blood return	9
5	Flush IV line with normal saline by pushing slowly on plunger	14*
6	Attach syringe containing prepared medication to the injection port	13*
7	Inject the medication slowly	13*
8	Ensure whole medicine has been administered	11
9	Flush injection port with normal saline or heplock after injection administration	16*
10	Recap the injection port.	14*

*Level I evidence (strongest type of evidence) included

Table9: Number of evidences found against each item of post procedure steps in observational checklist

S. NO.	POST-PROCEDURE STEPS OF INJECTION ADMINISTRATION	NUMBER OF EVIDENCES FOUND
1.	Cut the syringe hub and discard in bin according to hospital policy	17*
2.	Burn the needle and discard in puncture proof container	17*
3.	Discard the vial in appropriate bin according to hospital policy and ampoule in puncture proof container	18*
4.	Discard the alcohol wipe or swab in appropriate bin according to hospital policy	18*
5.	Discard the gauge in appropriate bin according to hospital policy	17*
6.	Discard the gloves in appropriate bin according to hospital policy	17*
7.	Wash hands	22*
8.	Document the procedure	19*
9.	Check the patient for immediate adverse reaction like excessive pain, swelling and hematoma.	18*

*Level I evidence (strongest type of evidence) included

Table 10: Practices performed by staff nurses with no evidences

S. No.	Practices
1	Hand hygiene with plain water
2	Press distal part of cannula before giving intravenous injection

CONCLUSION:

From the findings of study following conclusion is drawn:

The majority of the staff nurses i.e. 93.3% were having good intramuscular injection administration practices and 51.4% staff nurses were having good intravenous injection administration practices.

There was no significant association of injection administration practices with age, gender, education qualification, area of work and work experience.

Total 43 literatures were referred for each step of intravenous and intramuscular injection to form an evidence base.

After finding evidences for each item of injection administration checklist, an informational booklet on injection administration was developed and distributed to staff nurses indicating number of evidences against each step.

DISCUSSION:

· A cross sectional study conducted on 294 final year nursing students and nurses to assess their practices of intramuscular injection administration in hospital setting. Most respondents, 129 (86.6%) students and 109 (75.1%) nurses withdrew needle immediately after administering the drug. The injection site was not massaged by 95 (63.8%) students and 46 (31.7%) nurses. Whereas in present study,100% staff nurses withdraw needle before releasing skin and applied gentle pressure on injection site after giving injection rather than massaging.⁵

· According to WHO guidelines, hand washing should be done before injection administration. In present study 86.7% staff nurses performed hand washing before intramuscular injection administration and 68.6% staff nurses performed hand washing before intravenous injection administration.⁶

· An article on flushing and locking of venous catheters recommends that flushing of intravenous catheters before and after intravenous medication essential in the prevention of occlusion.⁷In present study, 37 (52.9%) staff nurses flush the intravenous catheter before injection administration and 31 (44.3%) staff nurses after injection administration.

· Safe injection global network suggests that the site should be cleaned with antiseptic swab before administering intramuscular injection⁸. In present study, 100 % of the staff nurses cleaned the injection site with antiseptic swab.

· “The Global Patient Safety Challenge” which recommends wearing gloves before administering the intramuscular injection.⁹In present study, 70% staff nurses wore gloves while administering intramuscular injection.

ACKNOWLEDGEMENT:

I would like to express my sincere gratitude to the participants of study who had spent their valuable time for giving the information. Grateful acknowledgement is extended to Mrs. Neelam Kalia for the valuable help in statistical analysis.

Ethical Clearance:

· A formal written permission was obtained from all necessary organizations.

· Written informed consent was taken from the staff nurses.

· Anonymity was maintained.

REFERENCES:

1. Nancy Sr. Principles and Practice of Nursing. N. R. Publishing House, Indore.2007.

2. Lazzari S, Allegranzi B, Concia E. Making hospitals safer: the need for a global strategy for infection control in health care settings: A review. Available from: URL: http://europepmc.org/abstract/med/15338996

3. Christine Case-Lo. Intravenous-medication-administration: A review. Available from: URL: http://www.healthline.com/health/intravenous-medication administration#Process2

4. WHO. Safety of injections: A brief background.Geneva.1999.

5. Sakic B, Dragana M. An assessment of intramuscular injection practices among nursing students and nurses in hospital settings: is it evidence-base: A review. Available from: URL: http://unvi.edu.ba/SEEHSJ/volume_2_no2/Branimirka%20Sakic%20SEEHSJ%20novembar%202012.pdf

6. WHO. Safety of injections in immunization program: WHO recommended policy. Geneva. 1998

7. Godelieve Alice Goossens, Flushing and Locking of Venous Catheters: Available Evidence and Evidence deficit: A review. Available from:https://www.hindawi.com/journals/nrp/2015/985686/

8. The Safe Injection Global Network (SIGN) Alliance Annual Meeting. Available from: URL http://who.int/injection_safety/sign/en

9. World Health Organization. The Global Patient Safety Challenge-Clean care is safer care. Information sheet. A review. Available from: URL: http://www.who.int/patientsafety/events/05/GPSC_Launch_ENGLISH_FINAL.pdf

Received on 08.10.2016 Modified on 14.01.2017

Asian J. Nur. Edu. and Research.2017; 7(3): 384-390.

DOI: 10.5958/2349-2996.2017.00077.5