Experienced donors, adverse events, and retention

Abstract

It is well established that even a mild vasovagal reaction has a negative impact on donor retention.1-3 Given the importance of retaining donors, significant efforts have been made to reduce the incidence of these adverse events (AEs).4, 5 This has led to a number of interventions being introduced—both physiological6-9 and psychological.10, 11 These interventions have primarily been focused on “high-risk” groups, such as the young and newly recruited,4, 5, 12 and there is evidence that both physiological and psychological interventions are efficacious. Recent evaluations suggest that there are at least four effective strategies for reducing vasovagal reactions:4, 5 excluding low-estimated-blood-volume (EBV) individuals from making a full donation,4, 5 refined predonation education,4 predonation water ingestion, and engaging in (elements of) applied muscle tension (AMT).4, 5 By reducing vasovagal reactions donor retention can be improved, for novice donors at least.1, 2 Retaining donors is especially important because these donors are safer and more cost-effective than newly recruited donors.13 As a cohort they are familiar with the script of donating and are, perhaps primarily through self-selection, statistically less likely to experience AEs. However, reactions among retained donors still occur2, 12 and their experience as donors does not keep them from being deterred.2, 14, 15 Importantly, we know little about what type of AEs deter, who is deterred, and what can be done to retain these experienced donors. Further, it is unclear whether the strategies developed for the young and novice donor are viable or relevant for the more experienced donor. The article by Veldhuizen and colleagues16 in this issue of TRANSFUSION addresses the issue of what deters and who is deterred and provides some preliminary answers as to what can be done to retain experienced donors. Their study draws on data from an experienced sample of whole blood donors (mean, 26.4 prior donations) from the Donor InSight study.17 Veldhuizen and colleagues examine the relationship between recall of an AE (vasovagal, needle, or other reaction), the Theory of Planned Behavior (TPB)18 and the risk of stopping donating in the next 2 years. Their analysis shows that needle and vasovagal reactions deter donors from donating in the future, with vasovagal reactions a stronger deterrent than needle reactions. Further, the magnitude of the relationship between vasovagal reactions and stopping is stronger for men than for women. Interestingly, the TPB variables are found to play a key role in explaining the relationship between AEs and stopping—with self-efficacy (a person's belief in his or her competence or successful performance of a behavior producing the desired outcome) playing a central role. Higher self-efficacy and more positive attitudes were associated with a reduction in the odds of future stopping. Recalling an AE was negatively associated with affective attitudes and self-efficacy, particularly for men. Further, the TPB variables partly explained the relationship between AEs and the risk of no longer donating. As Veldhuizen and coworkers did not test a causal relationship, the direction of the relationship between AEs, self-efficacy, and affective attitudes is unclear.19 However, despite this, the findings in this and other studies suggest a number of considerations in developing practical strategies to facilitate the retention of the experienced donor in the context of AEs. Experienced donors are a valuable resource for any blood collection agency because they are strongly internally motivated to remain as donors with their behavior either habitual or stemming from an emerging blood donor role identity.20, 21 These donors bring several benefits to blood collection agencies. They typically have well-defined scripts for donating (i.e., they know what to do and when), which allows for operational efficiencies. Further, they typically require minimal intervention to retain. There are also benefits for experienced donors. From their perspective, their blood donation scripts give them a sense of predictability and certainty over their behavior, and this may be psychologically comforting. Statistically it is likely that the experienced donor has had multiple phlebotomy attempts that have occurred without incident.2 Further, this successful repetition of the behavior allows for a strong sense of self-efficacy as a donor to develop.22 Experienced donors are statistically unlikely to have an AE.16 However, when they occur, their deterrence effect is notable. France and colleagues2 found that vasovagal reactions reduced return rates among experienced donors by 33%, compared to a 20% reduction for first-time donors who experienced the same form of reaction. In considering practical strategies to retain the experienced donor in the context of AEs, the very characteristics that make experienced blood donors a valuable resource for a blood collection agency also create some interesting challenges. Experienced donors are likely to resist any variations to their donation scripts that explicitly attempt to reduce vasovagal reactions, for example by incorporating new behaviors such as predonation water ingestion or AMT while donating. It is precisely because these donors are experienced that they have well-defined scripts for successful blood donation, with the donation behavior being one that they are confident they can successfully carry out. As such, experienced donors' scripts may well undermine adherence to these types of interventions. Even though novice or young donors do not have these well-developed scripts, there is some evidence that adherence rates for such donors are only modest for these interventions.4, 5, 23 Newman and Siegfried23 suggest that the “tedious and impractical” nature of aspects of these interventions prevent their inclusion in new donors' developing blood donation scripts. For the experienced donor who does not perceive that he or she is at risk of an AE and who has a well-developed script for successful blood donation, the recommendation of engaging in such behavior before or during phlebotomy may be resisted (“you want me to do what while donating?!?!?”). Further, attempts to implement such interventions with all experienced donors may increase the perceived costs of donating to an unacceptable level.24 The exception may be if the intervention comprises a “gift,” such as a bottle of water, which communicates concern or benefit as to the donor's well-being.25, 26 However, prior research suggests that such gifts may be of limited motivational value to the experienced donor.21 While the analysis by Veldhuizen and colleagues16 suggests that reducing the rate of AEs among experienced donors is the most direct way of improving retention, the universal inclusion of strategies such as water ingestion and AMT may have unintended consequences on the retention rate of experienced donors. Specifically, the very changes designed to increase retention of the few experienced donors who have an AE may result in a net loss of donors. This outcome could occur because those experienced donors who do not have AEs may be deterred in greater numbers as a result of undermining their donation scripts. As such, to facilitate the retention of the experienced donor in the context of AEs, blood collection agencies may need to take a more subtle approach. The role of blood collection agency staff in decreasing AEs has been noted for some time.12, 27 While improving the technical skills of phlebotomists and the aftercare provided may improve retention directly,16, 27 the social skills of, and social support by, blood collection agency staff can also play a role in reducing vasovagal reactions.16, 28, 29 In two samples of mainly experienced donors, Stewart and colleagues28 found that more socially skilled phlebotomists produced fewer donor reactions. Hanson and France29 tested the possible stress-buffering effect of social support in a sample of novice donors. They found that the presence of a stranger who was trained to act as a support person reduced donors' self-reported presyncope reactions to blood donation. In both studies, the role of the supportive individual in providing reassurance and/or distraction was presented as potentially explaining the reduced rate of vasovagal reactions observed. The results of these studies suggest that blood collection agencies could intervene to reduce the rate of AEs by ensuring that all staff and volunteers are able to provide adequate social support. As an intervention, however, this strategy may be seen as unduly costly in terms of both training costs and time taken to implement for the benefit it may yield, particularly among experienced donors. Further, experienced donors may be somewhat resistant to such advice and reassurance if it is given universally (“I have done this before, you know …”). An alternative, less costly, strategy may be to target specific experienced donors who have been assessed as being most at risk of an AE. As noted by Newman12“one cannot predict with any certainty which donors will or will not have a reaction” (p. 65) and this reality is certainly true within the experienced donor cohort. The challenge for blood collection agencies is therefore to identify those experienced donors who may be most at risk of AEs. Given that experienced donors are likely not to routinely experience AEs, many of the demographic and physical features typically used to identify donors vulnerable to the more severe AEs (i.e., vasovagal reactions) are likely to be poor predictors.30 Psychological and environmental factors may well be more useful as these can vary from donation to donation,12, 27 for example, fear of the blood draw,31 time since last meal, or fatigue and/or sleep duration.32 Recently France and colleagues31 found a significant association between responses to two questions assessing fear of the blood draw and presyncope symptoms within a sample of young novice and young experienced donors. This suggests that small modifications to the predonation interview might be useful in predicting which experienced donors are likely to be at risk. For example, the interview could incorporate questions focusing on the psychological and environmental factors associated with a heightened risk of experiencing an AE. Drawing on the findings of Stewart and colleagues28 and Hanson and France,29 these interventions could be as simple as ensuring that these “vulnerable” experienced donors are paired with particular phlebotomists or support staff. Bolstering the confidence of donors in their ability to successfully donate blood is an alternative approach to interventions to prevent AEs.16, 33 Veldhuizen and colleagues found that confidence—operationalized as self-efficacy—emerged as a key variable in their analyses. Within their experienced sample, AEs were associated with diminished self-efficacy, while heightened self-efficacy was associated with a diminished risk of stopping. In a blood donation context, self-efficacy can be enhanced either through repeated successful attempts at phlebotomy or through donor education, in which donors are persuaded that they have the skills and capabilities to successfully donate blood.22 A number of evaluations of revised predonation materials have now taken place with samples of both novice33-35 and more experienced donors.10, 22, 36 These materials typically include information about the ongoing need for blood, details about common donor concerns about the process (centering on fear, pain, and potential vasovagal reactions), along with information on effective coping strategies (to date, focusing on interventions such as water ingestion, AMT, and distraction10). These evaluations uniformly show that the revised materials35, 36 are beneficial because they produce more positive attitudes toward donating, more confidence in the ability to donate, and a stronger intention to donate.10, 33-36 Importantly, this intention translates into donation behavior. France and coworkers33 found that boosting participants' confidence in their ability to donate blood through revised predonation materials led to improved donor recruitment and retention. Novice donors may diligently attend to predonation materials as part of their developing blood donation script. Experienced donors, however, may disregard such information as irrelevant (“I know what I'm doing …”). These donors may need little persuasion that they can effectively cope with blood donation, with this self-efficacy most likely borne from repeated phlebotomy attempts that have occurred without incident.2 The benefit of these materials to the experienced donor at this stage of the donation process is therefore likely to be more direct—providing information on how to effectively negate vasovagal reactions (through AMT or distraction) should they occur. The challenge remains to get experienced donors to engage with these materials. One way of subtly encouraging experienced donors to participate is through incidental learning. For example, as part of their communication strategy with donors, blood collection agencies may disseminate information on the AE prevention initiatives undertaken with novice donors. As this information is not explicitly directed at the experienced donor it will not challenge his or her existing self-efficacy as a donor. However, it should provide those donors with information about effective coping strategies that they may recall or ask for assistance with should they subsequently experience an AE while donating. An alternative strategy that may be particularly useful with experienced donors is to provide easily accessible information on the breadth of factors that can cause an AE to occur while donating. This information should be framed to the positive (e.g., a “checklist for a better donation experience”) and should focus on those environmental factors known to be negatively associated with severe forms of AEs (e.g., being well rested32). The provision of this information in a nontargeted manner (e.g., through posters on the wall) in a predonation waiting area may allow donors to self-identify their own risk of an AE so that they can seek out further information on strategies that they can employ to avoid them. It is at this stage that experienced donors may be more receptive to information on techniques known to prevent vasovagal reactions, such as predonation water ingestion and AMT while donating.6-9 The widespread provision of predonation information that details the breadth of factors that can lead to an AE serves to “normalize” these reactions, even among experienced donors. While this may remove the surprise that experienced donors can feel if an AE occurs (“I've done this many times before, and I haven't felt this bad”), this information also potentially allows them to rationally attribute cause for the AE.14 This attribution may allow them to maintain their self-efficacy as a donor, which the data of Veldhuizen and colleagues16 show is negatively impacted on by an AE, and therefore be retained as blood donors. Specifically, donors may feel able to either externally attribute the cause of the reaction14 (“it was a bit warmer than usual in the blood collection unit”) or attribute in a way that allows them to control the situation in the future (e.g., by ensuring that they are well rested before donation32). The analysis by Veldhuizen and colleagues suggests that this ability to maintain self-efficacy even after an AE may be particularly important for the retention of experienced male donors. Veldhuizen and colleagues' analysis16 suggests that interventions can facilitate retention of experienced donors who have an AE, or whose self-efficacy and positivity toward donating has been diminished. These interventions can be as simple as providing information en masse after donation to all donors that normalizes AEs, bolsters self-efficacy, and provides information or structure on how to engage in effective coping strategies to avoid such reactions in the future.16, 37 For the experienced donor who has had an AE, this information will now be relevant and his or her engagement with it may facilitate retention. The risk remains, however, that the experienced donor who recalls an AE may disengage quickly from his or her blood donor role (“I'm no good as a blood donor …”20). As such, and given the strong correspondence between self-report of vasovagal reactions and phlebotomists ratings,38 blood collection agencies should pursue a more deliberate and targeted strategy with those experienced donors known to have had an AE. Sinclair and colleagues11 recently assessed the effect of a short (M < 9 min) postdonation motivational telephone interview on donor retention. They found that those who were interviewed reported more positive attitudes and greater confidence along with stronger intentions to donate in the future. Importantly, these intentions translated into behavior—interviewed donors returned to donate at a higher rate within 12 months than those blood donors in the control condition. While Sinclair and colleagues did not explicitly target donors who had reacted, such a strategy may well be effective for experienced donors who have had an AE. Such short telephone interviews would allow donors to reconcile their ambivalence toward donating11 in the context of information that normalizes, and appropriately attributes the cause of AEs. Further, and consistent with the suggestions by Veldhuizen and colleagues,16 donors could be encouraged to actively engage in coping planning11, 37 drawing on the strategies that prevent the physiological causes of the most serious AEs, vasovagal reactions. This targeted strategy may be particularly effective in promoting the retention of these valuable, experienced donors. In the context of AEs, experienced donors are a valuable but challenging asset for blood collection agencies. Through exploring the relationship between AEs, TPB variables, and risk of stopping in a sample of experienced donors, the analysis by Veldhuizen and colleagues16 suggests a number of practical strategies that may be employed in the context of AEs with the experienced donor to improve retention. Such low-cost “interventions by stealth” can be used before, and during, donation to prevent AEs, as well as after donation to bolster self-efficacy. These interventions will allow for the improved retention of experienced donors, a group whose continuing participation should not be taken for granted. The author certifies that she has no affiliation with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in this manuscript.

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