Vascular access provides the introduction of a device for administering therapy, obtaining blood for testing, or removing substances from the bloodstream. A vascular access device (VAD) is defined as a catheter device inserted into the patient's bloodstream for infusion or diagnostic purposes. One type of VAD is the peripheral intravenous catheter (PIVC), a small flexible tube inserted into the bloodstream for infusion therapy.1 For the purposes of this study, vascular access will focus on the peripheral intravenous catheter.
Nearly all patients admitted to the acute care hospital setting have some type of vascular access procedure. It is estimated that over 350 million PIVCs are inserted in the United States annually.2 Venous access is assessed through inspection, palpation, and visualization technology.3 Visualization technology includes ultrasonography, which uses high-frequency ultrasound waves to assess vasculature.2 Ultrasound improves PIVC placement when alternative methods have failed; however, it has a steep learning curve, requiring training and practice for proficiency. Because of this curve, many health care institutions across the United States have developed vascular access teams (VATs), which use intravenous ultrasonography in their practice. A VAT is a group of health care professionals whose primary role is to assess, insert, manage, perform surveillance, and analyze VADs.3,4 VATs have shown a positive impact by improved patient safety outcomes, advanced quality of care, and streamlining resource utilization.3–5 Of note, VATs have demonstrated successful comprehension in understanding the importance of using ultrasonography in clinical practice to improve success and outcomes for vascular procedures.4,5
Ultrasonography has revolutionized health care practice. It has evolved over time with improved design and advanced technology. Now, the standard size of a portable ultrasound machine is no larger than a mobile phone or computer tablet. Several nursing organizations support the use of ultrasound as a tool for vascular access, including the Association of Vascular Access (AVA), American Association of Critical Care Nurses (AACN), Infusion Nursing Society, American Association of Nurse Anesthetists, and the Emergency Nurses Association. Best practice guidelines for all practitioners inserting all types of VADs recommend the use of ultrasound for accuracy and safety.6–9
Understanding the broad impact on patients and the evidence supporting the use of ultrasound for PIVC procedures provides strong rationale for ultrasound-guided education in nursing programs. Simulation is a new and innovative way to meet increasing demands of educational needs. Simulation as an adjunct to formal classroom study and clinical hands-on practice has been proven effective.10,11 The National Council of State Board of Nursing (NCSBN) has demonstrated that simulation has emerged as an enhancement to nursing students' development and training.10 Currently, the NCSBN supports nursing curriculum adoption of using hands-on simulation in the classroom setting. The NCSBN study demonstrated that simulation of clinical hours up to 50% of the clinical didactic portion of training has been shown to be as effective as hands-on training.10 While the NCSBN supports nursing simulation, there is no specific focus on ultrasonography. Ultrasound may be a useful tool that nurses can use when faced with a difficult PIVC placement. Not all nurses will require ultrasound use in their work settings. However, having knowledge of ultrasonography can be beneficial, especially with difficult PIVC placement. In addition, ultrasound PIVC placement has been associated with a decrease in the need for central line placement in difficult-access patients who required nonvesicant infusion.12
Both the Accreditation Commission for Education in Nursing and the Commission on the Collegiate Nursing Education do not have any supportive statements on the use of ultrasonography or incorporation of ultrasound into formal nursing curriculum. The Advance Practice Registered Nurse (APRN) organizations such as the National Organization of Nurse Practitioner Faculties (NONPF) have not developed any position statements on the need for ultrasonography education in the APRN role. Recently, the NONPF did incorporate ultrasonography as a core competency in acute care programs. However, neither acute care nor primary care nurse practitioner (NP) master's degree programs have universally adopted this practice. This omission is despite sound evidence that ultrasonography can improve patient care and safety after successful training and simulation is provided.8,9,12–16
The U.S. Department of Health and Human Services and the Agency for Healthcare Research and Quality (AHRQ) concluded that point of care ultrasound (POCUS) is a new tool for modern assessment of the heart, lungs, abdomen, and vasculature. POCUS has even been said to be superior to the modern-day stethoscope.15,16 Based on the AACN APRN Consensus Model, NP programs mandate advanced health assessment as a course vital to understanding the fundamentals of care. Recently, the NONPF added using ultrasound as a component of its competencies for hemodynamic monitoring, line insertion, tube insertion, and lumbar puncture placement.17 However, for primary care NP programs, under the competency section for Technology and Information Literacy, there is no indication for the need of ultrasonography.17 This is a lack of knowledge for NP curriculums as ultrasonography is emerging as a vital tool for point of care testing. Traditional nursing programs such as a bachelor's degree-prepared nursing program should also consider incorporating ultrasonography-guided PIVC placement into their curriculum.
Intravenous (IV) therapy is a vital component of medical and surgical nursing. Without access, a nurse is unable to implement therapy needed for treatment. If traditional PIVC placement fails, a nurse can use ultrasound-guided IV placement as an alternative cannulation attempt. PIVC insertion failure rates range throughout the literature. Recent studies conducted on ultrasonography continue to show optimal outcomes with ultrasound-guided PIVC success in difficult-access patients. Infiltration rates with traditional PIVC placement compared with ultrasound-guided PIVC placement are identical in difficult-access patients.18 A randomized prospective study by Bahl19 evaluated nurses' level of knowledge after an ultrasound-guided PIVC training was completed. Nurses were randomly assigned patients into cohorts to evaluate ultrasound-guided PIVC success compared with traditional PIVC placement in difficult-access patients. It was noted that ultrasound-guided PIVC placement had a 20% higher incidence of success rate compared with traditional PIVC placement in difficult-access patients.19 Using ultrasound to guide PIVC placement improves patient care outcomes by preventing potential complications such as cellulitis, phlebitis, catheter-related bloodstream infections, and in many cases, avoiding the need for central lines.4,6–9,20,21 PIVC placement is not a benign procedure. There are pernicious risks associated with PIVC placement such as bacterial colonization of Staphylococcus aureus, which can lead to complications.20
Preventing complications during a patient's hospitalization leads to better quality outcomes and improved patient satisfaction.22 The accuracy for PIVC insertion is a vital component to patient satisfaction, and the use of ultrasound when conducting PIVC placement improves the success of catheter deployment. In emergency rooms, there are typically many difficult-access patients who require PIVC placement. The development of a hands-on ultrasound-guided PIVC course for emergency room nurses allows for a higher success rate, allows fewer needle redirections, and prevents the need for central line placement in patients who required line access for nonvesicant infusions.9,23–33 These advantages support the premise that ultrasonography-guided PIVC placement should be incorporated into nursing curriculums.
However, the practice of using ultrasound-guided PIVCs has not been adopted by nursing academia. Nursing curriculum evolves with evidenced-based best practices, and ultrasound-guided PIVC placement has shown to be a best practice measure in difficult-access patients.9,23–33 This study was designed to explore the lack of formal education on ultrasound-guided short PIVC placement in NP students' curriculum. This study further illuminates the need for formal education with hands-on training for ultrasound-guided PIVC placement.
Methods
The purpose of this quasiexperimental study was to analyze NP students' knowledge of ultrasound-guided PIVC placement after the implementation of an educational simulation course. The study was conducted at a Catholic private university school of nursing in New York State. Institutional review board approval was obtained through the university. A total of 29 NP students voluntarily participated in the study. Only two students (7%) out of 29 in the study had prior ultrasound-guided PIVC device placement exposure. However, they disclosed they had used an ultrasound device once unsuccessfully in an emergency room setting, with resident supervision. Participants' demographic data are noted in Table 1. Students were given a demographic questionnaire, a Likert scale question inquiring about their confidence using ultrasound, and a 10-question knowledge-based exam precourse. Prior to the study, none of the students demonstrated confidence in ultrasound as they were never exposed to education or training on ultrasonography. The two students who attempted ultrasound in the past stated no confidence in comprehension. Next, students participated in a 1-hour live didactic and a 2-hour simulation course conducted by a doctoral-prepared NP. After completion of the didactic and simulation courses, students were given a sealed envelope that contained the same Likert scale question about their confidence using ultrasound and the 10-question knowledge exam. During the simulation training, students were divided into four groups of seven, and one group of eight students. Each group used ultrasound along with a vein block to practice both accessing the vessel and obtaining blood return during the simulation. The didactic education and simulation course on vascular access with a focus on PIVC placement using ultrasonography was the intervention. The comparison to evaluate learning outcomes was presented via the 10-question analysis. After the implementation of the total 3-hour program, the hypothesis was that nursing knowledge and confidence in using ultrasound for PIVC insertion would increase after training and simulation.
| Parameter | Per cent | Total |
|---|---|---|
| Gender | ||
| Male | 17 | 5 |
| Female | 83 | 24 |
| Years of RN experience | ||
| 1–5 | 45 | 13 |
| 5–10 | 24 | 7 |
| 10–20 | 17 | 5 |
| >20 | 14 | 4 |
| History of using ultrasound in practice | ||
| Yes | 7 | 2 |
| No | 93 | 27 |
| Confidence incorporating ultrasound into practice after course | ||
| 1 Not confident | 14 | 4 |
| 2 Slightly confident | 62 | 18 |
| 3 Moderately confident | 24 | 7 |
| 4 Very confident | 0 | 0 |
| 5 Extremely confident | 0 | 0 |
| Pretest mean | 62 | - |
| Posttest mean | 78 | - |
| Total improvement | 16 | - |
Results
The data were analyzed using statistical software (SPSS version 24; IBM, Armonk, NY). Descriptive statistics were used to examine each pretest and posttest questions for differences. A significance level of P< 0.5 was set. Chi-square and Fisher exact tests were performed as appropriate. A paired t test was done on the total score for each subject before and after. Data analysis revealed that, as a cohort, each answer showed improvement from pretest to posttest (see Tables 3 and 4). A posttest was administered immediately after a live simulation training on ultrasound-guided PIVC insertion. A total improvement with a mean from the pretest is 62% with an improvement mean of 78% (see Table 2). A Likert scale was administered before and after the simulation training. Both pre- and post-Likert scale analysis revealed a statistical significance in comprehension of vascular access techniques using ultrasonography, before and after course completion. While the students may not practice ultrasonography-guided PIVC placement after the simulation, their confidence level allows the possibility of applying fundamental techniques to do so. After the implementation of a simulation training on ultrasound-guided PIVC insertion, students revealed a high level of confidence for transitioning this skill into practice. The NP students' level of confidence showed significant improvement among many of the participants. Fourteen percent demonstrated no change in confidence of ultrasonography post course. Of the students, 86% demonstrated an increase in confidence post course. Table 2 identifies the topic for each question and demonstrates the 10-item analysis with statistical P value improvement during posttest analysis. The calculated mean of total correct responses is compared pretest and posttest.
| Item description | Pretest mean | Posttest mean | P valuea | |
|---|---|---|---|---|
| 1 | Color of the vein | 16 (55.2) | 22 (75.9) | 0.001 |
| 2 | Color of the artery | 14 (48.3) | 21 (72.4) | 0.02 |
| 3 | Vein vs artery differentiation | 25 (86.2) | 26 (89.7) | 0.001 |
| 4 | Ultrasound dynamics | 22 (75.9) | 26 (89.7) | 0.010 |
| 5 | Peripheral IV insertion | 14 (48.3) | 19 (65.5) | 0.000 |
| 6 | Vessel selection on ultrasound | 17 (58.6) | 20 (69.0) | 0.074 |
| 7 | Ultrasound dynamics during IV placement | 19 (65.5) | 25 (86.2) | 0.105 |
| 8 | Ultrasound probe handling | 20 (69.0) | 27 (93.1) | 0.089 |
| 9 | Long axis vs short access comprehension | 23 (79.3) | 26 (89.7) | 0.005 |
| 10 | Artery VA vein in short access view comprehension | 10 (34.5) | 15 (51.7) | 0.000 |
The P values are Fisher exact results
| N | Mean | SD | SEM | |
|---|---|---|---|---|
| Total score B | 29 | 17.83 | 1.490 | 0.277 |
| Total score A | 29 | 16.45 | 1.975 | 0.367 |
SD = standard deviation; SEM = standard error of the mean.
| Mean | SD | SEM | Paired 95% CI: lower, upper | t | df | Sig. (2-tailed) |
|---|---|---|---|---|---|---|
| 1.379 | 1.840 | 0.342 | 0.679, 2.079 | 4.036 | 28 | 0.000 |
CI = confidence interval; Sig. = significance
Results demonstrated that there was a statistical significance in knowledge gained in ultrasound-guided PIVC placement after the introductory course and simulation training. Students successfully demonstrated an increase knowledge in ultrasound dynamics and dexterity. The highest knowledge improvement was from items two (color of the artery) and eight (ultrasound probe handling). In item two there was a 25% increase in knowledge, and the nurses learned that Doppler flow did not determine artery versus vein on ultrasound; however, it demonstrated blood flow. Both vessels are black on ultrasound, and the artery would be a pulsatile structure that was noncompressible. In item eight, there was a 25% increase in knowledge. The nurses learned to correctly hold the ultrasound probe in the nondominant hand while the VAD was in the dominant hand. Participants in the study had no prior knowledge on ultrasound, and the post-Likert scale revealed that 62% of nurses stated they were slightly confident in using ultrasound for difficult PIVC placement in their practice. A total of 24% of participants stated they were moderately confident in ultrasound-guided PIVC placement in their practice. All the students in the study were bachelor degree-prepared nurses in their final semester of their master's degree-prepared NP degree. There was no difference among sex or experience in nursing that illustrated a larger comprehension of ultrasound. However, the simulation course provided a cohesive improvement in ultrasound knowledge as a cohort.
Discussion
The impact of formal education and simulation training on NP students' confidence, as well as knowledge regarding ultrasound-guided PIVC techniques, is significant. It should be further evaluated for comprehension. It was revealed that nurses in an academic setting could successfully comprehend the fundamentals of using ultrasonography for PIVC placement. Technology is a vital component to high-quality effective care in practice. Introducing ultrasonography into bedside PIVC placement for difficult patient access can enhance nursing knowledge, as well as practice and patient outcomes.2,9,23–32 This study discovered that with basic education and simulation training, nurses' confidence level and skills in performing PIVC with ultrasonography was improved. Similarly, Ault and Galen29,31 both studied the proficiency of nursing knowledge regarding vascular access. Ault29 studied a phase-integrated educational model, which incorporated a didactic session on vascular anatomy and probe physics. The outcomes of Ault's study29 demonstrated an increase in nursing knowledge on vascular access. Other studies have shown that nurses are able to comprehend ultrasound PIVC placement and incorporate it into their practice with success.24–26,28 However, there is no universal recommended standard training on ultrasound for PIVC insertion adopted by either nursing organization or academic settings.
Feinsmith30 conducted a study analyzing nursing knowledge on ultrasound-guided PIVC insertion and focused on the success of PIVC insertion in real time as a measure for nursing knowledge. While real-time training is helpful for systems thinking, having a prior foundation and framework to relate it to is helpful. A development of such framework can be in the form of an instructional video and simulation as demonstration by Galen,31 who analyzed the enhancement of nursing knowledge on ultrasound-guided PIVC placement after a video tutorial and simulation. As research continues to explore the implications of ultrasonography training for nurses, there continues to remain a lack of ultrasound education and vessel selection in academia. Nursing programs should begin incorporating the foundations of ultrasound-guided PIVC placement into formal nursing curriculums.
The outcomes of the NP students' knowledge and confidence level after the introduction course on ultrasound-guided vascular access revealed a successful comprehension of ultrasound-guided PIVC placement. This suggests that nursing academic organizations, as well as professional nursing organizations, should develop a valid uniform training tool and model for ultrasound-guided PIVC placement. The form of integration can be conducted in various training methods such as web-based training, live didactics, simulation, and real-time training.32–35 Nursing organizations such as AVA and AACN provide various training on ultrasound-guided PIVC insertion. Although there are multiple training courses developed, there still lacks a consensus on developing a unified curriculum and training model for ultrasound-guided PIVC insertion.
Although this study examined NP students' knowledge and outcomes were measured, it is important to note the adoption of ultrasound-guided PIVC placement in medical academic institutions and the impact in medical literature. Research conducted on ultrasound-guided PIVC placement demonstrated that nursing competency is parallel that of a medical resident, and there was no statistically significant association between the two on ultrasound-guided PIVC placement success rates.34 While nursing programs have yet to adopt this practice, medical schools have incorporated this into their curriculums.
Evaluation of medical literature revealed development of a structured curriculum combining web-based education on vascular ultrasonography, as well as hands-on training, and simulation integrated early in the training of the residents can lead to better proficiency in performing ultrasound-guided techniques.33–35.
Medical residents who were trained in simulation in conjunction with hands-on training outperformed residents with only hands-on training on ultrasound-guided PIVC placement.35 There is potential for similar outcomes to be translated into a nursing curriculum.
Nursing literature supports ultrasound-guided PIVC catheter placement with optimal outcomes; however, there is no formal curriculum adopted in nursing programs. The retention of nursing knowledge over time depends on a variety of factors, such as implementing ultrasound-guided PIVC placement into daily practice. Studies support that PIVC with ultrasound guidance performed by nurses can be successfully implemented and can lead to a decrease in the need for central lines in appropriate infusions.12,25–26
Academia must also play a vital role in translating ultrasonography into vascular access practice. Currently, the APRN consensus model focuses on pathophysiology, health assessment, and advanced pharmacology as a fundamental foundation for all APRNs. It is recommended to incorporate POCUS assessments into general health assessments, parallel to that of a stethoscope. Some medical schools, such as Harvard School of Medicine, have already adopted POCUS into the existing medical school curriculum by using didactic and small-group hands-on sessions. Medical students reported the ultrasound training received to be beneficial. However, this practice has not translated to all health care professional training programs in the United States.35
Similarly, nursing organizations should consider incorporating ultrasound-guided PIVC placement into its nursing curriculums. Intravenous therapy has a high impact in medical-surgical nursing curriculums, and incorporating ultrasound-guided PIVC insertion would enhance nursing knowledge. It would also give nurses the skill needed to be successful with difficult cannulation when traditional methods are unsuccessful. Understanding ultrasound vascular anatomy can aide in the success of the inserted device's longevity. For example, when ultrasound is used, the inserter has the capability to evaluate vein anatomy in various views, such as longitudinal and transverse. This allows an inserter to assess needle-guided accuracy. Ultrasound vein assessment also has the capability of allowing the inserter to evaluate vein-to-catheter ratio, for example, which increases the likelihood of insertion success and improving desired catheter dwell time.36,37 After a brief introduction course including similar elements, NP students have the foundation to comprehend and adopt ultrasound-guided PIVC placement, which can enhance clinical practice. If nurses practice ultrasound-guided PIVC placement and understand its foundations prior to entry into the clinical arena, then patients with difficult access will benefit, with fewer IV puncture attempts translating to increased patient satisfaction and decrease in complications.9,20–22
This study had several limitations. The 10-item questionnaire used to assess knowledge before and after education and simulation was not a validated tool. The questionnaire was developed by a panel of five vascular access board-certified nurse experts and two board-certified vascular surgeons from an academic teaching institution. Another limitation was the small sample size. The study included a sample of 29 nurses from one program in New York State. Additional studies would need to be performed in various nursing programs in various states. This study is also limited in that confidence and comfort with new technology such as ultrasound in practice takes time to develop. Dexterity and hand-eye coordination as well as manipulation of the ultrasound takes years to master. This study analyzed the outcomes of NP students' knowledge and skills on ultrasound-guided PIVC insertion after classroom and simulation training. However, sustainability on NP knowledge was not measured. The lasting effects of knowledge gained from ultrasound courses can be evaluated in future studies as nurses continue to implement ultrasound-guided PIVC placement into practice.
Conclusions
Overall, ultrasound is a cost-effective tool that can improve patient outcomes when used for PIVC placement. Nursing and health care providers should adopt ultrasound into their practice as an adjunctive tool for PIVC insertion. Proficiency and skills with the use of ultrasound improves with formal training and skills practice. Outcomes from this study demonstrated that NP students' knowledge improved after implementation of an introductory course and simulation training. As a result, nursing programs and health care organizations should consider formal curriculum/training, competencies, and simulation practice to improve caregivers' knowledge and skills related to the use of ultrasound in their practice. Valid and standardized educational curriculum and simulation training should be developed and further studies conducted to analyze the impact of formal education and simulation training on the use of ultrasound during PIVC placement.