Most hospitalized people (70%–80%) require vascular access device placement (Alexandrou et al, 2012; Zingg and Pittet, 2009). These peripherally inserted thin plastic tubes allow venous system access for infusing essential fluids, blood, blood products, and medications. Although this common and complex skill is routinely taught in undergraduate nursing programs, peripheral intravenous cannulation (PIVC) first attempt success rates (FASRs) differ considerably between novice (23%) and expert (98%) nurses (Carr et al, 2016; Frey, 1998). When significant complications such as infection occur, increased hospital length of stay and patient's pain and suffering often result (Catarino et al, 2022; Marsh et al, 2020; Millington et al, 2020).
Factors affecting first-attempt success rates
Several factors contribute to inexperienced registered nurses' (RNs') and student nurses' low FASRs, including the lack of appropriate evidence-based education and PIVC skill development opportunities (Gorski et al, 2021; Rodriguez-Calero et al, 2020; Yalçınlı et al, 2019). Traditionally, nurses learn PIVC utilizing the cognitive apprenticeship model and simulation (Wooley and Jarvis, 2007). However, despite widespread PIVC teaching in nursing education and calls for close examination of individual clinical differences, there has not been a significant FASR improvement (Arslan et al, 2022; Frey, 1998; Parker et al, 2017). To increase FASRs more quickly and effectively, students and RNs urgently need improved training and support (Rivaz et al, 2017).
Outcomes of unsuccessful peripheral intravenous cannulation
Low FASRs result in negative outcomes, including multiple painful skin punctures, diagnostic test and treatment delays, and increased patient morbidity and mortality (Zingg et al, 2023). Repeated PIVC attempts can cause additional tissue damage and delay necessary medical interventions, resulting in longer hospital stays and increased healthcare costs (Buyukyilmaz et al, 2020; Santos-Costa et al, 2022). Also, repeated unsuccessful PIVC attempts usually necessitate alternative insertion methods, such as central venous cannulation, which is more invasive and associated with higher risk of complications (Santos et al, 2020). Therefore, it is crucial to ensure that nurses are equipped with proper evidence-based PIVC training to increase success rates and reduce negative outcomes associated with unsuccessful attempts.
Quiet Eye training
Novices and experts consistently demonstrate different gaze behaviours. Expert surgeons and athletes use a specific gaze immediately prior to the final task movement. For example, during surgical knot tying, expert surgeons have a long and stable final fixation on the knot location to ensure accurate placement and tension to avoid slippage or shear force or undue ischemia (Causer et al, 2014). This final fixation, referred to as the Quiet Eye (QE) is within three degrees (or less) of visual angle at a specific location for a minimum of 100 ms before a motor movement. An individual's information processing may be facilitated during this last fixation due to the external focus of attention and allowing key movement parameters, such as force and placement, to be effectively programmed, resulting in successful execution of a motor skill. The QE differentiates successful from unsuccessful performance, and novices from experts (Vickers, 2016). Most importantly, evidence-based QE training programs assist novices to adopt the characteristics of expert performers earlier in multiple sports, medicine, radiology, surgery, and pathology (Ashraf et al, 2018, Vickers, 2007). This results in performance gains that are maintained during high anxiety conditions (Causer et al, 2014). A recent study by Parker and colleagues (2021) confirmed that expert RNs utilize fewer eye fixations on the insertion site than novice student nurses and that their final fixation duration was associated with insertion success. The higher number of novices' fixations could indicate their higher information processing demands compared with experts. The experts' final fixation location and duration may indicate the need to focus on an essential cue used to guide the movement that novices have not yet learnt (Causer et al, 2014). Therefore, a QE training program, focusing on gaze behaviour could increase PIVC teaching effectiveness. To compare traditional technical (TT) training, focused on hand movements, with QE training, focused on gaze behaviours, we propose our current study.
Research objective
Our aim is to conduct a randomized controlled trial with undergraduate student nurses learning PIVC to investigate the effectiveness of QE training compared with TT training. We expect that QE training will result in both increased FASRs and increased PIVC procedural performance for these students.
Key definitions
Quiet Eye. The final fixation, within three degrees of visual angle, for a minimum of 100 ms before a critical motor movement (Vickers, 1996).
First Attempt Success. Insertion of the catheter into the vein as demonstrated by blood return into the catheter hub or successfully flushing the inserted catheter with 5–10 mL of normal saline.
Methods
Study population
The target population for this study comprises undergraduate student nurses. The in-depth PIVC and nursing knowledge, skills, and techniques commonly taught in nursing programs are essential for achieving an adequate FASR. By focusing on this population, we aim to deepen our understanding of QE training and its role in a successful first-attempt PIVC.
Study setting
The study will be conducted in the simulation centres at the Faculty of Nursing, University of Calgary, and Ward of the 21st Century (W21C), Calgary, Canada. The Clinical Simulation Learning Centre in the Faculty of Nursing and W21C feature state of the art simulation labs and high fidelity mannikins regularly used in undergraduate nursing education. The Faculty of Nursing offers several undergraduate, graduate, and post-graduate degree programs, inducting approximately 250 new undergraduate students each year.
Study design
We selected a parallel randomized controlled trial study design since observations will be collected from the participants in the TT training (control) and QE training (intervention) groups without any cross-over of the groups to a different condition (Polit and Beck, 2017).
Eligibility criteria
Student nurses with the following characteristics will be eligible for this study: a) self-reported normal or corrected to normal vision; b) completed Fundamentals of Nursing course; and c) received no formal PIVC training. Exclusion criteria will include (a) completion of any additional PIVC training; (b) reported regular PIVC practice in any context; (c) attempted more than five PIVCs or phlebotomies on a human or animal; and (d) any physical injury or disability that would prevent the effective completion of the PIVC.
Sample size
Overall, 44 student nurse participants (22 each in the control and intervention groups) will be recruited. This sample size was calculated using Statistical Package for Social Sciences (SPSSv29) software for a one-sided test using a large sample approximation. The estimation of statistical power was based on the Pearson Chi-Square test and the pooled standard deviation. Marsh et al (2018) conducted a pilot randomized controlled trial and identified that vascular expert specialists' PIVC first-attempt success rate was 100% compared to a 72% success rate in general nursing or medical specialists. We used these figures as a reference point for calculating our sample size. To achieve 80% power with an alpha of 0.05, the estimated sample size was 40 participants. A maximum 10% dropout is considered reasonable for this type of study, therefore the total sample size for this trial is 44 participants.
Sampling technique
A simple random sampling technique will be used to recruit participants, such that every individual in the population has a known chance to be selected (Polit and Beck, 2017). A comprehensive list of undergraduate student nurses will be obtained from the undergraduate nursing office and each student enrolled in years 2–4 of the program will be invited to participate in this voluntary study. These invitations will be extended by research assistants (RAs) attending classes to describe the study, posting recruitment flyers on bulletin boards around the Faculty of Nursing, and sending emails that include a description of the study and RA contact information. Research assistants will provide a gift card to students who participate for the duration of the study. Snowball sampling, where RAs ask participants to invite their peers to join the study, will be utilized if the desired sample size has not been reached when trials commence. Participants will not be required to reach out to peers, nor will they receive any added benefits from doing so.
Intervention
All participants will watch the same standardized PIVC training video and wear a mobile eye tracker while completing PIVC attempts on a light-skinned manikin arm (Laerdal Medical, product number 270-00001) capable of providing blood flashback in the needle hub and receiving the 10 mL saline flush to indicate PIVC success. The TT training group participants will receive ongoing feedback, focused on hand movements, while completing the pre-intervention, post-intervention, and one-week retention tests. The QE training group will view a video of an expert performing the procedure, with the ‘gold-standard’ eye movements overlaid. This expert model is based on the Parker et al (2021) paper, which showed a longer, stable, final fixation on the insertion site. A transfer task, utilizing a dark-skinned manikin arm, will assess participants' skills after trials (Ballard et al, 2022). While the TT training group will receive traditional instruction on hand movement improvement, the QE training group will receive feedback on their gaze behaviours. In addition, a RA will use a standard script to explain to the intervention group the significance of controlling eye movement and focusing on the area of interest during the PIVC procedure.
Randomization and blinding
After recruitment, RAs will obtain written informed consent (Appendix A, available online) from all participants before randomizing them to one of the two trial arms using freely available Research Randomizer software (2020; www.randomizer.org) designed specifically for this purpose. We will use the blocked randomization method, which ensures balanced groups when the total sample is less than 100 participants (Kang et al, 2008), to create a block size of four with two control and two intervention subjects.
Due to the nature of the intervention, participants will not be blinded to their study group. Two RAs will be present for each trial, one of whom will be blinded to the participants' group allocation. The blinded RA will leave the room during the trial, re-entering upon trial completion to assess the PIVC outcome (success or failure) based on video data that has been de-identified and had eye-tracking data removed. Therefore, outcome adjudicators will be blinded to group allocation to minimize differential treatment or outcome assessment during this study (Karanicolas et al, 2010).
Data collection tool
Demographic information including participants' highest level of education, age, gender, and any previous experience inserting a peripheral intravenous catheter or phlebotomy attempts on human or animal subjects will be collected using a structured digital questionnaire. Outcome variables that will be measured include first-attempt PIVC success (rated as a binary variable, yes, or no), quiet eye duration (%), number of fixations, movement phase time(s), and total movement time(s). A validated PIVC skills checklist will be utilized by trained raters to determine the PIVC procedural success (Schuster et al, 2016). Eye tracking-related data will be recorded using Tobii Pro Lab Analyzer Edition software (nd, www.vinis.co.kr/TPL_manual.pdf).
Data collection process
This study will be conducted in the Clinical Simulation Learning Centre at the Faculty of Nursing and W21C at the University of Calgary, where a realistic replicate of a common healthcare environment will be created, including the materials needed to complete a successful PIVC. Participants will be able to adjust aspects of this setting as they see fit, for example, the height of the hospital bed.
Each participant will wear a head-mounted Tobii Pro eye tracker (Tobii Technology, Danderyd, Sweden) that captures gaze and motor movements throughout their PIVC attempts on a simulated arm. Individual participant baseline data will be collected during three PIVC attempts. After this pre-intervention test stage, participants in both groups will complete the training stage. All participants will first view standardized video instruction about the PIVC insertion task and then read conventional instructions based on the current training provided by the Faculty of Nursing. Participants in the intervention group will be provided with QE instruction based on previous literature, watch a video showing an expert's QE while completing a PIVC attempt, and receive specific gaze behaviour feedback using a standard script followed by their own pre-intervention test video to compare to the expert model. Participants in the TT training group will be offered technical instruction based on the Faculty of Nursing teaching guides, view a video of an expert's hand movements during a PIVC, and view a video of their hand movements from the pre-intervention test.
The post-intervention test for both groups will consist of completing three PIVC attempts, along with a one-week retention test. Subsequently, a transfer task consisting of a more difficult PIVC insertion environment will be completed, utilizing a simulated arm with a dark skin color (Ballard et al, 2022). As darker skin provides less contrast to see the veins clearly, this post-intervention challenge will allow us to examine the training effects more clearly. Appendix B (available online) outlines the anticipated participant timeline.
Data analysis
All study data will be uploaded to the Tobii Pro Lab Analyzer Edition software (version 1.49) and exported to SPSS for analysis, using both descriptive and inferential statistics. The mean and standard deviation will be used to summarize continuous variables, while frequencies and percentages will be used with categorical variables. A mixed model Analysis of Variance (ANOVA) will be used to compare the groups' gaze behaviours and movement times and examine these results with appropriate follow-up tests. The difference in FASRs between the technical training and intervention groups will be compared for statistical significance, using a Chi-Square test with a significance level of 0.05.
Data monitoring
To ensure ethical conduct, accurate data collection and documentation, and protocol compliance, research team members will frequently monitor the data. As we are not testing new devices or therapeutics, no substantial safety risks exist that need continual monitoring (Lin and Lu, 2014).
Validity and reliability
Throughout the study, we will adhere to high quality research practices guided by the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) Statement (Chan, Tetzlaff, Altman et al, 2013; Chan, Tetzlaff, Gøtzsche et al, 2013). This includes prospective registration of the study protocol and regular auditing for allocation and protocol adherence by research staff and investigators.
Ethical and dissemination considerations
Ethical approval for this study will be obtained from the Conjoint Health Research Ethics Board at the University of Calgary, Canada. All potential and actual participants will be informed that their participation is completely voluntary, that their decision will not influence their education or standing in the nursing program in any way, and that the primary investigators will not have access to any personal identifiers. Written informed consent will be obtained from all study participants before commencing the trial, including an explanation of its risks and benefits and that they are free to withdraw from the study at any time prior to data analysis. We do not anticipate a need for post-trial care; however, participants assigned to the technical training group may request QE training after the trial is complete. Any protocol amendments will be approved by all trial investigators and the research ethics board, with updates submitted to the trial registry. All principal and co-investigators and collaborators will declare any financial and competing interests during the ethics approval process; the current authors have none to declare. The published protocol will be publicly accessible to ensure transparency of our research plan and appropriate reporting of study results. Results will be published in peer-reviewed journals and shared with educators through conference presentations.
Discussion
Our study will examine the implementation of QE training as a potential solution to the persistently low PIVC FASRs experienced by student nurses and novice RNs. This randomized controlled trial will compare a gaze-focused QE method with a TT training method on the PIVC FASRs for a group of 44 student nurse participants. Data will be collected via structured questionnaires and eye-tracking technology, with pre-intervention tests, post-intervention tests, retention tests, and transfer tests used to assess PIVC skills for each group. Descriptive and inferential statistics will be used to analyze similarities and differences between the intervention and control groups.
Implications
Study findings are likely to have substantial implications for nursing education and practice, at the University of Calgary and across the country. Currently, low PIVC FASRs lead to increased morbidity and mortality, unnecessary patient suffering, and increased healthcare costs. Implementing QE-based PIVC training will help ensure that novice nurses acquire these essential skills more effectively, thereby reducing patient complications, delays in treatment, and extended hospital stays.
This study also is expected to lay a foundation for the curricular adjustments needed to incorporate QE-based PIVC training modules as a standard component of undergraduate nursing programs at universities across Canada and around the world. For example, the structured, video-based training and expert model comparisons used with the intervention group could be readily integrated into existing curriculum at the University of Calgary, providing students with more practical and relevant training experiences. Implementing such curricular modifications is key to enhancing students' PIVC FASRs, a vital competency for these future nursing professionals.
Limitations
Certain potential limitations must be noted for this planned trial, including sample size. With only 44 participants, the study may not sufficiently capture the diversity of backgrounds and experiences among student nurses. Also, despite best efforts to avoid such circumstances, researchers or student participants may introduce bias relating to previous PIVC experience or training. These limitations could potentially impact the generalizability of study findings to the broader nursing population.
Future research
Future research should consider larger-scale trials involving more participants from various educational institutions (eg student nurses across Canada) and healthcare settings (eg novice RNs) to validate the effectiveness of QE training on PIVC FASRs. Additionally, a longitudinal study may be beneficial for investigating the long-term retention and application of QE-based PIVC training in clinical practice. Understanding how QE training influences nurses' PIVC performance over time is essential for enhancing patient outcomes and reducing healthcare costs.
Conclusion
This innovative study provides a strong foundational methodology for investigating the potential of QE-based training techniques for improving student nurse and novice RN first-attempt success rates in peripheral intravenous cannulation procedures. Moreover, it is expected to provide insightful and practical solutions for this common but challenging healthcare procedure.
The implications of this trial for patient care, healthcare costs, and nursing education are substantial, and future research will be needed to expand on our initial findings. Ultimately, the implementation of QE-based PIVC training in undergraduate nursing programs is expected to equip future nurses better to provide an improved quality of care for their patients.