Having worked in the specialist field of vascular access for almost 15 years, I was recently reflecting on the changes in vascular access we have seen during this time and throughout my career as a registered nurse.
When I qualified in 1996, siting a cannula was still seen as a specialist skill that sat predominantly within the remit of doctors. My cohort of qualifying nurses were among the first to be taught venepuncture and cannulation in our preceptorship. It was felt to be an innovative and proactive step in developing our skills to make us ready for our future healthcare careers.
Since then, the NHS seems to have adopted an approach where it is almost a right of passage for all qualified nurses to be taught cannulation, regardless of the number of patients in their care who actually require a cannula. Indeed, many nursing degrees now incorporate cannulation into the final year of training. All doctors receive cannulation instruction as part of their tuition, as well as a growing number of allied health professionals and healthcare support workers. However, is it time to reflect on whether this blanket approach to training is still right or if we have now gone for quantity of staff over quality?
Placing a cannula in a patient can be an uncomfortable procedure for them and it comes with what can be quite significant risks if not done competently. The literature to support the best approach for cannulation training and competence could be considered difficult to generalise as the studies published are often quite small scale, labour intensive and potentially difficult to replicate into all areas of clinical practice. To be competent, however, most programmes require staff to attend a classroom-based training session, followed up with practical consolidation of the skill by a number of successful supervised cannulation attempts in direct clinical practice. Therefore, essential for the practical consolidation of the skill is that the practitioner has regular access to patients who require cannulation to both gain and then maintain competence.
However, over the past 10 years vascular access strategies have worked towards significantly reducing the number of cannulas required to be placed in patients. Some of these strategies have included:
- Always asking if vascular access is genuinely required or whether other therapies could be used (Moureau et al, 2012; Jackson et al, 2013)
- Extending the dwell time of cannulas, no longer advocating routine replacement at 72 or 96 hour (Loveday et al, 2014; Webster et al, 2019)
- Access to early placement of extended dwell time vascular access devices – encouraging peripherall inserted central catheter (PICC) or midline use (Moureau et al, 2012; Jackson et al, 2013).
So, theoretically, if we are training more staff to cannulate but patients are requiring fewer cannulas, have we now reduced the clinical exposure some staff may get to be able to acquire and sustain competence? If this is the case, are we unnecessarily training staff in the classrooms who will never be able to practise cannulation?
With this in mind, before providing cannula training do we need to consider:
- The number of cannulas placed in each area, and the time of day they are placed
- The number of staff already trained in each area
- If there is robust 24-hour access for inpatients who require cannulation – this could be through the use of medical teams, IV access teams, site teams, outreach teams etc.
By understanding the demand a bit better, and aligning resources, it may allow training to be more focused and strategies put in place for core staff to become highly skilled and proficient at cannula placement, rather than diluting the skill across a large staff group and reducing proficiency. This tactic of rationalising training to only those who will genuinely be able to get the experience and exposure necessary to become truly competent could lead to a better patient experience, improved patient safety and improved staff confidence. So, is it time we adopted a more considered trainin approach to cannulation that facilitates quality over quantity?