Changes in nurses' knowledge and clinical practice in managing local IV complications following an education intervention

In hospitals, peripheral venous catheters (PVCs) are the most prevalent and commonly used intravenous (IV) route for administering fluids and medications throughout the body quickly. Although PVC insertion is relatively straightforward, it can be associated with complications such as extravascular infiltration, thrombophlebitis, haematoma, catheter-associated bloodstream infections, and air embolism (Nyamuryekung'e et al, 2021).

The incidence of PVC failure has been reported as 89.5 per 1000 catheter days (Takahashi et al, 2020): this and/or associated local complications consequently require prompt intervention. It is therefore often necessary to replace a PVC, a process that must adhere to local and international guidelines on the use and management of IV devices (Zhang et al, 2016; Ben Abdelaziz et al, 2017; Gorski et al 2017; Blanco-Mavillard et al, 2019; Gorski et al, 2021). The Infusion Nurses Society (INS) publishes Infusion Therapy Standards of Practice every 5 years, with the latest edition published last year (Gorski et al, 2021)—these are seen as the benchmark for good practice.

Assessment and monitoring of a PVC for local complications is a fundamental skill required of nurses in all healthcare settings. In addition, nurses' awareness of appropriate PVC maintenance and early identification of the risk factors can help minimise potential adverse consequences (Osti et al, 2019).

According to Salgueiro-Oliveira et al (2019), safe nursing practices with regard to PVC care depend on the size of the healthcare institution, the patient characteristics and level of nurses' knowledge. They stressed the importance of delivering regular continuing education programmes to improve knowledge and practice on PVC assessment and maintenance. Research, including the work by Salgueiro-Oliveira et al (2019), has emphasised the importance of nurses having knowledge of both the correct anatomical landmarks for PVC placement and the use of, for example, flushing techniques to minimise potential complications (Keleekai et al, 2016; Osti et al, 2019; Parreira et al, 2020). Research has also found that the quality of the nursing care provided is one of the risk factors for PVC-related complications, particularly phlebitis (Abolfotouh et al, 2014; Mandal and Raghu, 2019).

The Infusion Therapy Standards of Practice (Gorski et al, 2017; 2021) have highlighted that worldwide clinical practices on the maintenance and care of PVCs have evolved considerably as international best practice recommendations have changed in response to emerging evidence. Therefore, it is imperative for nurses to be updated on the latest guidelines and recommendations. A recent study conducted by Guanche-Sicilia et al (2021) emphasised the need to establish evidence-based education programmes to improve nurses' knowledge and practices on the management of venous catheters. Delivering high-quality care requires knowledgeable, skilled and highly qualified nurses. Hence, implementing education courses that translate knowledge into practice using simulation or walk-through scenarios provides a safe learning environment within which nurses are able to acquire a high level of proficiency, enabling them to identify commonly associated local complications of delivering IV therapy, to apply and interpret phlebitis evaluation scales and, consequently, make appropriate nursing interventions.

The study described in this article focused on transferring knowledge to practice via an education programme on preventing the common local complications of delivering IV therapy, with the aim of improving the knowledge and practice of nurses working in medical and surgical wards.

Ethical considerations

Formal letters were sent from the Faculty of Nursing to the medical, surgical and nursing directors of the proposed study settings. The researcher met with the nursing directors and potential nurse participants to explain the aim and process of the study. Formal consent was gained from all nurses who were enrolled in the study, with informed consent obtained from all participants.

Complete confidentiality was assured. The researchers also assured the nursing directors that the conduct of the study would not affect the nurses' work in the study settings and that the management and health authorities of participating hospitals would be provided with the findings to maximise the benefits.

Aim

The study aimed to transfer nurses' theoretical knowledge on the prevention of common local complications of IV therapy into practice. The following research questions were posed:

• What is the level of nurses' theoretical knowledge and clinical practice regarding the care and maintenance of PVCs?
• How can nurses' knowledge be transferred to practice?
• What action do nurses take if there are no signs and symptoms of complications or infection after 72 hours after cannula insertion. Until the intervention, local guidelines in the participating hospital recommended replacing cannula used for the infusion of non-blood/non-blood-related products after they had been in situ for 72 hours, whether or not any complications were identified. (These guidelines were based on the 2006 Infusion Nursing Standards of Practice (INS, 2006))
• What barriers do nurses encounter to the delivery of appropriate care and maintenance of PVCs (eg lack of supplies or a blocked vein).

Rationale

High-quality nursing practice requires the application of knowledge and skills in an effective, efficient and compassionate manner, and research contributes significantly to the knowledge applied in clinical practice. Ideally, decisions related to patient care should be based on scientific data, so to ensure that scientific action is applied in practice, it is crucial to apply ‘theory-guided practice’, which is often described as the practice of knowledge. The primary goal of theory in the context of nursing is to enhance practice by positively influencing patient health and quality of life. Theory and practice are interlinked: nursing theory is based on practice and it must therefore be verified in practice (Saleh, 2018).

Theory-guided nursing practice improves the quality of care delivered by allowing nurses to describe what they do for patients and why they do it (Younas and Quennell, 2019). Nursing education is evolving, and pedagogical techniques may be helpful to close the gap between theory learning and clinical practice (Martinez-Galiano et al, 2021). The present study focused on the application of nurses' knowledge to patient care, or the application of theory-guided practice, resulting in improved patient outcomes.

Methods

Design

A quasi-experimental research design was used. The study was undertaken between December 2020 and February 2021.

Setting and sample

The study used a convenience sample of nurses working in surgical and medical wards (n=64).

Data collection

Data collection was carried out using a validated semi-structured questionnaire developed by Arbaee and Mohd Ghazali (2013). The questionnaire includes a standard structured tool (parts 1–3) and an assessment section (part 4). Part 4 assessments were undertaken using the clinical visual infusion phlebitis (VIP) scale developed by Jackson (1998), updated and modified by Gallant and Schultz (2006). The final part elicited information on nurses' practices 72 hours post-insertion of a cannula. The following information was elicited for the study:

Part 1: demographic data

Collection of participants' demographic data: sex, age, education level, ward, years of experience, and whether the nurses had received continuous education on IV cannulation and therapy in the past.

Part 2: nursing practice

This section covered nursing practice on the care and maintenance of peripheral IV cannulas. It included 16 questions, which were scored on a three-point scale: 1=‘not at all’, 2=‘sometimes’ and 3=‘always’. Bloom's (1956) cut-off point was applied to determine nurses' practice, with a score of more than 80% recorded as satisfactory and less than 80% as unsatisfactory.

Part 3: theoretical knowledge

Nurses' knowledge regarding the care and maintenance of peripheral IV cannulas pre- and post-intervention was recorded. This section consisted of 19 questions requiring a simple ‘no’/’yes’ response. As in part 2, Bloom's (1956) cut-off point was applied to determine nurses' level of knowledge: less then 80% indicated poor knowledge and above 80% a good level of knowledge.

Part 4: use of visual infusion phlebitis scale

Assessment of nurses' ability to use and interpret Jackson's (1998) VIP scale (updated by Gallant and Schultz, 2006) to determine their knowledge and ability to identify complications or signs of infection was undertaken using a manikin arm.

Part 5: practices 72 hours post-insertion of cannula

To establish whether nurses' would make an intervention, ie to replace a cannula after 72 hours after insertion as recommended in local hospital guidelines at the time of the study, which nurses routinely followed even in patients who had no signs of complications or infection, but which were not based on the latest available INS guidelines. This part of the study also aimed to identify any barriers encountered in caring for, and maintaining, a peripheral IV cannula.

Framework

The study consisted of three phases:

• Phase 1: to identify nurses' theoretical knowledge and clinical practice on the care and management of IV cannulas, and to determine the skills in the use of Jackson's VIP scale. It was scheduled to take 2 weeks
• Phase 2: the delivery of an education intervention, which consisted of lectures on theory, lasting 45 minutes, and a clinical demonstration using IV manikin arms, with each session lasting 30 minutes. Nurses each attended one session. The sessions were repeated twice a day to avoid any disruption to nurses' work shifts. Posters explaining the VIP scale and listing possible common local complications of infusion therapy were also placed at the nursing stations in the wards. This phase was scheduled to take 3 weeks
• Phase 3: the final phase of the study was scheduled to take 2–3 weeks following nurses' participation in the education intervention and aimed to evaluate changes in nurses' knowledge and practice on the care and maintenance of peripheral IV cannulas, as well to determine their knowledge and skills on how to use and interpret the VIP scale post-intervention.

Analysis

The data were analysed using the SPSSv20.0 software package. The Kolmogorov-Smirnov test was used to verify the normality of the distribution. Quantitative data were described using range (minimum and maximum), mean and standard deviation (SD). The significance of the results was judged at the 5% level. The paired t-test was used to determine normally distributed quantitative variables, and to compare nurses' knowledge pre- and post-intervention. The McNemar marginal homogeneity test was used to determine statistically significant changes between knowledge and practice pre- and post-intervention.

Results

Participants' demographic characteristics are presented in Table 1. The age range was 18–45 years, with a mean of 25.52 years; more than two thirds (67.2%) were women. The majority had a diploma qualification from technical institutes (45.3%) (institutions that offer specialist 2-year courses), a university baccalaureate (39.1%), or a standard diploma (15.6%). Years of experience ranged from novice to expert, with a mean of 4.14 years. Participants were almost equally split between surgical wards (53.1%) and medical wards (46.9%). Only 18 participants had previously attended continuous education courses on IV cannulation and therapy. Most were IV nurse specialists (88.9%).

Following the education intervention, the data showed improvements in nurses' practice on the care and maintenance of PVCs on a number of aspects compared with practices pre-intervention. The most significant findings were that nurses were more likely to apply the following in practice:

• To use a transparent dressing to secure the cannula, with 60.9% post-intervention responding ‘always’ versus 15.6% pre-intervention (P<0.001)
• To record the date, time, site, size, the due date for changing the IV, and the patient's name: 73.4% post-intervention versus 39.1% pre-intervention (P<0.001)
• To always maintain aseptic technique during preparation, insertion and removal of the cannula: post-intervention 100% versus 78.1% pre-intervention (P<0.001)
• To change the dressing when wet or it has dislodged: 100% answered ‘always’ post-intervention versus 68.8% pre-intervention (P=0.001).

In addition, after attending the lectures and practical sessions, almost twice as many nurses responded that they ‘always’ provided patient education on the following aspects of IV cannula management:

• Cannula care: 75% post-intervention versus 40.6% pre-intervention (P=0.001)
• How to recognise the signs symptoms of IV cannulation infection: 76.6% vs 31.3% (P<0.001).

After taking part in the educational course, nurses also had a better understanding of the following areas, with ‘always’ answered on the following aspects:

• Risk factors for potential skin infection: 100% vs 81.3% (P<0.001)
• Following hospital guidelines on IV cannulation: 100% vs 84.4% (P=0.002)
• Flushing the IV line with normal saline following the administration of an IV infusion: 100% vs 23.4% (P<0.001).

There was also improvement in nurses' knowledge in terms of the care and maintenance of peripheral IVs post-intervention. The results were statistically significant across the range of items on which nurses were tested, except for the timing of peripheral IV cannula removal every 12-72 hours post-insertion (P=0.223). Table 2 shows improvements in nurses' skills in identifying the severity of phlebitis using a VIP scale post-intervention in comparison with their skills pre-intervention (P<0.001).

Figure 1 shows nurses' responses pre- and post-intervention on whether they would replace the cannula in the absence of complications or signs of infection, following education intervention, which included updating them on the latest international INS standards available at the time of the study (Gorski et al, 2017). Following the intervention, more than two-thirds (64.1%) of nurses responded that they would record the condition of the cannula site and hand over to the next nursing shift to continue observation of the site, a finding that was statistically significant (P=0.005).

Possible barriers to caring for and maintaining peripheral IV cannulation were also investigated. One barrier identified was the lack of an available alternative vein (‘no alternative vein’), with a similar response rate pre- and post-intervention (around 19%). The greatest barrier to replacing a cannula reported post-intervention was having an unco-operative patient (25.0% vs 17% pre-intervention)—ie the person was in pain, had a fear of needles, was agitated or anxious—although this difference was not statistically significant.

There were significant improvements in terms of both knowledge and practice on the care and maintenance of peripheral IV cannulas, as well in the application of the VIP scale with an arm manikin in a simulated environment post-intervention. The changes were statistically significant across three parameters:

• Nurses' theoretical knowledge (P<0.001)
• Nurses' clinical practice (P<0.001)
• Nurses' use of a VIP scale to identify any problems (P<0.001).

Pre-intervention, nurses scored an average 67.6% on theory and 70.3% on clinical practice, which rose to more than 89% and 85% respectively, post-intervention. Nurses' use of a VIP scale improved following the simulation with an arm manikin, rising from 25.5% pre-intervention to 100% post-intervention.

Discussion

Vascular access cannulation using PVCs is a common practice and is most frequently undertaken with patients admitted to hospital who require IV administration of medication, fluids and/or blood products (Urbanetto et al, 2016). In the USA, for example, around 330 million PVCs are sold each year. According to an NHS Scotland national healthcare-associated infections prevalence survey, one in every three inpatients in Scotland has at least one PVC in place (Reilly et al, 2007). Despite the advantages, PVC insertion is associated with complications, as many studies have reported (Alexandrou et al, 2018; Marsh et al, 2018, Ray-Barruel, et al, 2019).

Each year, about 60% of patients worldwide undergo PVC insertion for IV administration and infusion therapy in hospital settings (Webster et al, 2015; Osti et al, 2019). In these studies, the incidence of complications was expected, including thrombophlebitis (2.3%-67%), phlebitis (1.5%-60%), and hospital-acquired bacteraemia (6.2%) (Webster et al, 2015; Osti et al, 2019).

A study by George and Muninarayanappa (2013), which also compared theoretical knowledge and nursing practice pre- and post-education intervention, as in this study, found that pre-intervention most nurses had average theoretical knowledge and good skills in preventing IV cannula problems. Their findings are at variance with the results of the present study, however, in which nurses' theoretical knowledge pre-intervention was found to be poor (67.6%), as was their clinical practices on the care and maintenance of PVC (70.3%). According to Bloom's cut-off point of 80%, both these scores were unsatisfactory.

In the present study, nurses' knowledge was found to have improved post-intervention. This is consistent with the findings of Simonetti et al (2015), who reported that nurses who had taken part in education courses had higher knowledge scores than those who had not (P<0.001). Ravik et al (2017) also suggested that continuous education improves nurses' performance on PVC core competencies.

In the present study, nurses' theoretical knowledge, which had been poor pre-intervention, was found to have greatly improved post-intervention, a finding comparable with that of a number of other studies, which also reported that nurses were unable to demonstrate good clinical practice on the care and maintenance of PVCs (Cicolini et al, 2014; Milutinović et al, 2015). Findings from a qualitative study (Salgueiro-Oliveira et al, 2019) indicated that unsatisfactory nursing practices are linked to nurses' lack of knowledge.

George and Muninarayanappa (2013) studied the effectiveness of structured teaching programmes on nurses' performance to prevent IV-associated complications, with their results highlighting that knowledge significantly improved post-participation in the programme (P=0.05), although the differences in scores pre- and post-intervention were not significant (P>0.05). In a recent study, Etafa et al (2020) found a positive significant association between nursing students' knowledge and their educational experience. It is therefore important that education courses are designed to support newly qualified nurses to improve their performance.

A study by Keleekai et al (2016) used simulation-based blended learning to teach insertion of PVCs, offering learners a safe environment, with the results showing that nurses' knowledge, skills and confidence had improved significantly post-intervention. The findings of the present study are similar, in that the use of an IV arm manikin and the VIP scale to identify severity of phlebitis supported nurses to improve their theoretical knowledge and clinical practice post-intervention significantly (P<0.001). Phlebitis is a common local complication of infusion therapy in clinical practice, so nursing care that includes daily assessment of the PVC insertion site is imperative to prevent this complication (Mandal and Raghu, 2019).

The findings of the present study are also in line with those of Takahashi et al (2020), in whose study nurses encountered barriers to replacing a PVC, such as vascular damage due to previous PVC placement, limited patient mobility and patient discomfort due to pain, which increased nurses' workload and added to costs of care.

The nursing care of peripheral venepuncture sites after cannulation depends on the level of nurses' knowledge and clinical practice skills: if nurses knowledge and skills are not of a sufficiently high standard, this could be problematic. Consequently, providing continuous education to bridge the gap between knowledge and practice is necessary in order to create a safe learning environment within which nurses can learn and practise. The use of a manikin can aid nurses to improve their skills and, therefore, the quality of the nursing care they deliver.

Recommendations

In light of the study findings and in the context of Egypt, the authors make the followings recommendations:

• The introduction of continuous assessment of nurses' theoretical knowledge and clinical practice on the care and maintenance of PVC at government hospitals
• The implementation of education programmes for nurses on a wider scale, with regular review in order to introduce further improvements
• The design and introduction of posters in relevant work areas to help nurses identify the signs and symptoms of common local complications of infusion therapy and an illustrated guide on the use of a VIP scale
• Introduce an in-service training programme based on the latest evidence-based practice to update nurses.

The authors also suggest that further research is undertaken to assess and analyse the incidence of common local complications of infusion therapy in Egyptian hospitals.

Conclusion

This quasi-experimental study highlighted the importance of implementing continuous education programmes for nurses to improve their knowledge and practice with regard to PVC maintenance and prevention of associated complications. The premise for the study was that theory-guided practice enhances the delivery of nursing care, leading to improved patient outcomes.

The findings show a clear improvement in nurses' knowledge and practice after the education intervention as the comparison of pre- and post-intervention assessments show, with statistically significant differences. Hence, the results provide evidence that the education intervention was effective, enabling nurses to practise their skills on arm manikins within a safe environment and to then transfer this new theoretical knowledge to their clinical practice.

Furthermore, the study investigated nurses' skills in identifying the most common IV complications, with the results illustrating improvements in their ability to identify phlebitis. The main barriers to caring and maintaining peripheral IV cannulation were having unco-operative patients (those in pain, with a fear of needles, agitated or anxious) or not having access to an ‘alternative vein’.

In addition, nurses' practice showed improvement post-intervention on whether to replace the IV cannula 72 hours post-insertion. Pre-intervention, more than half the nurses (54.7%) reported that they would replace it (Figure 1), even if there were no signs and symptoms of complications or infection. Post-intervention just under a quarter (23.4%) reported that they would, which shows considerable improvement in knowledge. The intervention provided the nurses with the most up-to-date knowledge available at the time of the study—the 2016 INS standards of IV practice (Gorski et al, 2017)—which do not recommend changing an IV cannula after 72 hours where there are no signs or symptoms of complications, a recommendation that is reiterated in the latest standards published last year (Gorski et al, 2021).

KEY POINTS

• Local complications of intravenous (IV) therapy develop due to adverse reactions or injury to a venepuncture site, so it is vital that nurses monitor the site for signs and symptoms of phlebitis
• To ensure local complications of infusion therapy do not develop, nurses must be provided with regular updates and education on the risk factors, and on the care and maintenance of peripheral venous catheters
• The use of transparent, semi-permeable dressings to secure cannulas provides protection from infection and allows for a visual inspection and assessment of the site

CPD reflective questions

• How do you optimise the care and maintenance of peripheral venous catheters (PVCs)?
• In your place or work, do you consider that you are provided with adequate continuous education based on the latest evidence to improve your knowledge and practice?
• What bearing could the findings of the present study have on the care and maintenance of peripheral IV cannulas in your practice?