Healthcare-associated infections (HAIs) are the most frequently occurring, yet often preventable, threat to patient safety and a significant cause of morbidity and mortality. Millions of hospitalised patients are affected by HAIs each year (World Health Organization (WHO), 2016), but with the application of optimal infection prevention and control (IPC) measures and standardised practice, products and processes, it is possible to reduce the numbers. One of the main determinants of HAIs is the inappropriate use and suboptimal care of vascular access devices (VADs). Although these devices are essential for delivering therapeutic treatment, they are not without risk of complications, including bloodstream infection. To help reduce these risks, clinical staff must be competent in all aspects of their insertion, use and management, including the application of optimal standards of care, the recognition of complications and timely action to correct and prevent them. To achieve this, uniformity in standards and practice is vital.
A project using a bundle approach was developed by the intravascular (IV) team at the authors' Trust and implemented to standardise and improve clinical practice for VADs (Caguioa et al, 2012); this resulted in positive change and major improvements. Despite the improvements, VAD-related complications have continued to be a patient safety issue. One strategy by the IV team to sustain the changes and improvements in practice was to develop an IV link nurse network: ‘Finding the missing link’. LNs are traditionally defined as ‘practising nurses with an expressed interest in a specialty and a formal link to specialist team members’ (MacArthur, 1998). LNs have been used in clinical practice to support many areas of specialist nursing practice since the 1980s. They actively nurture relationships with teams and colleagues working in the clinical environment, and carry out their link roles as required in the sphere of their responsibility (Royal College of Nursing (RCN), 2012).
Method
The project was discussed with managers to gain support and agreement for staff to attend quarterly IV masterclasses. Members of the IV team (IV practitioners (IVPs)) recruited nurses within their clinical areas, primarily those with a keen interest and motivation to make a difference in the care and management of VADs. The IV LN pathway, which included role, responsibilities and competencies, was developed based on focus group discussions. The LNs were supported by the IVPs in collaboration with practice development nurses (PDNs), ward managers and matrons to:
| Role | Responsibilities |
|---|---|
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CVC=central venous catheter
| Competencies |
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| Performance criteria | To be able to: |
| Knowledge and understanding |
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| Attitude and behaviour |
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| Timescale |
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CVC=central venous catheter; CRBSI=catheter-related bloodstream infection; LN=link nurse Adapted from: Royal College of Nursing, 2012; Roach, 1992
Competency can be defined as ‘the state of having the knowledge, judgement, skills, energy, experience and motivation required to respond adequately to the demands of one's professional responsibilities’ (Roach, 1992).
The LNs have an online resource page that is frequently updated by the IVPs to ensure they have relevant, timely, evidence-based information that is easily accessible. They are also supported to attend external conferences/forums, and encouraged to write for publication.
The overall aim was to create a culture where safety and quality as it relates to IV device care and management are valued and sustained—not simply complied with because it is Trust policy.
Results
An initial total of 70 LNs were identified across the Trust in 2012. Since then, the Trust has expanded over several different sites and there are currently more than 100 LNs. They have pledged and committed to take on the challenge, and were encouraged and supported to work on initiatives in their respective areas to promote best practice in VAD care and management. The quarterly masterclasses facilitated by the IVPs provide forums and workshops for learning, sharing initiatives, processes, progress and feedback. The LNs are recognised by individual infographic/picture posters displayed in relevant ward areas and IV badges designed in partnership and agreement with them. They also receive individual certificates when competencies are achieved and an end-of-year citation for those nominated for impactful innovation and/or ‘going the extra mile’ initiatives.
Each masterclass session is evaluated by the LNs. They are encouraged to provide feedback/comments, and to note topics they would like covered in the following session; however, the topics covered in practical workshops remain relatively constant. All 158 completed feedback forms from workshops held in April, July and October 2018 and 2019 were collated. Results are shown in Table 3 and Table 4. As can be seen, the results are favourable as 80% scored the workshops as excellent, 14% good, less than 1% fair and poor; 4% did not provide an answer.
| PICC dressing change (%) | CVC removal (%) | Restoring patency of CVC lines (%) | Blood culture (%) | Portacath access/de-access (%) | |
|---|---|---|---|---|---|
| Excellent | 82 | 82 | 76 | 80 | 79 |
| Good | 12 | 10 | 15 | 14 | 12 |
| Fair | 0 | 0 | 0 | 0 | 0 |
| Poor | 0 | 1 | 2 | 0 | 0 |
| No answer | 6 | 7 | 7 | 6 | 9 |
CVC=central venous catheter; PICC= peripherally inserted central catheter
| PICC dressing change (%) | CVC removal (%) | Restoring patency of CVC lines (%) | Blood culture (%) | Portacath access/de-access (%) | |
|---|---|---|---|---|---|
| Excellent | 81 | 81 | 84 | 79 | 82 |
| Good | 18 | 18 | 15 | 18 | 15 |
| Fair | 0 | 1 | 0 | 1 | 0 |
| Poor | 0 | 0 | 0 | 0 | 0 |
| No answer | 1 | 0 | 1 | 1 | 3 |
CVC=central venous catheter; PICC= peripherally inserted central catheter
To capture the experience from the programme, a questionnaire was sent to the LN network in July 2020 to evaluate the support they received, their learning, perceived benefits and overall recommendation. In total, 30 completed questionnaire were received after a 2-week period, with one reminder sent at the end of week one. Some LNs have been part of the network from inception, with duration ranging from 6 months to 8 years. Overall, the feedback was positive and encouraging, with 87% of respondents extremely likely to recommend the programme (Table 5). To further understand the LNs' experiences, the questions in Table 6 were included in the evaluation.
| Extremely likely | 26 (87%) |
| Likely | 4 (13%) |
| Neither likely or unlikely | − |
| Unlikely | − |
| Extremely unlikely | − |
| Don't know | − |
| How do you feel about: | Very satisfied | Satisfied | Dissatisfied | Very dissatisfied | Comments |
|---|---|---|---|---|---|
| The role expectations set as an intravascular (IV) link nurse | 67% | 33% | − | − |
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| The support you received from your ward | 50% | 43% | 7% | − |
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| The support provided by the IV team | 73% | 27% | − | − |
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| The education and training you received from the masterclasses and workshops you attended | 90% | 10% | − | − |
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| The impact your role has on improvement in IV practice | 67% | 30% | 3% | − |
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| Your overall experience as an IV link nurse | 63% | 37% | − | − |
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Four key themes were identified from the responses:
| Areas of learning | IV link nurses' personal experience |
|---|---|
| Knowledge |
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| Professional growth |
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| Quality improvement initiative |
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| Skills |
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Discussion
Recent years have seen increased development of specialist IV teams within acute hospital settings. However, manpower and resource issues make it difficult for these teams to be involved with every aspect of venous access and its associated issues. Although other nursing teams, including infection control, dementia and palliative care, have established link nurse networks for their specialties (Heals, 2008; Kaur, et al, 2010; Williams et al, 2019), no reference to an IV LN network/programme was found in the literature. However, in their evaluation of the palliative care LN programme, Downing et al (2016) recommended ongoing development and expansion of the programme within health care as an effective health system-strengthening approach to improve nursing and medical education. Dekker et al (2019) recommended future research to evaluate the effects on clinical practice and further development of the programme to maximise impact.
The IV LN role in the authors' Trust was developed and established primarily as a resource to increase awareness of the importance of VAD care, and to promote IPC measures in optimal patient care by way of evidence-based practice to maintain high standards throughout the Trust.
To facilitate this, IVPs worked closely with LNs individually and in group settings to ensure they acquired the requisite knowledge, skills and expertise to equip them to provide excellent patient care, and to train and educate colleagues. This is also an effective way to promote the ownership of optimal IPC standards as it relates to VADs locally. Cascading training in this way ensures care is timely, efficient, consistent and uniform. Although Forrester et al (2013) acknowledged that there are barriers and potential downsides to cascading training through LNs, they found that LNs add value as they provide a practical and timely way of sharing information and knowledge, and raising awareness with the wider disciplinary team. LNs are also in a unique position to support patient safety by challenging sub-optimal practice and the inappropriate use of VADs. However, this requires ongoing training and support by management and facilitators to empower and support LNs to undertake their role (Waldron et al, 2008). For the process to be successful, management support is pivotal (Sopirala et al, 2014; Peter et al, 2018).
The Infusion Nursing Society (2020) found that the prevalence of failure for all peripheral catheter types varies between 12% and 50% and, with the exception of device malfunction, failures are associated with human error, differences in practice and levels of competence in VAD insertion and care. Therefore, all clinical staff caring for patients with IV devices should be trained and assessed as competent (Loveday et al, 2014). Evidence-based training and education is imperative to ensure high-quality VAD care. The quarterly IV masterclasses underpinned by the current evidence-base is one strategy used to achieve this. Nevertheless, high staff turnover can be problematic; therefore, to counteract this LNs are encouraged and supported to recruit a replacement and provide a handover prior to leaving their position.
The masterclasses are approved by the Trust and facilitated by the IVPs with support from industry partners, who provide information, educational materials/equipment, and lunch; they also help to run practical workshops. The workshops are set up with training aids to allow the LNs to practise all the skills required. Basic ultrasound-guided cannulation is included in some sessions. The LNs are also presented with real scenarios to discuss and solutions to problems are achieved through analysis and troubleshooting.
Patients are also invited to share their stories/experiences of having a VAD and these are discussed. Patients stories are used to humanise experiences, emphasise why high standards in VAD care are so important and to help staff focus on individual aspects of care. These are impactful and insightful testimonies from patients' own experiences and perspectives.
The LNs appreciate the interactive nature of the masterclasses, which provide them with a better understanding of risks and benefits, insight and different ways to action/resolve issues in a timely manner. They have the potential to promote and enhance clinical effectiveness and disseminate information (McKeeney, 2003). Findings from a randomised controlled trial (Donati et al, 2020) have significant implications for hospitals seeking to improve compliance with IPC measures. The researchers found using LNs, combined with audit and feedback, was effective.
The network is an effective platform for nurses across the hospital and within the community setting to learn and share. Some community nurses attend the masterclasses and have had community-based training sessions facilitated by the IVPs. This way of working has helped to reduce the ‘revolving door’ effect of patients being sent into hospital from the community for issues such as occluded or migrated devices, thus contributing to improvements in practice and standards. LNs in some of the high dependency units within the Trust have developed their own independent teams. They share effective initiatives that have been adapted and implemented across other divisions, resulting in a reduction in complications, better patient experiences and satisfaction, cost avoidance for the Trust and a sense of pride for staff. Some have also developed IV LN ‘Teaching Boards' in their ward/unit, providing information on the devices used in the unit. With requisite training and support, the LNs feel empowered and confident in their role and are fully engaged, enthused and committed to providing excellent IV device care and management. This is evident in the attendance to the masterclasses (with some attending in their own time) and the positive feedback provided based on sessional, and overall evaluation as the responses to the questionnaire showed.
The LNs acknowledged that the IV masterclasses were a very good learning resource and a pathway to improve skills and knowledge, which equips them to share learning with colleagues. As can be seen from the results, 67% (n=20) of respondents identified evidenced-based learning as one of the highlights of being a LN. This enabled them to promote high-quality and safe care through effective project implementation. They act as role models and are able to influence IV care and management, thus creating a positive impact to reduce IV device-related infections and hospital stay. Below is some feedback from respondents:
‘I have been involved in creating some projects for liver ITU and on the previous unit I have worked with in terms of IV practices and have aimed higher in improving and advancing the teams' IV practices.’
‘This link nurse role was extremely rewarding as I played a key part in setting the standards, and contributed to improving IV line care in my department under the direction of the IV practitioner for surgery.’
‘Being a link nurse empowers us to effect change in our practice as well as empowers our colleagues to initiate positive changes in their own clinical practice. Being a link nurse is also being a role model in raising the standard of practice in our respective departments.’
As stipulated by the Nursing and Midwifery Council (NMC) (2019), professionals have a duty to keep their knowledge and skills up to date through a continuous process of learning and reflection. The NMC also requires professionals to undertake 35 hours of continuing professional development (CPD) relevant to their scope of practice and, of these, 20 hours must include participatory learning. The IV masterclasses provide 7.5 hours of participatory CPD learning, which help the LNs grow and develop in their role. A prerequisite to attending the masterclasses is that each LNs must register via the Trust's learning education appraisal platform (LEAP). Their attendance is logged on LEAP and can be used as part of their record for NMC revalidation.
One source of support identified by the respondents is the close working with the IV team in practice and the workshops. As a result of the support they received, more than half (73% n=22) would recommend the LN network. Through the network, some LNs gained independence and a voice to create change. They collaborate with the wider multidisciplinary team members to effect change by using audits and feedback in their wards. With support and encouragement, they felt empowered to advocate for patients by challenging sub-optimal practice, and to act as mentor for other staff.
Almost all of the participants (93% n=28) found the programme helpful in their personal and professional growth. They acknowledged that they found it beneficial and cited some of their best learning experiences while undertaking the role.
Overall the LNs proved to be an essential and effective resource that is having a beneficial effect on patient care, experiences and outcomes. The programme has helped LNs to develop lifelong skills; one LN is currently a vascular access practitioner and independent bedside PICC inserter within the IV team. Although Dekker et al (2019) found a lack of robust evidence on the effectiveness of IPC LN programmes, the IV LN network has proven to be an effective strategy within the authors' Trust.
Recommendations
The majority of the LNs are satisfied with the support they receive from the IV team, and considered the IV masterclasses as vital and effective. Due to the COVID-19 pandemic, the masterclasses planned for April, July and October 2020 were cancelled. Finding ways to provide updates during these unforeseen circumstances would be beneficial for the LNs. Recommendations for future could include:
Conclusion
The overall goal of the LN network is to protect patients from VAD-related complications through excellent care and management. The IV LNs' ability to complete tasks and reach goals based on the identified pathway depends on their own self-efficacy and how this affects the choices they make in sustaining best practice. They have demonstrated and documented the benefits of undertaking the LN role with 93% noting that it helped in their personal and professional development; 87% extremely likely to recommend the programme to others and 80% found the workshops excellent. The IVPs are committed to continue working with and supporting the LNs and other clinical staff to change behaviours, and in so doing improve practice in order to provide high quality, and high standards of VAD care free from avoidable infections and other complications. The IVPs endeavour to maintain ‘the missing link’, by continuing to share their knowledge and expertise with the LNs, and support them to set norms and maintain high standards. Collectively staff can, and must, do all they can to prevent harm, provide, promote and maintain excellence in VAD care to benefit the patients, organisation and the wider community.