EDUCATION
A blended learning approach to
teaching CVAD care and maintenance
Karen Hainey, Audrey Green and Linda J Kelly
ABSTRACT
Nurses working within both acute and primary care settings are required to
care for and maintain central venous access devices (CVADs). To support
these nurses in practice, a higher education institution and local health
board developed and delivered CVAD workshops, which were supported by
a workbook and competency portfolio. Following positive evaluation of the
workshops, an electronic learning (e-learning) package was also introduced to
further support this clinical skill in practice. To ascertain whether this blended
learning approach to teaching CVAD care and maintenance prepared nurses
for practice, the learning package was evaluated through the use of electronic
questionnaires. Results highlighted that the introduction of the e-learning
package supported nurses’ practice, and increased their confidence around
correct clinical procedures.
Key words: Central venous access devices  ■ CVAD  ■ e-learning
■ Care and maintenance  ■ Clinical skills  ■ Guideline variation
T
he use of long-term central vascular access
devices (CVADs) has increased in the past decade.
Although CVADs have many advantages, they
are also associated with significant complications
(Napalkov et al, 2013). It is vital that those who
manage these devices are educated about potential complications
and the strategies necessary to reduce them (Moreau et al,
2013). To support nurses in undertaking this role, a ‘blended
learning’ approach to delivering education and training on
CVAD care and maintenance was developed by the University
of the West of Scotland and its local NHS health board (NHS
Lanarkshire).This approach consisted of the development of a
CVAD workshop, a workbook and competency portfolio that
had previously been evaluated positively (Kelly et al, 2015).
However, to support this clinical skill in practice, an e-learning
package was also developed within the local health board to
support learning further.
Up until the early 2000s, most education was delivered in a
classroom with a teacher who led the process. However, since the
Karen Hainey, Practice Development Practitioner for Resuscitation
and Clinical Skills, Practice Development NHS Lanarkshire
Linda J Kelly, Vascular Access Clinical Nurse Advisor, Vygon UK
Audrey Green, Lecturer, University of the West of Scotland
Accepted for publication: September 2016
S4
launch of the internet and the spread of network technologies,
the use of information and communication technology (ICT)
for educational purposes has increased rapidly (Kahiigi et al,
2008).Technology-enhanced learning, also known as e-learning,
considers the use of ICT in its widest sense to support and
improve the learning experience, and typically involves the use
of a computer to deliver part, or all, of a course. E-learning is
now recognised as an effective and popular platform for the
delivery of educational materials. According to Natarajan and
Kirsham Marg (2015), the rising popularity of e-learning can
be attributed to the flexibility and accessibility that this form
of teaching offers by enabling students to study without the
constraints of time and space.
Blended learning
Williams et al (2008) defined ‘blended learning’ as the use
of multiple methods to deliver learning, typically by using a
combination of traditional face-to-face teaching with some
online or distributed activities. Blended learning is seen to
be beneficial to both students and institutions, as it improves
learning outcomes, allows flexibility and delivers an effective
use of resources. In addition, it has been shown to increase
student satisfaction (Poon, 2012).
These forms of learner-centred teaching methods enable
learners to choose aspects of their study, typically the ‘when,
where and how’ of learning (Moran and Myringer, 1999; Higher
Education Academy, 2013). This shift from the teacher-centred
approach to the more learner-centred approach is recognised as
being useful in the healthcare setting.This is because it is a cost-
effective, time-efficient and a flexible way to access training. In
a sector such as health care, where people can be quickly pulled
away by professional commitments, it is something that can be
dipped in and out of, and reduces the amount of classroom
teaching. According to Chenkin et al (2008) and Moureau et el
(2013), web-based tutorials are as effective as didactic lectures
when learning procedural skills. Teaching the skills associated
with vascular access lends itself well to online learning and
there is evidence of such courses in the literature (Parquet and
Marchionni, 2015).
Equally, vascular access skills can be delivered as blended
© 2017 MA Healthcare Ltd
learning. As well as receiving some theoretical input, students
get important hands-on practical sessions in a classroom, clinical
setting or simulation suite.The students can subsequently access
an online resource to cement their knowledge at a time and
place that suits them.
British Journal of Nursing, 2017, (IV Therapy Supplement) Vol 26, No 2
EDUCATION

Table 1. Where do you currently work

e-learning package has been evaluated to ascertain whether
this blended learning approach to teaching CVAD care and
Location Percentage maintenance adequately prepares nurses for practice in NHS
Acute hospital 43% Lanarkshire (NHSL).
Community 53%
Method
Other 3% A mixed-method approach, including the use of an electronic
questionnaire, was used to gather data.The electronic questionnaire
had ten questions designed to capture information on whether
20 the workshop and e-learning module prepared nurses for using
CVADs in clinical practice. The survey tool used to gather the
data electronically was SurveyMonkey. This type of electronic
15
survey tool was already being used by NHSL, so access to this
resource was readily available.
Designing a questionnaire that yields worthwhile data can be
Responses

difficult (Gillham, 2008). To overcome this, the questions were

10 semi-structured and the majority had free text boxes available,
allowing for richer data to be gained.
The local NHS research and development department was
5 contacted to seek guidance on ethical approval for the study.The
study did not need ethical approval as it was a service evaluation.
A total of 80 nurses attended the workshop over the course
0 of 12 months; 45 of them completed the e-learning.The sample
Central line PICC line Tunelled CVC Port Renal included only nurses who had completed both the workshop
line dialysis line and the e-learning component of the CVAD programme over
the same 12-month period. This was because the survey was
specifically looking at how e-learning had supported nurses in
Figure 1. Which central venous access lines have you used? clinical practice. The sample size was therefore 45.
The survey responses were anonymous. The questionnaire
was sent out on three occasions to generate sufficient data.
30 The first time it was sent (in January 2016) was after a busy
Christmas holiday period, and the initial response was low,
25 with only seven returns. Gillham (2008) suggested that follow-
up requests can increase response rates by up to a third. The
20 questionnaire was therefore resent 4 weeks later, again with a
fairly low response rate (only 11 responses had been generated by
15 this point).The third time the questionnaire was sent, a closing
date was included and this generated the most returns. In total,
10 30 nurses participated in the online survey. The response rate
to the electronic questionnaire was considered positive: 67%
5 were returned with responses.The non-response rate was 33%.
The electronic survey tool used automatically collated the data
0 collected from the questionnaires.
To increase To increase To promote Other
knowledge and confidence safe practice
understanding Results
Demographics
Just over half of staff (53%) who responded worked in the
Figure 2. Why did you access the CVAD module? Particpants could tick all that community setting (Table 1); 43% worked in the acute hospital
applied to them setting; and 3% identified that they worked in ‘other’.The data
identified this setting as the day-bed unit at the acute hospital.
This was the approach taken in this study. The CVAD This department looks after patients who are living at home but
e-learning module was made available to all staff in the health are attending the hospital for treatments such as chemotherapy
© 2017 MA Healthcare Ltd

board via individual Learnpro accounts. Learnpro has multiple
electronic learning packages, from mandatory training to modules
that can be selected for professional development. The CVAD
module is listed under professional development and is available
for any staff member to select and complete if they wish. This
and blood transfusions.
Opportunity to practise
The majority of respondents (87%) had been using CVADS
in the clinical area following the completion of the workshop.

S6 British Journal of Nursing, 2017, (IV Therapy Supplement) Vol 26, No 2
EDUCATION
Complementing the Procedural guidance
practical workshop ‘Increased confidence
73% of nurses identified of proper procedure’
that the workshop and
‘A reminder of the
e-learning complemented proper procedure for
each other flushing PICC lines’
‘Refreshes my
memory’
Identified benefits of
supplementing the
CVAD training with
an e-learning tool
Supporting current practice
92% of nurses found the
e-learning tool useful in
supporting practice
Figure 3. Benefits of using an e-learning tool
Only 13% of those who had attended the workshop and accessed
the e-learning had not had the opportunity to use CVADs
clinically.The survey data therefore indicated that the appropriate
candidates were accessing training on CVADs.
Variety of devices in use
Respondents indicated that peripherally inserted central
catheters (PICCs) were the most frequently accessed lines;
73% of respondents had accessed PICC lines.This was followed
by equal numbers of central lines (26%) and tunelled cental
venous catheters (cuffed tunnelled lines) at 26%.These data are
not surprising given the number of respondents who worked
in the community. Short-term central lines can only be used
in the acute setting, while PICCs and tunelled central venous
catheters can be used in both acute and community settings.
Implanted ports had been used by 15% of respondents, divided
equally between acute and community settings. Ports have not
been used regularly in the past, so this may indicate an increase
in the different types of CVADs being used in NHSL, or a
change in trend of the types of lines being used, possibly as a
result of the CAVA (Cancer and Venous Access) trial (National
Institute for Health Research), which is taking place in
Glasgow’s cancer centre (Moss et al, 2014).This trial is looking
at which venous access device offers the best outcome from
safety, clinical-effectiveness and cost-effectiveness perspectives
for cancer patients.
The impact of the e-learning programme
E-learning is now a widely used method for teaching clinical
skills.A systematic review by McCutcheon et al (2015) identified
that learning for clinical skills can be as effective as traditional
teaching methods. De Beurs et al (2015) showed that e-learning
was an effective strategy for supporting the implementation of
clinical guidelines for nursing staff. E-learning is now a widely
S8
used method of learning within NHSL. Many of the clinical-
skills programmes now have e-learning components, which
have not been widely evaluated. It is therefore important to
consider how the blended learning approach to the CVAD
programme supported nurses in clinical practice.
The questionnaire looked at why nurses accessed the
e-learning module (Figure 2). Access to the e-learning module
is voluntary, so staff have an option to access it before or after
the workshop or at any point via the electronic learning
platform used by NHSL. The study identified that the CVAD
e-learning module was accessed for a variety of reasons. The
majority of respondents indicated that they used it to increase
knowledge and understanding of the use of CVADs (86%). A
significant number also indicated that they used it to promote
safe practice (76%).A total of 63% of respondents also indicated
that e-learning helped to increase their confidence in the use
of lines.
Positive outcomes from the e-learning
Procedural guidance was a key theme to emerge from the
additional responses nurses were able to give in the survey.The
rich data gained here supported the findings of De Beurs et al
(2015), who identified that e-learning is a useful strategy for
implementing and supporting clinical guidelines. Nurses who
participated in the study described the e-learning as a tool that
‘increased confidence in the proper procedure’ and ‘refreshed
their memory of procedures’. In total, 92% of participants
identified that the e-learning supported their practice and that
the workshop and the e-learning complemented each other
(Figure 3).
The study also looked at how nurses who had not used
CVADs perceived the e-learning could help them. They were
offered a series of options to pick from:
■■ Increase knowledge and understanding
■■ Increase confidence
■■ Promote safe practice
■■ Confirm procedures
■■ Other.
The participants were able to select all options that applied.
If they selected ‘other’, they also had to specify by leaving a
written comment.
Procedural guidance was also a common theme for these
nurses: 71% identified that they would use the e-learning again to
confirm procedures and 41% said that it would benefit them to
consolidate and refresh knowledge.Additional comments about
the blended learning package were also collated by the three
authors from nurses who had not used CVADS.The following
themes were identified:
■■ Opportunities for clinical practice
■■ Inclusion of guidelines from adjoining health boards
■■ The workshop was an essential part of the educational package.
© 2017 MA Healthcare Ltd
Opportunities for clinical practice
Some nurses identified that they would like greater opportunity
to use CVADs in clinical practice after attending the workshop;
13% of respondents had not had the opportunity to use a
CVAD before. Although this was a small number, facilitation
British Journal of Nursing, 2017, (IV Therapy Supplement) Vol 26, No 2
EDUCATION
KEY POINTS
■■ E-learning is widely used for teaching clinical skills and can be as effective
as traditional methods
■■ A blended learning approach to teaching central venous access device care
and maintenance can help to prepare nurses for practice
■■ Where possible, guidelines should be standardised to reduce practice
variations
■■ E-learning can support correct procedural guidance
of practice through other channels was identified as being
problematic. NHSL has three acute hospitals and each hospital
site has a day unit.The day units frequently use CVADs for the
administration of medicines and blood products, as well as for
delivering daily care and maintenance of these lines.The nurses
in the day units are competent in the care and maintenance of
CVADs, and can support staff from other clinical areas in the
development of these clinical skills. The day units can offer
the opportunity for nurses to use and develop the skill of
CVAD care and maintenance in a supported environment if
this opportunity is not available in the clinician’s own practice
environment. The day units can also offer the opportunity
for clinicians to maintain skills by supporting clinical practice
when required, such as supervised practice in the care and
maintenance of CVAD lines. The e-learning module could
be developed further to ensure that clinicians accessing the
e-learning module are aware of the availability of clinical areas
that can support the development of this skill by facilitating
the opportunity for clinical practice.
Inclusion of guidelines from adjoining
health boards
Nurses in this study indicated that they noticed variation in
practice as guidelines for care and maintenance appeared to be
different across health board areas. Writing in a text box, one
nurse commented:
‘Beatson (cancer centre) procedures are
different; it would be good to have the same
procedures or both on the e-learning.’
The nurses felt that they needed more information about the
guidelines that existed outside their own health board to reassure
them that they were delivering safe care. Another nurse wrote:
‘Information regarding Beatson protocol should
be included.’
Many of the patients they were caring for live in the local
area and receive treatment in the local acute hospitals or in
the community setting. However, they also receive care and
treatment at a specialist cancer centre, which is based in a
different health board. According to Gryttten et al (2013), the
most common measure for reducing practice variation is the
use of practice guidelines. Guidelines are typically based on
systematic reviews of available evidence and the effectiveness of
interventions (Eden et al, 2008). The aim of guidelines should
be to reduce inappropriate variations in practice and to promote
S10
the delivery of high-quality, evidence-based health care. They
may also provide a mechanism by which health professionals
can be made accountable for clinical activities.
However, national (external) guidelines are often adapted
for local use (internal guidelines), resulting in variations across
health board areas.This might be owing to the fact that there are
a variety of international and national guidelines available across
the world (O’Grady et al, 2011; Loveday et al, 2013;Association
for Professionals in Infection Control and Epidemiology, 2016;
Bodenham et al, 2016; Gorski et al, 2016; Royal College of
Nursing, 2016).These guidelines are very similar in content, but
when adapted for local use they vary. In addition, variation in
available devices (e.g. valved, non-valved, needle-free, etc) leads
to further differences that may be built into local guidelines.
Internal guidelines often require fewer resources and may be
more likely to be adopted in clinical practice because individuals
tend to have greater ownership of locally written guidelines
(Thomas, 1999).
This study identified that these variations caused issues for
the nurses and potentially for the patients. Many of the patients
crossed different organisations and health and social care settings
and therefore experienced these variations in practice. The
NHS Alliance recognises this and has a commitment to lead
clinicians, managers, commissioners and providers to deliver
patient care that is excellent.The NHS Alliance also states that
those who work in the NHS should take responsibility for
reducing clinical variation while ensuring quality and safety
(NHS Alliance, 2016).
The workshop as an essential part
of the educational package
The rich data identified that the workshop was a valuable part
of the training package.The workshop was evaluated by Kelly
et al (2015), who identified that the workshop that used part
task simulation was able to build the confidence of nurses,
provide a safe environment for practice, and reduce the number
of interruptions to learning. The workshop therefore offered
a safe and positive environment for learning about CVAD
care and maintenance. Nurses welcomed the opportunity to
learn about CVADs outside the clinical setting. In the present
follow-up study, nurses also expressed the importance of the
workshop. One said:
‘The workshop was great for confidence and
also to practise.’
Nurses found the workshop an extremely valuable element
of the learning. They also commented on how well-informed
the facilitators of the workshop were, with one nurse saying:
‘The lecturers were incredibly knowledgeable
about the subject.’
The nurses identified that the workshop and the e-learning
© 2017 MA Healthcare Ltd
complemented each other, and were both useful tools in the
delivery of education around CVAD care and maintenance.
Limitations
This was a small study conducted within one health board
British Journal of Nursing, 2017, (IV Therapy Supplement) Vol 26, No 2
EDUCATION
area; therefore a larger study would be required to ascertain if
similar positive results could be achieved. Furthermore, there
were nurses who attended the workshop who did not access
the e-learning tool, so establishing possible reasons for this
may be useful.
In total, 402 staff completed the e-learning; 80 attended the
workshop, of whom 45 had used the e-learning.
Only staff who had completed both elements in the study
were included, as the authors wanted to gain information on
the blended learning approach rather than e-learning alone.
The number of participants who completed the e-learning-
only component were significantly higher than those who
had attended the workshop. This suggests that staff in NHSL
are using e-learning to update knowledge and skills that they
already have, but without any compulsory ties to it.
Recommendations and implications
for practice
The e-learning module should be updated to provide further
guidance on:
■■ Standardisation of guidelines. This will reduce variations in
practice and in turn reduce risk
■■ Information should be made available about areas that staff can
attend to use and develop further skills in the use of CVADs
■■ Collaboration between the health board and the higher
education institute should continue in order to support
education for both acute and community nurses in caring
for patients with and maintaining CVADs.
Conclusion
The nurses who participated in the study identified that
using a blended learning approach to teaching CVAD care
and maintenance helped to prepare them for practice. Nurses
from both acute and community settings have been using a
variety of different CVADs and identified that e-learning was
useful to increase their knowledge and understanding, promote
safe practice, and increase confidence in the use of different
CVADs. Nurses who had not used CVADs also suggested that
they could use the e-learning to support their practice in the
use of CVADs.
The common theme that emerged from the comments
nurses made around the e-learning tool focused on clinical
procedures. The e-learning was able to confirm and clarify
procedures for nurses and therefore support them in their
clinical practice. Nurses identified that procedures across health
boards varied and that clearer guidance would be beneficial, as
slight differences in procedures across health boards can cause
confusion.Therefore, information on other local health boards’
procedures would be useful. Nurses also identified that the
workshop was a valuable part of their learning, giving them
the opportunity to practise procedures and gain confidence
before using lines in the clinical setting.  BJN
Declaration of interest: after completion of the study, Linda Kelly took
up employment with Vygon. During the study, Linda was employed
at UWS. Although Linda now works for Vygon, the company had no
input into the study.
S12
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