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Knowledge and Proficiency Level in Peripheral Intravenous Catheter Insertion of Bedside

Nurses in a Tertiary Hospital:

Basis for Enhanced Training Program

Bryan R. Balatbat, RN

St. Paul University – Manila

MSN 200: Advanced Research with Statistics

Bradley Goldie K. Loo, Ed.D.,MSN,DBA(ue), RN,LPT

September 29, 2020

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CHAPTER 1

INTRODUCTION

Inserting a peripheral intravenous catheter (PIVC) is one of the most frequently

performed invasive procedures by nurses (Ann Jacobson, 2005). More than 90% on worldwide

data show that patients are started with an intravenous line for management of a certain disease

condition (Alexander, 2011). It includes administration of fluids for hydration, administration of

medications, administration of blood products, etc. This access allows for an increased chance of

promoting therapeutic response to patients compared if treatment would be given through a

different route such as oral or sublingual.

History would dictate that it used to be physicians who perform venoclysis. During the

1930s, Dr. Thomas Latta found that salt water, injected into the bloodstream, could help fight

cholera. A couple of years later, Dr. James Blundell used transfusions during postpartum

hemorrhages and observed that the speed of infusion had a direct impact on its success (Med One

Blog: A Brief History Of IV Infusion Therapy, From The Middle Ages To Today, 2018). Through

the years, nurses were already empowered to perform this procedure. In the Philippine Nursing

Law (RA 9173), it is stipulated that registered nurses can initiate an intravenous line provided

that appropriate training should have been taken (De Belen & De Belen, 2007). For some

hospitals in the Philippines, it has been a requirement for nurse applicants to undergo the

Intravenous Therapy (IVT) Training Program. In St. Lukes Medical Center – Global City,
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bedside nurses are provided with a training pertaining to Infusion Therapy which is called St.

Luke’s Intravenous Therapy Program (SLIV) as part of their induction to the institution. Included

in the program are the standards set by the hospital in infusion therapy.

Despite these training programs that nurses have to undergo prior to their actual

immersion and handling of patients, the skill on IV insertion remains challenging to learn and

perform that sometimes leads to several attempts before a successful line can be secured to a

patient. These multiple IV insertion can cause different levels of pain, anxiety and patient can

even develop phobias to at some point, refusing any treatment because of the trauma. It also adds

burden on the part of the patient because of additional cost it will incur for another set of

materials needed for the re-insertion that might lead to possible complaints that will greatly

affect the perception of the customer on the type of service that the institution is providing. In

SLMC – Global City alone, there were 10 reported patient / relative’s complaints related to

multiple IV insertion for the year 2019. Not to mention all the failed attempts that was not

captured and documented because no formal complaints have been made.

In general there is little research focusing on the assessment of knowledge and skills level

of bedside nurses in relationship with the success rate of PIVC insertion especially in the local

setting.   To date some studies have concluded that nurses were lacking knowledge as well

practice towards peripheral intravenous cannulation (Port Said Scientific Journal of Nursing,

2019). To overcome gaps in existing works, this study aims to determine the level of knowledge

and skills of nurses in PIVC.  Overall, identifying which competency is perceived differently can

help design a training program that is learner centered.  Moreover, addressing the gaps of the

study may contribute to improvement of quality outcomes

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STATEMENT OF THE PROBLEM:

The study aims to determine the following:

1. What is the profile of the respondents according to:

a. Age

b. Sex

c. Tenure

d. Last insertion made

2. What is the level of knowledge of the respondents?

3. What is the level of proficiency of the respondents?

4. Is there a significant relationship between knowledge and profile of the respondents?

5. Is there a significant relationship between proficiency level and profile of the

respondents?

6. Based on the result of the study, what enhancement program can be recommended?

PURPOSE OF THE STUDY:

The purpose of this study is to identify the significant relationship on the demographics, skills

and proficiency level of registered nurses in a tertiary hospital on success rate of PIVC insertion

as a basis for improved training program.

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REVIEW OF RELATED LITERATURE:

This portion primarily presents the different researches and literatures which have

significant bearing in support and relevance to the present study.

Having the ability to insert IVs correctly and efficiently is an essential skill for a nurse,

especially one in an acute care setting such as the emergency room. However, even if you are not

in a more acute care setting, you should still know how to use the correct technique to insert a

peripheral IV line (Nursing Skills, weebly.com). In an editorial published at Philippine Journal

of Nursing entitled: Care, Competence, Compassion and Nursing, caring nurses just do not just

possess a good intelligence quotient, a traditional indicator of success, but human and personal

skills (Castro-Palaganas, 2014). Nurses’ competence is based on the knowledge and skill taught

to them. Nursing training is a combination of theoretical and practical learning experiences that

enable nursing students to acquire the knowledge, skills, and attitudes for providing nursing care.

Nursing education is composed of two complementary parts: theoretical training and practical

training (Jamshidi, et.al, 2016).

Access to peripheral veins is necessary for sample collection, transfusion and infusion of

fluids or medications. The peripheral intravenous catheterization (PIVC) procedure is the

introduction of a short catheter into a peripheral vein and can be problematic, leading to multiple

failed attempts. Factors associated with the currently utilized PIVC success include: (1) patient's

characteristics such as age, gender, race, weight/BMI, co-existing medical conditions and

skin/vein characteristics, (2) procedure related factors such as the insertion site and catheter

caliber, and (3) the operator's expertise. Strategies to improve PIVC success include: (1) bedside

techniques such as venodilation, vascular visualization and vein entry indication, (2) pain
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management and (3) engagement of expert health care providers. Bedside techniques have

shown more improvement in PIVC success rates as opposed to pain management. Expert health

care providers have shown higher performance levels with regard to the difficult cases of PIVC

(Sabri, et.al, 2013). There was a study conducted by Carr, et.al (2019) regarding Fist-Time

Insertion Success (FITS). FTIS is influenced by patient and clinician factors. Patient

characteristics reported in the literature which compromise FTIS include: few visible and or

palpable veins; diabetes or cancer diagnoses and emaciated and obese weight. Clinician

characteristics associated with FTIS include: greater years of experience; numerical quantity of

PIVC insertions performed; professional roles such as specialist vascular access teams, specialist

nurses or medical consultants.

IV insertion skills training has endured a varied history, from sticking a needle into a

piece of fruit to starting IVs on fellow learners and students. Today, full body nursing

manikins present a safer and decidedly more reliable alternative for developing this skill

(Blandford, 2017).

Based on the researches and write-ups that have been made related to PIVC insertion, it

has been proven that this procedure is one of the most frequently done by the nurses in every

institution. Modules and face-to-face lecture will not be enough to prepare the nurses to become

skillful and confident in performing nursing skills.

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THEORETICAL FRAMEWORK:

This research is anchored on Benner’s From Novice to Expert Nursing Theory. The

novice to expert model was introduced into nursing by Dr. Patricia Benner in 1982 and discussed

how nurses develop skills and understanding of patient care over time. Dr. Benner’s novice to

expert model was derived from the Dreyfus Model of Skill Acquisition and adapted to provide a

more objective way for evaluating progress of nursing skills and subjects (Dale, Drews, Dimmitt,

Hildebrandt, Hittle, & Tielsch-Goddard, 2013). The model essentially discusses how an

individual begins in the novice stage and, as new skills and knowledge are gained, progresses

through a number of stages to end in the expert realm.

The theory identifies five levels of nursing experience: novice, advanced beginner,

competent, proficient, and expert. (Benner, 1982).

a. A novice is a beginner with no experience. They are taught general rules to help

perform tasks, and their rule-governed behavior is limited and inflexible. In other

words, they are told what to do and simply follow instruction.

b. The advanced beginner shows acceptable performance, and has gained prior

experience in actual nursing situations. This helps the nurse recognize recurring

meaningful components so that principles, based on those experiences, begin to

formulate in order to guide actions.

c. A competent nurse generally has two or three years’ experience on the job in the

same field. For example, two or three years in intensive care. The experience may

also be similar day-to-day situations. These nurses are more aware of long-term
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goals, and they gain perspective from planning their own actions, which helps them

achieve greater efficiency and organization.

d. A proficient nurse perceives and understands situations as whole parts. He or she has

a more holistic understanding of nursing, which improves decision-making. These

nurses learn from experiences what to expect in certain situations, as well as how to

modify plans as needed.

e. Expert nurses no longer rely on principles, rules, or guidelines to connect situations

and determine actions. They have a deeper background of experience and an intuitive

grasp of clinical situations. Their performances are fluid, flexible, and highly-

proficient. Benner’s writings explain that nursing skills through experience are a

prerequisite for becoming an expert nurse.

The significance of this theory is that these levels reflect a movement from past, abstract

concepts to past, and concrete experiences. Each step builds from the previous one as these

abstract principles are expanded by experience, and the nurse gains clinical experience. This

theory has changed the perception of what it means to be an expert nurse. The expert is no longer

the nurse with the highest paying job, but the nurse who provides the most exquisite nursing

care.

In line with the research study, the said theory will serve as the backbone on analyzing

how certain skills develop after assessing the theoretical knowledge of the bedside nurses on

PIVC insertion and how they will apply it on the actual performance of the said nursing

procedure. As they say, you cannot be called an expert nurse overnight. This requires a balance

of good foundation of knowledge and precise demonstration of the skill overtime.

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CONCEPTUAL FRAMEWORK:

INPUT PROCESS OUTPUT

Respondent’s Written Questionnaire Enhanced Training

Demographics: Program on PIVC
Skills Validation Insertion
 Age

 Sex

 Tenure

 Last insertion

done

FIGURE 1

Figure 1 describes the conceptual framework of the study wherein the input is consisting

of the respondent’s demographics: Age, Sex, Tenure, and the last PIVC insertion done.

On the other side, process to be used is in the form of written examination to validate the

respondent’s knowledge and an actual performance of the skill guided by the checklist of the

step-by-step procedure on how PIVC is to be done.

On the output, the researcher wants to find out the significant relationship between input

and process as a guide in formulation an enhanced training program on PIVC Insertion.

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DEFINITION OF TERMS:

a. Peripheral intravenous catheters (PIVC) - are the most commonly used intravenous device

used for therapeutic purposes such as administration of medications, fluids and/or blood

products, etc.

b. Venoclysis - the continuous infusion into a vein of saline or other solution

c. Bedside Nurse – hospital personnel assigned to deliver direct and immediate care to patient

HYPOTHESIS:

1. There is no significant relationship between the demographic profile and knowledge level

of the respondents.

2. There is no significant relationship between the demographic profile and skills level of

the respondents.

SCOPE AND LIMITATIONS:

SCOPE

The scope of the study will focus on the knowledge and skills level of bedside nurses

assigned on General Nursing Unit 1 of St. Lukes Medical Center – Global City which is consist

of 6South (General Ward), 7North (Executive Check-up Unit, 9North and 9South (Oncology
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Units). Data collection will only be conducted to 20% of the overall population of the said

identified units. The study will be done through the utilization of a structured written

questionnaire to be answered by the selected sample before the actual return demonstration of

the skill graded and evaluated using a checklist.

LIMITATION

The researcher wants to emphasize that one hospital does not reflect the other hospitals

that may have different variables. One limitation of the study is no actual patient attempts for

PIVC insertion, rather each participant will have to perform 3 attempts of PIVC insertion: one on

a dummy hand and two on actual living person (co-nurses).

SIGNIFICANCE OF THE STUDY:

NURSES

The researcher believes that securing a PIVC line is an under-evaluated problem that is existing

in all healthcare institution. With this study, the researcher is targeting to come up with a

beneficial outcome to both St. Lukes nurses and the institution in general. Skills and the

competency cannot be earned overnight but with proper foundation on assessment and skills

validation, the all nurses will be well-equipped and confident enough as they immerse on the

actual bedside nursing care.

PATIENTS
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With this study, the researcher would like to also address complaints and concerns related to

failed and multiple PIVC insertion that will have a big impact on the great patient experience.

EDUCATORS

There are lots of researches being made to address different nursing problems and issues but

there are times wherein the most basics are often neglected. The researcher had even a hard time

looking for local literatures that tackles this issue. This research can be an eye-opener and may

be a stepping stone on a better training module and program for our millennial nurses every

institution can be proud of.