Paul C. Snelling, BSc (Hons), RN.
Senior Lecturer, University of the West of England, Gloucester
Most nurses are familiar with the care needed by a patient receiving intravenous therapy. Common to the patient receiving drugs or intravenous fluids is the vascular access device (VAD). Increasingly, nurses now insert as well as care for VADs - often a peripheral intravenous catheter (Figure 1). They are successfully expanding their role in this field in general as well as specialist areas. At Gloucestershire Royal Hospital, a one-year clinical skills project provided the opportunity to investigate how training in insertion and management of peripheral intravenous cannulation could be developed.
Previously, VAD training was done by company representatives on an ad hoc basis, arranged individually by clinical managers. The resuscitation training officer did some training but the overall workload prevented this from being a long-term solution.
A follow-up audit found that only 25% of nurses who had done the training were performing cannulation one year later. Four reasons were suggested:
- The wrong people were coming for the training
- There was a lack of support in the workplace for assessment
- Cannulation was not seen as a skill to be carried out by nurses and other practitioners such as midwives, radiographers and operating department practitioners
- There is a reluctance to take on new roles for fear of increasing an already heavy workload.
These issues were kept in mind when the new training was developed. Insertion of a cannula is only part of the care of patients who need them and further audit of cannula care post-insertion found that cannulae:
- Were not replaced routinely
- Were not dressed according to the latest evidence-based guidelines
- Were not documented adequately.
These findings were disappointing but not unexpected as many of the trust’s nursing policies were due for review, and some had not been fully implemented at ward level. It was recognised that developing and implementing a comprehensive new cannulation policy would be the most effective way of addressing all these issues together.
A literature search of the Cinahl and British Nursing Index databases was conducting using the key words ‘cannulation’ and ‘intravenous’, as the basis for drafting a policy. The policy covers choosing an insertion site, cannula size, skin preparation, and care of the site. A core careplan based on the corporate nursing documentation was devised, and after consultation, trial and revision, printed and distributed to clinical areas (Table 1). The care plan has sections for recording cannulation, advises on phlebitis assessment, and provides evidence-based standards for routine care of the site. It has space to plan individualised care. Following another related audit on drug calculations, drip rates were included.
Training for inserting cannulae
In devising the process, lessons from the earlier training systems were kept in mind, as were three principles that guided training development at the trust. These are that training should be:
- Flexible - offering a number of different routes
- Consistent - ensuring the same educational material and assessment of competence are used
- Delivered, where possible, by practitioners.
Competence consists of skills, knowledge and attitude (Chapman, 1999). Attitude in performing a clinical skill in practice is principally a matter for the individual practitioners and the clinical manager. Training in clinical skills is concerned primarily with theoretical knowledge and practical performance of the skill. Previously, training had been delivered through a study day or half-day, with lectures, demonstrations and simulated cannulation via a cannulation arm. This was followed by supervised practice. The learner had to perform 10 supervised cannulations before being considered competent to perform the skill unsupervised.
The new training should be seen more as a process, rather than an event, splitting up the component parts of knowledge and practical training in the skill (Figure 2). Educational materials are provided for the learner on the necessary theory. These allow learners to direct their learning at their own pace and in their own style, away from the classroom, linking the subject with their daily professional lives. Completion of the workbook ensures essential material is covered. If staff do not want to learn the skill, no time has been wasted in sending them on a study day that is not then translated into changes in practice. This self-directed process is known as an andragogical learning style (Quinn, 2000).
A pack of educational material containing a video and booklet was produced and distributed to learners before any practical training.
The video - The manufacturer of the Optiva cannula in use in the trust, Johnson and Johnson, has an instructional video as part of its teaching package, which had been shown during study days. With permission, the video was digitised and additional material specific to the training process inserted. The video contains information about all aspects of cannulation, including graphics about possible complications. The inserted sections explain the training process, policy guidance, and trust documentation. Promotional material was removed, so that the video was still about 15 minutes long. Some new filming was required to produce the video, using the services of a digital editing suite at the University of the West of England. A staff member provided a new commentary. A local company duplicated the video for around £2 a copy.
The booklet - The spiral-bound A4 booklet with a clear plastic cover contains:
- An introduction and a brief discussion about competence and accountability
- Some journal papers. Three were selected (Jackson, 1998; Dougherty, 1997; Jackson, 1997), which can be replaced as newer research becomes available. Advice was sought from the Copyright Licensing Agency
- The new Gloucestershire Royal Hospital Policy, which includes:
- Procedures for inserting and removing cannulae. However, the video makes it clear that there are other equally valid methods of inserting cannulae, as detailed in the journal papers
- Guidance on the size of cannula to be used
- Guidance on how to use the visual phlebitis score, a tool to assess the degree of phlebitis, together with guidance on how it may be treated, adapted from Jackson (1998)
- A flow diagram of the training process (Figure 2)
- The cannulation assessment documentation.
- The new trust care plan, to be used for all patients who have a cannula
- A workbook adapted from Johnson and Johnson educational material, containing multiple-choice questions and questions that require short written answers.
The video and the booklet contain enough information to enable the learner to complete the workbook. Successful completion assures the trainer that the learner has sufficient knowledge.
Learners complete the workbook at their own pace after reading the papers and watching the video. A traditional study session can be arranged if numbers make this more efficient. Evidence of previous learning means that a new member of staff need not read the papers or watch the video, but must still complete the workbook. In all but the most exceptional cases completing the workbook is required before progressing to practical training.
Practical instruction can be delivered in several ways, as part of a study session or as a one-to-one session with an approved trainer in the clinical area. This session provides a chance to ask questions and practical instruction in cannulating, using a manikin arm. At the end, an assessment in cannulating the manikin arm is required, judged against performance criteria that follow the procedure. When the assessment is passed, the learner progresses to attempt cannulation on a patient. A minimum of three assessed cannulations, using the same performance criteria, are required. Practitioners who have an assessment qualification and are regularly performing the skill are allowed to be assessors. The extra assessors plus the reduction to a minimum of three assessed cannulations should reduce the previous hiatus.
After the third successful assessed cannulation the learner and the assessor hold a discussion to agree if further instruction and assessment is needed or if the learner is ready to try the procedure unsupervised. When the learner has reached the required standard, at least seven further successful cannulations are required. These need not be assessed, but learners should keep a reflective log so they can refine their technique and learn from successes and failures.
Regular formal reassessment is not required but discussion should take place at an annual individual performance and development review or supervision meeting. The learner and clinical manager or supervisor should agree whether competence has been maintained. A named member of the clinical staff with expertise in the area should update the policy and linked documents regularly.
Pre-registration house officers attend a session led by the clinical skills facilitator. All have had instruction on cannulation in previous jobs or in medical school. However, they value a broader approach, and many have been helpful in assessing learners in the ward. We hope shared learning will improve the performance of all staff groups and enhance the team approach to patient care.
The booklet contains an evaluation form, including a brief questionnaire about the ease of use and relevance of the video and the booklet. In the first four months of operating, more than 50 educational packs were sent out. A network of practice-based trainers ensured that a motivated nurse could complete the process. Although only 11 completed evaluation forms had been returned, these showed the practitioners found them helpful and intend to continue practising the skill. But it is early days and these are not necessarily representative. One problem is that learners do not always complete and return the forms in the workbook. Further evaluation, audit and research into why practitioners choose not to start or complete training is planned. Verbal evaluations from the trainers have been positive.
Four suggestions were offered as to why traditional training for cannulation failed: the wrong people being trained, lack of workplace support, not a job for nurses and reluctance to increase workload.
Under the new arrangements, only practitioners who have given some thought to expanding the scope of their practice - with the agreement of their clinical manager - who are motivated to complete the self-directed learning package, are expected to do the training. Progression depends on completion of the previous part of the process. The previous hiatus at assessment stage has been tackled by reducing the need for supervision in practice.
The final two suggestions question whether cannulation should be seen as a skill which ought to be performed by practitioners outside specialist areas, and whether they have the time to do it. As more staff go through training, more will be available to assess learners and the process should become easier. We need a critical mass of practitioners who can cannulate in the clinical area. When this has been achieved and cannulae are routinely placed by nurses, colleagues will recognise the benefits to their patients (Workman, 2000) and access the training themselves.
Assessment of competence
The search for competence in nursing has been described as a ‘bottomless pit’ (Watson et al, 2002), although most of the literature concerns pre-registration education. Since the publication of The Scope of Professional Practice (UKCC, 1992) 10 years ago, there has been much debate about the role of assessment for what were then considered as ‘extended roles’. Scope de-emphasised the issuing of certificates but this is not always easy to reconcile with a growing requirement for competency-based training (DoH, 2000). Our approach tries to reconcile the two apparently contradictory positions. We believe that for some skills there is a place for formal assessment, loosely described as ‘ticks in boxes’. This approach is designed to ensure consistency of assessment. The assumption that these performance criteria ensure consistency has been challenged (Hunt and Wainwright, 1994) but they have been used successfully for a number of years in skills-based education, for example National Vocational Qualification and by the Resuscitation Council (UK) in their Advanced Life Support Course and other courses.
Various assessment methods exist, but all are performed in practice (Watkins, 2000). Scales have been developed (Fearon, 1998) allowing assessors to rate performance levels. Pearce and Trennery (2000) argue that these are more appropriate than simple pass and fail distinctions. However, they can be subjective and potentially inconsistent. Our choice of a simple assessment tool aimed to keep the assessment robust yet simple to use, reducing the need for training for assessors. It is also consistent with practice in other areas in the trust.
The principles in The Scope of Professional Practice were also accommodated. Accountability for the performance or non-performance of the skill is emphasised. Deciding when the practitioner is competent to attempt the procedure unsupervised is a matter for discussion and agreement, rather than ritually signing and presenting a certificate. Maintaining competence is principally a matter for each practitioner (NMC, 2002) and this involves discussion, agreement and reflection, rather than a simplistic decision that a practitioner is competent or not, and that competence after training is maintained for an arbitrary and fixed period of time.
If the process succeeds, we aim to adapt it for multiprofessional training in other skills and professional groups. Many adults prefer an andragogical approach to learning (Reece and Walker, 1997), yet this is rarely reflected in our teaching of clinical skills. A further problem is that workload often prevents staff from attending study sessions. By combining flexibility with consistency, we hope to help resolve this and other difficulties, allowing practitioners to build a portfolio of clinical skills at their own pace for their own practice.
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