Nurse and Patient Education

Tina T. Smith

Linda A. Cayan

Julie L. Millenbruch

KNOWLEDGE SHARING

Approximately 80% of patients admitted to hospitals receive some form of intravenous (IV) therapy (Ozyazicioglu & Arikan, 2008), which can be high risk and also problematic. Among patients with central vascular access devices (CVADs), 5% to 26% will develop an infectious complication such as a bloodstream infection (CDC, 2011; Taylor, 2012). Furthermore,
patients and families may experience stress, anxiety, and/or pain during IV therapy (Cox & Westbrook, 2005; Stafford & Emery, 2007).

Consistency in evidence-based IV insertion and site care, expert surveillance, and timely interventions by health care personnel with education and competency in infusion therapy may prevent complications (CDC, 2011) and lessen patients’ emotional reactions to infusion therapy. This chapter provides content about the knowledge and skills required for nurses to be competent in infusion therapy; how infusion nurses can develop their knowledge, skills, and competence throughout their careers; and the role of the infusion nurse in teaching patients and significant others about infusion therapy.

THE INFUSION NURSE

An infusion nurse has acquired a body of knowledge that encompasses expertise in technical infusion therapy skills and clinical reasoning. The nurse focuses on patientcentered care and interpersonal communication. The individual expertly manages infusion therapy, including an awareness of the inherent risks of therapy. The infusion nurse functions in a variety of practice areas, is vigilant and meticulous in initiating and maintaining infusion therapy, and shares infusion-specific knowledge and skill to develop others, for example, nurses new to infusion therapy. Sharing knowledge and skills, and developing other nurses, helps promote competence in infusion therapy practice by all nurses when an infusion nurse may not be present on a twenty-four hour and sevenday basis.

An infusion nurse practices in all health care settings and with patients of all age groups, diagnoses, comorbidities, and severity of illness. Practice areas may include but are not limited to acute care, home health care, long-term care, outpatient clinics, surgical procedure centers, ambulatory infusion centers, and health care provider offices. Responsibilities of the infusion nurse may vary according to state nurse practice acts and organizational or departmental policies and procedures.

Promoting Effective Communication

A majority of untoward events occurring in health care settings involve miscommunication. According to The Joint Commission, patient safety is improved when communication is clear, accurate, complete, and timely; in 2008 communication was made a patient safety goal. Since that time, tools have been developed to assist health care team members in structuring focused communication. Effective communication and teamwork are critical to the delivery of quality patient care.

Communication is an essential component of all health care curricula; unfortunately, we typically focus on intradisciplinary communication. Each discipline has its own terminology, expectations, and idiosyncrasies relative to communication, all of which can impact the effectiveness of communication across disciplines. Because health care involves multiple disciplines, we need a method of standardized interdisciplinary communication to enhance quality of care and promote patient safety. SBAR, which stands for Situation-Background-Assessment-Recommendation, is one communication technique that can assist infusion nurses. SBAR is a shared model for standardized communication designed to facilitate and improve communication between and among health care personnel. It can be applied to
both verbal and written communication (Haig, Sutton, & Whittington, 2006). The model has four components:

Situation—statement of what is happening at the present time that has triggered the SBAR. For example, “I am calling about Mr. Jones who has a central line and the antibiotic will not infuse.”
Background—information that puts the situation into context and explains the circumstances that have led to the situation. Continuing the example, “The central line was inserted one week ago into the subclavian and has been used daily without difficulty. Trouble-shooting according to policy has been completed. The antibiotic is due now.”
Assessment—statement of the communicator’s ideas about the problem. “I believe the line is occluded.”
Recommendation—statement of what should be done to correct the problem, by when, and by whom. “Would you want to order a thrombolytic per policy to try and open the line or should I remove the line?”

INFUSION NURSES’ EDUCATION, COMPETENCY, AND PROFESSIONAL DEVELOPMENT

The American Nurses Association (ANA), in its standards (2010), identifies that registered nurses (RNs) have “the professional obligation to acquire and maintain the knowledge and competencies necessary for current nursing practice” (Kulbok, 2012, p. 123). To acquire the unique body of knowledge and skills for infusion nursing practice, the RN must pursue infusion therapy education beyond that which was learned in nursing school. Once infusion specialty knowledge and skills have been acquired and demonstrated, the infusion nurse must then maintain competence in evidence-based infusion therapy through active participation in professional development activities.

Infusion Nurses’ Education

To acquire infusion therapy knowledge and skills, the RN may attend formal and/or informal classes, in-services, webinars, or complete self-learning modules on infusion therapy (Collins, Phillips, Dougherty, de Verteuil, & Morris, 2006; Roslien & Alcock, 2009). One size, or one educational approach, will not fit all. For example, an education session for a nurse with limited IV therapy knowledge and skill will include content, practice, and competency validation for IV insertion, aseptic dressing changes, pharmacology, and transfusion therapies. Education for an experienced infusion therapy nurse might focus on developing knowledge regarding IV equipment specific to the setting/patient populations or successful completion of more advanced competencies.

The nurse who desires to become expert in infusion therapy should first identify what he or she knows and does not know regarding published IV standards, guidelines, and content. The nurse then can seek out an evidence-based curriculum that incorporates these standards and guidelines and builds upon their learning needs. This planned program of study will guide learning, mastery, and competence in infusion nursing practice.

There are several resources and educational recommendations that can help the nurse gain further infusion therapy knowledge. The Infusion Nurses Society (INS) has standards
of practice (2011) as well as a core curriculum (Alexander et al., 2014), which identify needed content for infusion nursing knowledge and competence. The CDC also recommends education in the following areas: (a) reasons for infusion therapy, (b) correct insertion and maintenance of IV catheters, and (c) prevention of catheter-associated infections (CDC, 2011). These and other appropriate references should inform any curriculum that prepares infusion nurses.

EVIDENCE FOR PRACTICE

Fakih, M. G., Jones, K., Rey, J.E., Berriel-Cass, D., Kalinicheva, T., Saravolatz, L.D. (2012). Sustained improvements in peripheral venous catheter care in non-intensive care units: A quasi-experimental controlled study of education and feedback. Infection Control and Hospital Epidemiology, 33(5), 449-455.

In a study of 10 non-ICU units and over 4,000 peripheral venous catheters, providing education and “real-time feedback” to nurses significantly reduced peripheral venous catheter-associated bloodstream infection. Process information provided to direct care nurses and nurse managers included dressing change documentation, dressing being intact, and correctly scrubbing the hub. Outcome information about infection rate also was provided.

CURRICULUM DEVELOPMENT FOR INFUSION THERAPY NURSE EDUCATION

Nurses benefit from a well-conceived curriculum (Boland & Finke, 2012). A comprehensive curriculum also provides for consistency in delivery of IV content to assure that learners receive the required information. Adult teaching, learning, and assessment strategies inform the design of curricula and learning experiences so that those who attend infusion therapy education sessions are engaged, understand the learning outcomes they are to achieve, and are involved in the planning and managing of their learning (Boland & Finke, 2012). Without active and engaged learners, knowledge and skill acquisition to enhance the infusion nurse’s practice may be limited.

A curriculum, or plan for instruction, should be developmental, based upon the learner, the learner’s goals, and the learner’s competency. In order for the appropriate curriculum to be created and taught, the purpose and objectives of the education should be identified after the needs of the learner are identified. An example of a curriculum plan from a needs assessment for developing RNs’ knowledge and clinical skills to care for patients with peripherally inserted central catheters (PICCs) and to prevent central line-associated bloodstream infections (CLABSIs) is included in Table 5-1. This curriculum plan is one of many that could be included in evidence-based, structured, and developmental infusion therapy curricula to prepare competent infusion therapy nurses.

TABLE 5-1 CURRICULUM PLAN AND CONTENT FOR CARE OF THE PATIENT WITH A PERIPHERALLY INSERTED CENTRAL CATHETER (PICC)

Part A: Curriculum Plan
Program Purpose		Develop knowledge and clinical skills in PICC nursing care and prevention of CLABSI.
Learning Objectives		At the end of the session, the participant will be able to: Describe a PICC. Identify one action to prevent CLABSI in PICCs. Perform a dressing change for a PICC. Administer medication through a PICC.
Instructional Methods		Audience response participation system Presentation Discussion Video Simulation (task trainer)
Target Audience		Infusion Nurses
Instructional Tools for PICC Education Learning Stations		Dressing change learning station: PICC arm with catheter Alcohol swabs Waterless hand sanitizer Gloves Transparent semipermeable chlorhexidine gluconate dressing kit	Medication administration learning station: PICC arm with catheter Alcohol swabs Waterless hand sanitizer Gloves IV tubing primary and secondary 10 mL 0.9 NS prefilled syringes Heparin prefilled syringe (based upon policy for PICC locking)
Instructor Resources for Planning Curriculum Content		Alexander, M., Corrigan, A.M., Gorski, L.A., Hankins, J., & Perucca, R. (2010). Infusion nursing: An evidence-based approach (3rd ed.). St Louis, MO: Saunders Elsevier. Alexander, M., Corrigan, A.M., Gorski, L.A., & Phillips, L. (2014). Core curriculum for infusion nursing (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Bartock, L. (2010). An evidence-based systematic review of literature for the reduction of PICC line occlusions. Journal of the Association for Vascular Access, 15, 58-63. Bucher, L., & Sanderson, L.V. (2011). Peripherally inserted central catheter. In D. Wiegand (Ed.), AACN procedure manual for critical care (6th ed., pp. 763-774). Philadelphia, PA: Saunders. Camp-Sorrell, D. (2011). Access device guidelines: Recommendations for nursing practice and education (3rd ed.). Pittsburgh, PA: Oncology Nursing Society. CDC. (2011). Guidelines for the prevention of intravascular catheter-related infections. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf Infusion Nurses Society. (2011). Infusion nursing standards of practice. Journal of Infusion Nursing, 34(15), S1-S110. Organizational policy
Preclass Learner Assignment		Instructor could assign an article for participants to review.
Kirkpatrick’s Evaluation		Level 1: Class evaluation Level 2: Preevaluation of knowledge compared to postevaluation of knowledge using audience response system
Part B: Content
Time	Objectives	Content	Instructional Methods
15 minutes	Introduction	Introduction of instructor Ice breaker: name and first paying job Review locations of restrooms and personal electronic device expectations Review objectives Complete preevaluation questions using audience response participation system	Audience response participation system
15 minutes	Describe a PICC	PICC suggested content: Definition Arm anatomy for insertion sites: cephalic, basilic, median cubital, and brachial veins Heart anatomy: chambers, superior/inferior vena cava, circulation, tip rests in the distal superior vena cava Rationale for use Insertion sites, contradictions for placement, and what to avoid when a patient has a PICC Catheter: single or multilumen, power injectable, staggered lumen exits, various gauges and lengths, 10-mL syringe or greater for medication/blood draw/flushing	Arm diagram Heart diagram Single- and multilumen PICC and power injectable PICC
15 minutes	Identify one action to prevent catheter-associated bloodstream infections in PICCs	Activity from audience response participation system suggested content: Q: Audience response: What one patient demographic increases risk for infection? A: Age: premature infants and patients older than 65 Q: Audience response: Name this potential PICC complication. A: Phlebitis, infiltration, extravasation, infection, air embolism, catheter embolism, venous thrombosis, and malposition. Include content on why the complication occurs and prevention strategies CLABSI prevention and standard assessment-suggested content: CLABSI prevention guidelines from the CDC include health care provider training, correct hand hygiene, use of maximal barrier protection, use of chlorhexidine gluconate solution for skin antisepsis, and daily review of continuation of need for access device. Standardized assessment: visual condition of site, palpation of site, patient discomfort at insertion site or arm, external catheter length, integrity of device, closed secure system, signs/symptoms of infection	Audience response system slides Pictures of complications Demonstrate with task trainer
30 min	Perform a dressing change for a PICC	Dressing suggested content: aseptic application, product integrity, transparent semipermeable dressing, occlusive, site label, device secure, and frequency of dressing change Use a standardized checklist Learners to perform PICC dressing change with removal of dressing, placement of new dressing, and documentation based upon agency policy	Video demonstration and show materials Simulation: task trainer and materials
30 min	Administer medication through a PICC	Medication administration suggested content: product integrity, add-on devices only when needed, access port integrity, aseptic technique, venous blood return and patency, flushing PICC pre- and postmedication administration, use of heparin or antireflux device based upon agency policy Use a standardized checklist Learners to perform PICC medication administration with flushing/locking of PICC line based upon agency policy	Video Demonstration and show materials Simulation: task trainer and materials
10 min	End of class	Review objectives Complete postevaluation using audience response participation system	Audience response participation system

METHODS FOR EDUCATION

Simulation, as an instructional method for education and training and incorporated in the sample PICC curriculum plan, is not new. Simulation offers the opportunity for novice infusion nurses to practice psychomotor skills and then advance to integration of clinical decision making in the nursing process of assessment, planning, implementation, and evaluation. Simulation can be incorporated within the infusion nurse orientation with a combination of instructional methods including task trainers, human patient simulators, and standardized patients (Figure 5-1).

The sample PICC curriculum plan (Table 5-1) uses task trainers for learning select technical skills. A task trainer is a life-like model of a body part or organ; it also can be a nonanatomical device to teach a skill, such as a specialized stethoscope to learn heart sounds. A task trainer is well suited for infusion therapy instruction since it breaks down a physical activity into understandable steps. This instructional method is considered low-fidelity simulation as it does not place the learner in a realistic environment and the focus is on skill development.

Human patient simulators are fully automatic mannequins with comprehensive clinical functioning and react to the learner’s actions or inactions. High-fidelity simulation, using a human patient simulator, addresses technical skills and integrates the dimensions of decision making and clinical judgment while incorporating teamwork in a fully interactive real work environment. High-fidelity simulation experience is as close to the live patient situation as possible and places the learner in a realistic setting and situation (Gaba, 2007; Kuehster & Hall, 2010; Taylor, 2012).

FIGURE 5-1 Computer simulation training for venipuncture. (Courtesy of Laerdal Medical.)

High-fidelity simulation allows for validation of competency of the infusion nurse as an individual, as well as within a team, and provides a setting for “learning without risk in a controlled, predictable, safe environment” (Finkelman & Kenner, 2009, p. 58). An example of a high-fidelity simulation using a human patient simulator that integrates cognitive, psychomotor, and interpersonal skills to develop practice and critical thinking for problem solving can be found in Table 5-2. Further, during and after the simulation, the learner is able to develop self-awareness and self-regulation in a nonthreatening environment through debriefing (Czaplewski, 2010). This simulation could be sequenced after the initial classroom session and patient care experiences with one-to-one preceptor support.

Simulation can be a teaching technique for education and training for infusion nurses and a validation method of competency for key aspects of knowledge, skill, and behavior (Figure 5-2). “Simulation will never replace clinical experience. It does, however, allow nurses to experience clinical situations in areas where occurrences are rare” (Kuehster & Hall, 2010, p. 127). Use of simulation as a competency validation method may be necessary when the opportunity is low volume yet high risk (e.g., chemotherapy administration with allergic reaction).

Competency

Competency as an infusion nurse is achieved as the nurse gains specialty knowledge and effective clinical reasoning and demonstrates expert technical and interpersonal skills in infusion therapy practice (INS, 2011). It is defined as “an expected and measureable level

of nursing performance that integrates knowledge, skills, abilities, and judgment, based on established scientific knowledge and expectations for nursing practice” (American Nurses Association (ANA), 2010). Competency assessment is the review and documentation of an individual’s ability to achieve job expectations and performance standards (The Joint Commission, 2013). Competency validation is often used to reflect that the individual has demonstrated, in simulation or in a clinical setting, specific knowledge and skills related to a clinical practice, such as a dressing change for a CVAD. Core competencies for professional nurses in infusion therapy are based upon

TABLE 5-2 SIMULATION CASE WORKSHEET AND SCENARIO^a

Part A: Simulation Case Worksheet
Scenario name		Proficiency in PICC patient assessment and medication administration
Target audience		Infusion nurse
Simulator mechanics		Simulation technical person for computer Facilitator: leads the session/debriefing
Patient		Human patient simulator
Standardized patient actor		Wife
Patient profile		Tom Gonzalez, admitted with infection to right foot. PICC line placed right arm basilic vein 4 d ago for long-term antibiotic administration Allergic to sulfa, history of atrial fibrillation, full code Married 44 y, lives with wife, wife has macular degeneration B/P 120/64, HR 72, RR 12, temp 98.9 Orders: vancomycin 250 mg/250 mL every 12 h via PICC line
Environment and Equipment Scenario Setting and Patient		Medications
Patient room with all equipment Arm band, gown, sheet, pillow Bandage to right arm PICC line (single lumen) right basilic vein		IV fluid: 0.9 NS 1,000 mL Vancomycin 250 mg/250 mL 10 mL 0.9 NS prefilled syringes × 4
Documentation/Charting		Equipment and Supplies
Patient history and physical Lab result: CBC, BMP PICC radiology report Licensed independent practitioner (LIP) orders 12-lead EKG Vital sign record		Infusion pump Transparent semipermeable chlorhexidine Gluconate dressing kit Primary and secondary IV tubing Gloves Alcohol wipes
Part B: Simulation Scenario Learner Guidelines: 1. All electronics including cell phones and pagers should be turned off 2. Learners wash hands prior to participation in the simulation and use proper PPE (personal protection equipment) 3. Sharps utilized will be disposed of using the approved red sharps containers 4. No food or drink in the simulation area 5. Mannequin’s privacy should be maintained just like a real patient Introduction to the Mannequin Review Confidentiality The Student Will: 1. Perform a focused PICC site assessment prior to medication administration 2. Initiate teaching to patient and family 3. Respond courteously with care and compassion to the patient/family 4. Use aseptic technique to administer IV medication through a PICC 5. Demonstrate ability to troubleshoot, and perform nursing intervention to maintain patient safety 6. Communicate to provider using SBAR Initiation of Scenario: Mr. Gonzalez requires his 0900 antibiotic to be administered.
State	Patient Status Monitor Settings	Learner Outcome or Actions Desired and Triggers to Next State
Frame 0: Patient presentation/computer setting	B/P: 120/64 RR: 16 HR: 72 Temp: 98.9 Rhythm: a-fib IV setup: 0.9 NS connected to IV tubing with sterile cap on end with secondary line not present bandage to right foot Lungs/heart/bowel: normal Vocal sounds: Hello Oh that hurts when you press on my arm This is my wife Caroline	Learner Actions: Introduces self to patient and family Performs hand hygiene Performs assessment of PICC site: Visual inspection for signs and symptoms of infection External length Integrity of device Closed system Palpation of site Documents assessment	Trigger: Documents site and catheter assessment
Frame 1: Evaluation for infection	Vocal sounds: Why did that hurt when you touched my arm? Wife: Is there something wrong? You are making me nervous. The other nurse did not cause my husband pain!	Learner Actions: Courteously explain to patient and family/provide reassurance Review radiology report Review lab results (infection)	Trigger: Reviewed chart documents and patient vital signs
Frame 2: Administration of IV antibiotcs	Vocal sounds: My wife has difficulty seeing. Wife: I thought he only had to have the antibiotic once a day? Did you wash your hands? Facilitator: Create occlusion after antibiotic infusion is started.	Learner Actions: Provide patient education: medication and procedure Perform hand hygiene Assemble materials Open all supply packages to be used on a sterile field Clean port with alcohol, and allow to dry Attach 0.9 NS prefilled syringe to port Obtain blood return, and flush line Luer lock the IV Infusion line to the PICC port Start the IV infusion of 0.9 NS at 25 mL/h Connect antibiotic to secondary line and back prime Program the infusion device for secondary medication administration and start administration	Trigger: IV infusion device alarms occlusion
Frame 3: Line occlusion and troubleshooting	Vocal sounds: How long will this medication take to give to me? I have to see the wound nurse. Facilitator: Create occlusion after learner restarts infusion pump.	Learner Actions: Assures all IV tubing clamps are open Assures PICC line clamp is open Visualize the site Restarts IV administration on infusion pump	Trigger: IV infusion device alarms occlusion
State	Patient Status Monitor Settings	Learner Outcome or Actions Desired and Triggers to Next State
Frame 4: Thrombosis identification/call provider using SBAR	Vocal Sounds: Why is it not working? It worked last night. Wife: Do you know what you are doing? What is wrong, why is that beeping?	Learner Actions: Turns off infusion device Disconnects IV infusion line from PICC Aseptically cleans the device hub Attaches 0.9 NS syringe to hub and attempts to obtain blood return—no blood return Courteously explains to patient why the PICC line is not working and intervention he/she will take Notifies LIP of potential of thrombosis using SBAR
Scenario End Point: calls LIP to report occlusion of line with request for an order for medication to obtain patency of line Debriefing Question Examples: What did the initial site assessment tell you? What were your thoughts when Mr. Gonzalez complained of pain? What actions may prevent a CLABSI? Were there any actions that may have contributed to a CLABSI? How did you incorporate the patient and family into your care? When did you choose to notify the LIP? Describe the communication. What are two key takeaways from the learning experience
^aAdapted from Taekman, J. (2003). Template for simulation patient design. Durham, NC: Duke University Medical Center.