Going Beyond Education to Improve Outcomes for Central Venous Access Device Care

As a hospital educator, it was not uncommon for me to receive urgent requests from critical care units seeking additional education for nurses on the care of central venous access devices. I answered the call, bringing new and additional education to the units. I believed our nurses generally understood how to perform this care and were committed to achieving the best outcomes for their patients. However, infections continued to occur despite the education. I became curious and wanted to take the opportunity to understand from the nurses’ perspective what helped or hindered their practice, so I could support nursing practice and positive patient outcomes in a more intentional and meaningful way.

Nurses are educated professionals dedicated to delivering patient care that heals, not harms. The care of critically ill patients often requires the use of central venous access devices (CVADs), which can pose an infection risk if not maintained properly (Centers for Disease Control (CDC), 2011). Evidence-based bundle guidelines have been available for practice since about 2011; however, patients continue to experience hospital-associated CVAD infections (AHRQ, 2011; CDC, 2011; IHI, 2012; The Joint Commission, 2013). Despite the availability of evidence-based guidelines for the care and maintenance of CVADs, adherence is inconsistent (Foka, et al., 2021), and critical care nurses may not always practice all aspects of a CLABSI prevention bundle (Lee et al., 2018).

The Gap Between CVAD Care Knowledge and Practice

There’s a potential solution in a 2022 research study conducted in eight ICUs in a large U.S. hospital system (the study site). The site’s nurse leaders and infection preventionists aimed for sustained improvements in the infection rates they observed. Potential causes for not eliminating hospital-associated CVAD infections in the ICUs were attributed to nurses’ lack of knowledge of the guidelines, inexperience and unit culture. As a result, the study site’s hospitals deployed clinical educators to the ICUs many times to reeducate nurses and revalidate their CVAD care skills.

The strategy of reeducation did not consistently lead to improved outcomes; nurses, leaders and educators shared their frustrations. The hospital leaders, including infection prevention, quality, education and nurse managers, recognized that blanket reeducation and mandates to change were not considering nurses’ individual perceptions of barriers to practice and were not the only answer to sustainable, positive outcomes for patients. With that in mind, the principal study investigator sought to better understand what drives or hinders a nurse’s intention or desire to perform CVAD care as noted in established infection prevention guidelines and policies.

The Study

With myself serving as principal investigator, an IRB-approved nursing research study was conducted in 2022 in eight ICUs at a large U.S. hospital system. One purpose of the study was to gain a better understanding of the critical care nurses’ attitudes and perceived barriers to performing CVAD care.

The Theory of Planned Behavior was the theoretical framework for the study. The theory proposes that a person’s intention or desire to perform a behavior is based on their attitude toward the behavior, the social norms (culture or peer pressure), and their perception of barriers to performing the behavior and how easily it is navigated (Ajzen, 1985, 1991). The more favorable an individual’s attitudes, norms and perception of barriers are to the behavior, the more likely they are to perform the behavior and vice versa.

The Results

An analysis of the participants’ responses showed the same drivers of intention described in the Theory of Planned Behavior. Attitudes, norms and barriers determined the participants’ intention to follow CVAD care guidelines. Knowing how to perform the care, their years of nursing or critical care experience, and type of ICU or degree correlated with their intention or desire to follow the CVAD care guidelines.

The study produced significant results with implications for practice; however, of particular interest were the specific barriers the participants experienced or perceived in their daily practice of CVAD care. The self-reported barriers were not surprising and were similar to those in previously published studies (Alexander et al., 2022; Badparva et al., 2022; Henderson et al., 2020; Jeffery & Pickler, 2014). The investigator acknowledged the significant role these barriers would likely play in planning a new approach to reduce CVAD infections.

The participants’ results are noted below:

Perceived Barriers to CVAD Care

A New Approach

The insight gained from the study gave the ICU leaders and educators several options to create a more robust and meaningful approach to supporting nursing practice and patient outcomes. Rather than focus solely on reeducation of CVAD care policies and skills, careful consideration of the reported barriers has led to a closer, collaborative approach “with” nurses versus “at” nurses to consider the systems, environment and personal barriers nurses reported.

The organization has changed its approach to root cause analyses of hospital-associated infections by inviting nurses, educators and leaders to participate without judgment and soliciting their voices, as noted below

Nurses:

• Build a culture that supports and recognizes evidence-based practice and facilitates open discussion with other nurses about infection prevention.
• Invite unit-based councils to assess how well the unit culture supports evidence-based practice, and discuss potential solutions for improvements.

Educators:

• Pivot education to address attitudes toward infection prevention, strategies to navigate barriers, and improving nursing confidence to overcome barriers to care while also teaching guidelines and CVAD care skills.
• Prepare newly graduated nurses by discussing the types of barriers they may encounter while performing CVAD care in the ICU, including time management, prioritization and patient condition, with strategies to overcome them.

Nursing and Quality Leaders:

• Demonstrate the importance of CVAD care by conducting collaborative bedside rounds with nurses that include discussions of barriers to care, and foster a culture where recognition for good practice is shared, and peers hold one another accountable and show respect.
• Recognize nurses and units that demonstrate positive performance, and provide a way for nurses to share their practices with peers.
• Listen to nurses’ concerns about supplies. Share their concerns with partner departments to ensure stock-outs, product inconveniences and locations are addressed.
• Work with unit-based councils, and include nurses in quality reviews of patient infections or root cause analyses. Ask if anything prevented them from providing care, as noted in the guidelines.

Seeking a new perspective on critical care nurses’ perceptions of barriers to providing care provided the study site’s ICU leaders the opportunity for a unique approach to improving systems and outcomes. They continue to explore how the results of this study can be used to support critical care nursing practice, positive patient outcomes and implications for other areas of nursing care.

Take a New Approach

Consider a pause on offering repeated education and/or blanket leadership mandates when looking at how to improve or eliminate CVAD-associated infections. Use the points shared from this study to try a new approach that addresses not only CVAD care knowledge and skills but the role of attitudes, unit culture and barriers in influencing intentions to perform care that helps eliminate these infections.

What solutions are you using to reduce CVAD infections?