Interprofessional Approach to Learning Vascular Access with Ultrasonography by Medical Students and Nurses

Abstract

The current study evaluated an interprofessional approach involving medical students and nurses for learning vascular access with ultrasonography. Vascular access laboratories included needle-guidance training and provided an efficient way to master technically difficult venipuncture cases. Most agreed ultrasound technology was useful for these venipuncture cases. Participants felt prepared to perform venipuncture using ultrasonography in a clinical setting after training. Such laboratories should be considered for interprofessional learning of difficult procedures in the medical school curriculum.

Introduction

Active learning and communication within a team require shared learning and dialog, often leading to the acquisition of additional knowledge through interprofessional collaboration.¹ Thus, interprofessional collaboration is an approach in which healthcare professionals work together to deliver the best patient care.²

A recent statement from the National Health System recommended improved teamwork between healthcare professionals,³ and previous studies have investigated what working together can accomplish and where it can fail.^{4, 5} Those studies concluded that participants have to welcome the challenge, need to be confident enough to face the unfamiliar, and have to be respectful and trusting enough to listen openly to others.^4,5 In the critical care environment, interprofessional collaboration is especially challenging because of increased stress. For instance, several studies reported an association between weak collaboration in intensive care units and poor patient outcomes.^{6, 7} In the emergency room environment, difficulty in obtaining intravenous access can result in adverse outcomes, such as delays in diagnostics and treatments.⁸ With improved cross-training and communication among the team members these delays can be avoided.

Interprofessional education (IPE) can be defined as “two or more professions learning with, from, and about each other to improve collaboration and the quality of care.”⁹ When IPE includes medical and nursing students, it has been shown to increase fellowship and enhance knowledge and perceptions of the expertise of the other profession.¹⁰

Modern healthcare has an increasing overlap in the knowledge and skills required by various healthcare professionals. Recent changes in the delivery of healthcare have blurred the boundaries that once defined the roles and responsibilities that established the identities of different healthcare professionals.^10–12 Since IPE provides opportunities for sharing knowledge and inculcating respect for one another, its early introduction in the medical education and nursing curricula may reduce the tendency to stereotype professional groups.^{13, 14} For example, IPE implemented during intermediate life support courses increased teamwork, collaboration, and personal identity between medical and nursing students.⁹ Medical and nursing students also showed improved perceptions of interprofessional collaboration and changes in stereotypical views of each profession after a short series of interprofessional simulation-based educational exercises.¹⁵ In another study, IPE increased medical and pharmacy students’ confidence in various aspects of the transition of care process.¹⁶ When IPE is included in undergraduate medical education, it is believed to better prepare students for the evolving team-based environment they will encounter during practice and to enhance collaboration among various medical disciplines, especially in areas of medicine that deal with a high acuity of care.¹²

The use of ultrasonography by trained emergency room nurses has been shown to decrease the perceived difficulty and increase successful access rates in procedures that are considered “difficult sticks.”⁸ Using ultrasonography to visualize anatomy could be valuable in IPE experiences involving medical and nursing students because it would enable students to learn about the other discipline while also learning from each other. Numerous studies have explored IPE approaches in healthcare training, but to our best knowledge, there is no data on using an interprofessional approach to teach venipuncture with ultrasonography to medical students and nurses.

Therefore, the purpose of the current study was to evaluate an interprofessional approach involving medical students and nurses for learning vascular access with ultrasonography. After participating in a vascular access laboratory, improvements in knowledge of ultrasonography, anatomy, and nursing techniques related to venipuncture were assessed. We hypothesized that medical students would show most improvement in learning about nursing techniques and nurses would show most improvement in learning ultrasound techniques related to venipuncture.

Methods

Second-year medical students (n=11) and nurses (n=6) participated in the current study. Participants signed informed consent before participating in the laboratory, and the local institutional review board granted exempt status for all educational procedures used in the study.

Student participants received ultrasonography training through four semesters of clinical ultrasound coursework. The clinical ultrasound course was taught during the first two years of the medical curriculum by a physician licensed in diagnostic medical sonography. During semester 1, students learn how to use the ultrasound machine and perform upper and lower limb musculoskeletal ultrasound and neck vascular and ocular ultrasound examinations. Semester 2 includes abdominal, echocardiography, upper and lower extremity vascular, and pelvic ultrasound examinations. Second-year ultrasound courses are more clinically oriented, so semester 3 focuses on lung, endocrine, obstetrics, gynecology, and breast ultrasound examinations. During semester 4, students master nerve imaging, needle-guided procedures, and focused assessment with sonography for trauma (FAST). ¹⁷ Nurses who participated in the current study had completed their nursing training and had at least five years of clinical experience but did not have any prior ultrasound training.

Interprofessional vascular access laboratories focused on identifying structures of interest using ultrasonography and on performing venipuncture under ultrasound guidance. Individual interprofessional laboratory groups included two medical students and one nurse. Laboratory content included the following: (1) introduction to ultrasound, (2) vascular anatomy of the upper extremity with ultrasound, (3) ultrasound needle-guidance training using vascular models, and (4) venipuncture with ultrasound needle-guidance training on the partner. Laboratories were preceded by a PowerPoint (Microsoft Corp.) presentation that explained the objectives and clinical relevance of the ultrasound exercise followed by a live demonstration of the ultrasound scanning and venipuncture technique. To enhance participant success, ultrasound-compatible vascular access training models (Blue Phantom’s Branched 2 Vessel Ultrasound Training Block Model, CAE Healthcare, Inc.) were used for ultrasound needle-guidance training. This vein access training model contains a blood vessel that branches into two vessels, allowing the user to guide needles into the targeted vessel using ultrasound imaging. Participants performed upper extremity vascular ultrasound examination using a Mindray-5 ultrasound machine with a 10L4s linear ultrasound transducer with a frequency bandwidth of 8.0/10.0/12.0 MHz (Shenzhen Mindray Bio-Medical Electronics Co., Ltd.). After identifying upper limb vascular structures of interest using ultrasonography, participants performed a supervised venipuncture under ultrasound guidance on the partner. Additional instruction on identifying venous structures with ultrasonography and venipuncture technique was provided during the venipuncture training time. All procedures were supervised by a licensed medical sonographer and registered nurses.

Before the vascular access laboratories, medical students and nurses completed an 18-question pretest consisting of three types of questions related to ultrasonography, anatomy, and nursing (specific to venipuncture) (Appendix). After completing the vascular access laboratories, the participants took an identical 18-question posttest and a voluntary, anonymous paper survey created specifically for the current study. The 10-item survey included seven Likert-scale questions and three open-ended questions. The survey was designed to assess participant perception of ultrasound technology and its use for venipuncture as well as their perception of the interprofessional vascular access laboratories. The Likert-scale questions included the following: (1) I feel capable of operating an ultrasound machine, (2) I feel capable of performing an upper extremity vascular ultrasound exam in a clinical setting, (3) I find it challenging to interpret a 2D ultrasound image, (4) I find it challenging to interpret an ultrasound image with color Doppler, (5) The use of vascular training block models during the interprofessional ultrasound laboratories was beneficial for the development of my clinical skills, (6) I believe that the ultrasound needle-guidance vascular training block model is a useful tool to learn and practice skills associated with venipuncture, and (7) Ultrasound technology is useful for technically difficult venipuncture cases. A standard Likert scale (strongly disagree, disagree, neither agree nor disagree, agree, and strongly agree) was used to evaluate agreement or disagreement with the questions. The last three survey items were open-ended questions: (8) What is one thing that you found most useful about the interprofessional vascular access laboratories? (9) What is one thing you would like to see as part of the interprofessional vascular access laboratories that we did not include? and (10) Please leave comments about the use of ultrasound technology in medical/nursing education.

All data analyses were completed using SAS software version 9.4 (SAS Institute, Inc.). Frequency and percentage were reported for survey responses. The Wilcoxon rank sum test was used to test for differences between medical students and nurses for survey responses or change in test scores. The Wilcoxon signed rank test was used to test for differences from “neither agree nor disagree” in the median survey responses or for changes in test scores. A p<0.05 was considered statistically significant.

Results

Pretest and Posttest Scores

Pooling test results for both medical students and nurses, improvements were found in performance on posttest questions in total and for each of the three question types (ultrasonography, anatomy, and nursing specific to venipuncture) when compared with the pretest (all p≤0.03) (Table and Figure 1). By question, all participants answered questions 1 and 2 correctly both times, so there was no change. For all other questions, more medical students and more nurses answered correctly on the posttest than pretest, with the exception of question 9 (anatomy question) where one less nurse answered correctly at posttest. Among those with a score change, we found a greater likelihood to be correct on the posttest for questions 3 and 4 (ultrasonography questions) and questions 14 through 18 (nursing questions, all p≤0.03). When considered by group, results were consistent for medical students for questions 3, 16, and 18 (all p≤0.03). For nurses, no question had enough evidence to support a greater likelihood to be correct at posttest (all p>0.06).

Figure 1.

Performance of medical students (n=11) and nurses (n=6) on the pretest and posttest by total score and by score for question type. Error bars represent the minimum and maximum scores.

Differences in improvement were found between medical students and nurses overall and for the three types of questions: overall (22% points and 45% points mean improvement for medical student and nurses, respectively), ultrasound questions (16% points and 48% points mean improvement for medical students and nurses, respectively), and anatomy questions (4% points and 40% points mean improvement for medical student and nurses, respectively; all p<0.01) (Table 1). No differences were found for the nursing questions (49% points and 47% points mean improvement for medical student and nurses, respectively; p=0.88).

Table 1.

Summary statistics of pretest and posttest scores of medical students (n=11) and nurses (n=6) participating in an interprofessional vascular access laboratory

Question Type	Group	Mean (SD) [Min, Max] or No. (%)				P Value
		Pretest Score, %	Posttest Score, %	No. Participants Improved	Change, % (Post-Pre)
All (18 questions)	Medical Student	74 (11) [50, 83]	96 (5) [83, 100]	10 (91)	22 (14) [0, 50]	0.002
	Nurse	42 (6) [33, 50]	87 (9) [72, 100]	6 (100)	45 (12) [22, 56]
Ultrasonography (8 questions)	Medical Student	82 (12) [50, 88]	98 (8) [75, 100]	10 (91)	16 (15) [−13, 50]	0.007
	Nurse	48 (9) [38, 63]	96 (6) [88, 100]	6 (100)	48 (9) [38, 63]
Anatomy (5 questions)	Medical Student	93 (13) [6, 100]	96 (8) [80, 100]	2 (18)	4 (15) [−20, 40]	0.01
	Nurse	47 (10) [40, 60]	87 (24) [40, 100]	5 (83)	40 (25) [0, 60]
Nursing (5 questions)	Medical Student	44 (22) [0, 60]	93 (10) [80, 100]	11 (100)	49 (27) [20, 100]	0.88
	Nurse	27 (16) [20, 60]	73 (24) [40, 100]	6 (100) 47	(27) [20, 80]

The p values indicate comparisons for changes in test scores between medical students and nurses.

Survey Results

Medical students’ and nurses’ responses to the survey Likert-scale questions are shown in Figure 2. Differences were found between medical students and nurses for survey questions 1 through 4 (all p≤0.02), but not for questions 5 through 7 (all p≥0.62). After pooling all participants for questions 5 through 7, those with an opinion were more likely to agree than disagree (all p≤0.008). Medical students tended to agree more with questions 1 and 2 and disagree more with questions 3 and 4 than nurses (all p≤0.04). When agree and strongly agree responses were combined, 100% of medical students and 50% of nurses reported feeling capable of operating an ultrasound machine, 91% of medical students and 67% of nurses felt capable of performing an upper extremity vascular ultrasound exam in a clinical setting, 9% of medical students and 67% of nurses found it challenging to interpret a 2D ultrasound image, and 9% of medical students and 17% of nurses found it challenging to interpret an ultrasound image with color Doppler. All medical students (100%) and the majority of nurses (83%) noted that the use of vascular training block models during the interprofessional ultrasound laboratories was beneficial for the development of their clinical skills, 91% of medical students and 67% of nurses believed that the ultrasound needle-guidance vascular training block model was a useful tool to learn and practice skills associated with venipuncture, and 91% of medical students and 100% of nurses noted that ultrasound technology was useful for technically difficult venipuncture cases. In written comments, the majority of participants indicated the interprofessional vascular access laboratory was useful for learning vascular access.

Figure 2.

Levels of agreement between medical students (n=11) and nurses (n=6) for all Likert-scale survey questions

a. Wilcoxon rank sum test for difference between medical students and nurses.

b. Wilcoxon signed rank test for median difference from “neither agree or disagree” by group, where 1=medical student and 2=nurse.

c. Wilcoxon signed rank test for median difference from “neither agree or disagree” after pooling groups.

Discussion

The current study evaluated an interprofessional approach involving medical students and nurses for learning vascular access with ultrasonography after participating in a vascular access laboratory. A survey was used to determine their level of comfort with performing venipuncture under ultrasound guidance and to evaluate their perceptions of venipuncture laboratories delivered in an interprofessional environment. The majority of participants believed the interprofessional vascular access laboratory was beneficial to their learning. We found significant differences between medical students and nurses on questions about capability of operating an ultrasound machine, performing an upper vascular ultrasound exam, and interpreting the ultrasound image. Medical students had completed two years of ultrasound coursework before the vascular access laboratory, which likely explains their higher level of comfort with the ultrasound equipment and imaging. However, their experience seemed to be beneficial during this team-based collaboration. Because the students were more knowledgeable in ultrasonography, they could enhance the education of the participating nurses by helping them to master this imaging modality. This benefit was reflected in the nurses’ written comments, which emphasized that the use of ultrasound technology was very important. For the open-ended question about how the laboratory could be improved, the only suggestion from the nurses was to provide more time to use the ultrasound machine.

We also found significant improvements in performance for medical students and nurses on posttest questions for total scores and for the three question types when compared with the pretest. Both groups benefited from the exercise. Students showed most improvement in nursing questions, and nurses improved significantly in all three areas (knowledge of ultrasound, anatomy, and nursing aspects of venipuncture). Our hypothesis that students would show most improvement on the nursing questions was supported by the results of the study. However, the improvement of the nurses in all three areas was not expected. These results indicate that practicing nurses who have been away from the classroom and didactic exercises might benefit from exposure to basic information related to ultrasonography, anatomy, and even nursing techniques.

The interprofessional approach of this training exercise, where two medical students were paired with an experienced nurse, allowed participants to learn from each other to interpret ultrasound images, identify the vein for venipuncture, and perform the invasive procedure. All students successfully completed the venipuncture procedure, performing it under the guidance of the experienced nurses; and all nurses successfully interpreted the ultrasound images and visualized the veins with help from the medical students. The success of the laboratory objectives suggested that participants were competent in obtaining and interpreting ultrasound imaging and performing ultrasound-guided venipuncture.

Acquiring intravenous access in the emergency department and intensive care unit is a common task. Several studies have evaluated the use of ultrasound guidance for central venous access by physicians in the emergency department.^{18, 19} Some patients, such as those who are obese or hypovolemic, use drugs intravenously, or have vascular pathology, are known as “difficult sticks” for peripheral intravenous placement. Therefore, an ultrasound-guidance technique was recently adopted for better peripheral venous access.^20,21 Several studies have noted the positive effect of ultrasound guidance on the perceived difficulty experienced by emergency nurses when obtaining peripheral intravenous access.^{8, 21} Written comments from the medical students and nurses in the current study indicated they were receptive to IPE of an invasive procedure using ultrasound technology in both their education and future practice. The majority of participants also agreed that ultrasound technology was useful for technically difficult venipuncture cases. Students also commented that they felt more prepared for clinical rotations, while the nurses emphasized that ultrasound technology added to their confidence when performing “difficult sticks.” The qualitative analysis of our open-ended survey items revealed that participants were overwhelmingly positive about the IPE exercise. The most common comments from students reflected the fact that they learned a lot from the nurses about the venipuncture technique. For instance, students commented that “I learned a lot from her advice,” “Got some knowledge/tricks from a nurse,” “They were able to provide insight in vascular access,” and “Learning how to obtain venous access from nurses helped me learn some of the differences between performing the procedure with and without ultrasound and the indications for using ultrasound.” Students also commented that this training should be included in the medical school curriculum.

One limitation of the current study was that participants did not have access to a difficult patient when performing the venipuncture. As one participant commented, “we were all young and had nice veins.” In addition, students commonly indicated that they would have liked to practice ultrasound-guided venipuncture more often. Another limitation was the small group size: the current study was the first time the IPE approach was used for venipuncture with ultrasound guidance learning and was meant to serve as a pilot for future studies.

In the current study, medical students and nurses showed marked improvement in their understanding of the aspects of ultrasonography, anatomy, and nursing techniques associated with venipuncture. Results suggested that the interprofessional vascular access laboratory was beneficial for all participants. For medical students, it helped them improve their understanding of the venipuncture procedure and build technical skills. For nurses, it boosted their confidence in performing “difficult sticks” and introduced them to the use of ultrasound technology for peripheral venous access. Thus, the interprofessional approach provided realistic exposure to venipuncture for medical students and a review of related anatomy and imaging for practicing nurses. As such, the interprofessional vascular access laboratory of the current study was beneficial for the future physicians and practicing nurses who participated, and it should be considered as a model for IPE of procedures that otherwise are difficult to address in a medical school curriculum.