Abstract
Background:
Difficult intravenous access is a condition that decreases the first-attempt success rate of intravenous catheterisation. It is important to evaluate patients with difficult vascular access using a standardised scale. This study was carried out to establish the Turkish validity and reliability of the ‘Adult Difficult Intravenous Access Scale’.
Methods:
The methodological descriptive study was carried out in the Adult Emergency Department. The research sample consisted of 100 patients over 18 years of age, who were conscious, whose condition was not critical or who did not require resuscitation. ‘Case Report Form’ and ‘Adult Difficult Intravenous Access Scale’ were used.
Results:
The mean age of the patients was 57.54 ± 19.44 years, and 55% (n = 55) were female and 77% (n = 77) had a chronic disease. The factor loads of the scale items are between 0.366 and 0.852. The Cronbach’s alpha coefficient was found to be 0.708.
Conclusions:
The Turkish version of the scale is a valid and reliable scale for determining the risk of difficult intravenous access. The practical use of this scale by healthcare professionals will enable earlier diagnosis of patients with difficult vascular access.
Keywords: difficult vascular, emergency department, nurse, peripheral intravenous access, reliability, validity
Introduction
Although peripheral intravenous (PIV) catheterisation seems to be a routine practice in the clinic, it may be difficult to employ in some cases even for experienced practitioners. Serious problems are experienced in practice during IV catheter administration due to different factors such as peripheral vascular collapse, being very young or very old, obesity, vascular problems due to continuous IV drug use, peripheral oedema, hypothermia and dehydration (Dat et al., 2021; Piredda et al., 2017).
Difficult intravenous access decreases first attempt success rate, subjecting the patient to repeated interventions, which may cause serious complications such as catheter-related infection, phlebitis, extravasation, bruising, bleeding and sepsis, which lead to deterioration of the venous structure and delay in treatment (Miliani et al., 2017; Santos-Costa et al., 2020; Scoppettuolo et al., 2016). In addition, difficulties experienced in IV access may cause delay in diagnosis and treatment, prolongation of hospital stay, exposure of patients to replicate invasive interventions, stress in patients and their relatives, increased workload of healthcare personnel and economic losses (Carr et al., 2017; Piredda et al., 2017). It is emphasised in the literature that patients’ peripheral vascular structure should be evaluated appropriately to avoid such negative outcomes (Alexandrou, 2019). Some instruments have been developed to adopt a common approach and to have uniform criteria to evaluate patients’ peripheral venous structure (Carr et al., 2017). However, the lack of a theoretically validated and reliable instrument in Turkey and the inability to detect risks in this regard in the clinic create a gap in this field. The Adult Difficult Intra Venous Access (A-DIVA) Scale is a tool that enables nurses to identify patients who may have difficulties in IV access at an early stage, based on easily obtainable clinical data. Thus, the vascular structure of the patients will be preserved by reducing the number of repetitive trials. In addition, if patients with a risk of difficult vascular access are detected with A-DIVA, it will be possible to apply other facilitating methods in practice, such as using ultrasound or asking for help from more experienced individuals at an earlier stage (Sebbane et al., 2013). Finally, it is crucial to ensure the use of the scale in practice to increase the effectiveness of the patient’s IV treatment, reduce complications and reduce the costs arising from repeated trials (Carr et al., 2017).
Purpose: This study was carried out to establish the Turkish validity and reliability of the ‘A-DIVA Scale’.
Method
Research type
Methodological descriptive study.
Setting
The study was conducted at the Adult Emergency Department of a City Hospital in Turkey between October 2021 and January 2022.
Sample
One hundred patients over the age of 18, who were conscious, who would be administered a peripheral intravenous catheter, whose condition was not critical or who did not require resuscitation, and who volunteered were included in the study. The sample size was planned as 100 patients (in validity and reliability studies, the number of samples should be at least 10 times the number of items in the scale; Çam and Arabacı, 2010; Şencan, 2005). Exclusion criteria included being under the age of 18, being agitated, having advanced reading and comprehension problems, having advanced hearing problems and unwilling.
Data collection
Step 1: The patient was informed about the study.
Step 2: Prior to insertion of the PIV catheter, the researcher evaluated the peripheral venous structure of each patient. For this, the researcher first applied a tourniquet 5–10 cm above the site of the intended venepuncture, and then evaluated the patient’s vein structure by observing and palpating.
Step 3: Based on the evaluation, the researcher scored the A-DIVA Scale.
Step 4: After scoring, the researcher observed how the PIV catheter was inserted by the nurse responsible for the patient. In this step, the researcher recorded in the case report form the place and side of the PIV catheter, the catheter size, the success of PIV catheterisation, the number of attempts and the complications that developed.
Data collection tools
Case report form: In this form, there are questions about the patients’ age, gender, body mass index, reason for being in the emergency department and whether they have a chronic disease. In addition, information about the anatomical region and side where the PIV catheter was inserted, catheter size, the success of the PIV intervention, the number of unsuccessful attempts and complications are included in the form (Gerçeker et al., 2017; Van Loon et al., 2019).
A-DIVA Scale: The scale was developed by Van Loon et al. (2016). In 2019, the scale items were modified (van Loon et al., 2019). The scale includes five parameters (patient’s history, expected difficult intravenous access, visibility and palpability of the vein and vein diameter) in determining difficult intravenous access. According to the score obtained from the scale, the probability of finding vascular access is classified as low (0 or 1), moderate (2 or 3) and high (4 or 5; van Loon et al., 2019).
Data analysis
The validity-reliability analyses were made in SPSS and AMOS programs.
Lingusitic validation
Stage 1 – Translation: The original scale was translated into Turkish separately by a committee of four experts in the first stage.
Stage 2 – Semantic explanations: The research team and the same committee created a draft by identifying the appropriate terms from four separately translated forms to create the final scale.
Stage 3 – Back translation: The scale was translated back by two translators.
Stage 4 – Expert panel: The expert committee reviewed the final draft to minimise the differences between the original and the back-translated scale and to ensure it was culturally compatible. The Turkish form of the scale was sent to six individuals to calculate the content validity index. These individuals reviewed the items for distinctiveness, intelligibility, relevance, and cultural relevance. For content validity, individuals scored items from 1 = not suitable to 4 = appropriate. Necessary modifications were made in line with the suggestions.
Stage 5 – Pilot application: The scale was implemented with patients.
Stage 6 – Final version: When the full scale was accepted as easy to understand and suitable in Turkish, the form was finalised (Beaton et al., 2000; Çapık et al., 2018; Esin, 2014).
Psychometric validation
Validity: Construct validity was evaluated with exploratory factor analysis (Extraction Method: Principal Axis Factoring, Rotation Method: Varimax) and confirmatory factor analysis (CFA).
Reliability: Cronbach’s alpha value was calculated for internal consistency. Factor analysis was used for item selection for the scale and item-total test correlation coefficients were used to determine the discrimination power of the items (Alpar, 2016; Karakoç, 2019).
Results
The patients’ mean age was 57.54 ± 19.44 years, and 55% (n = 55) were female. Of the patients, 25% (n = 25) had abdominal pain, 23% (n = 23) experienced headache, dizziness, syncope, falls, 21% (n = 21) had shortness of breath, 18% (n) = 18) had chest pain when they came to the emergency department. Of the participants, 77% had a chronic disease. These diseases were identified as hypertension (33.8%, n = 26), diabetes (28.6%, n = 22), COPD-Asthma (14.2%, n = 11), cancer (11.7%, n = 9) and other chronic diseases (epilepsy, Parkinson’s, Alzheimer’s, kidney failure, cirrhosis; 11.7%, n = 9)
Ninety-eight percent of PIV catheter attempts are successful. The most (60.2%) catheters were placed in the antecubital region. Number 20 catheter was used in 69.4%. Complications did not develop in 88% of the patients (Table 1).
Table 1.
Distribution of success of catheterisation, number of attempts, anatomic region, complication and size of the catheter.
| Variables | n | % |
|---|---|---|
| Success | ||
| Successful | 98 | 98 |
| Unsuccessful | 2 | 2 |
| Number of attempts | ||
| 1 | 27 | 27 |
| 2 | 32 | 32 |
| 3 | 19 | 19 |
| 4 | 22 | 22 |
| Dominant side | ||
| Right | 49 | 50 |
| Left | 49 | 50 |
| Anatomic region | ||
| Antecubital region | 61 | 62.2 |
| Hand | 16 | 16.3 |
| Forearm | 14 | 14.3 |
| Upper arm | 7 | 7.2 |
| Size | ||
| 20 Gauge | 68 | 69.4 |
| 22 Gauge | 27 | 27.5 |
| 18 Gauge | 3 | 3.1 |
| Complication | ||
| Developed | 12 | 12 |
| Did not develop | 88 | 88 |
| Type of complication | ||
| Ecchymosis | 7 | 58.4 |
| Hematoma | 3 | 25 |
| Fluid under the skin | 1 | 8.3 |
| Oedema | 1 | 8.3 |
Content validity
The mean score of the items varied between 3 and 4. Content validity index of the scale was calculated as 100% in the study. The obtained index results were found to be sufficient for including all five items in the scale.
Construct validity
The Kaiser-Meyer-Olkin (KMO) value was 0.576 and the Bartlett’s test results were χ 2 = 160.906, p ˂ 0.001 (Table 2). According to the exploratory factor analysis, factor loadings of the scale items: 0.366 for the first item, 0.703 for the second item, 0.852 for the third item, 0.524 for the fourth item and 0.84 for the fifth item. This result shows that the relationships between the items were significant and factor analysis was appropriate (Table 2).
Table 2.
Factor analysis results of the Adult Difficult Intravenous Access Scale.
| Scale items | Factor loads | |
|---|---|---|
| Item 1 | Is there a known history of difficult peripheral intravenous access? | 0.366 |
| Item 2 | Do you anticipate a failed first attempt or a difficult intravenous attempt? | 0.703 |
| Item 3 | Is there an inability to identify an enlarged vein by palpating the upper extremity? | 0.852 |
| Item 4 | Is there inability to identify an enlarged vein by visualising the upper extremity? | 0.524 |
| Item 5 | Is the most enlarged vein less than 3 mm in diameter?? | 0.84 |
KMO = 0.576, χ2(10) = 160,906; Bartlett’s test of sphericity (p) <0.001.
The chi-square degree of freedom ratio of the scale χ2/df = 2.031; root mean square error of approximation (RMSEA) = 0.102; The non-normed fit index (NNFI) = 0.934; comparative fit index (CFI) = 0.98; goodness of fit index (GFI) = 0.978; incremental fit index (IFI) = 0.981 (Table 3).
Table 3.
General Fit Index results of the Adult Difficult Intravenous Access Scale.
| General Fit Index | CFA results |
|---|---|
| Chi square value | 6.093 |
| Degree of freedom | 10 |
| Chi square value/degree of freedom | 2.031 |
| RMSEA | 0.102 |
| NNFI | 0.934 |
| CFI | 0.98 |
| GFI | 0.978 |
| IFI | 0.981 |
RMSEA: root mean square error of approximation; NNFI: non-normed fit index; CFI: comparative fit index, GFI: goodness of fit index, IFI: incremental fit index.
Internal consistency
The Cronbach alpha internal consistency coefficient obtained from the scoring system of the A-DIVA scale was α = 0.708. Item-total correlation coefficients of the scores obtained from each item of the scale were as follows: r = 0.209 (item 1), r = 0.494 (item 2), r = 0.685 (item 3), r = 0.318 (item4) and 0.699 (item 5; Table 4).
Table 4.
Item-total score correlations and Cronbach alpha coefficient of the Adult Difficult Intravenous Access Scale.
| Scale items | Item total correlation coefficients | Multiple explanatory coefficient (R2) | Cronbach’s alpha |
|---|---|---|---|
| Item 1 | 0.209 | 0.069 | 0.708 |
| Item 2 | 0.494 | 0.387 | |
| Item 3 | 0.685 | 0.726 | |
| Item 4 | 0.318 | 0.276 | |
| Item 5 | 0.699 | 0.696 |
X: mean, SD: standard deviation.
Descriptive statistics of the A-DIVA Scale
A-DIVA Scale’s total score average was 3.77 ± 1.48 (Table 5). Seventy-three percent of the patients were in the high risk, 25% of them were in the intermediate and 2% of them were in the low-risk group. The success rate at the first attempt was 48.1% in the medium-risk group, and 19.2% in the high-risk group. There was a difference between the risk groups in terms of success rate at the first attempt (χ 2 = 9.60, p = 0.002).
Table 5.
Descriptive statistics of the Adult Difficult Intravenous Access Scale.
| Scale Items | X ± SD | Scale mean when item is removed | Scale variance when item is removed |
|---|---|---|---|
| Item 1 | 0.88 ± 0.33 | 2.98 | 3.52 |
| Item 2 | 0.71 ± 0.45 | 3.15 | 2.91 |
| Item 3 | 0.57 ± 0.5 | 3.23 | 1.76 |
| Item 4 | 0.76 ± 0.43 | 3.1 | 3.21 |
| Item 5 | 0.81 ± 0.39 | 2.99 | 1.93 |
| Item | 3.77 ± 1.48 | – | – |
X = mean, SD = standard deviation.
Discussion
The sphericity test, which is an important step in factor analysis, can be performed in several ways and KMO is one of them. The lower limit for KMO, which takes a value between 0 and 1, is 0.50. The Bartlett’s test determines whether the scale scores are suitable for factor analysis (Alpar, 2016). In this study, the KMO value was 0.576 and the Bartlett’s test results were χ 2 = 160.906, p ˂ 0.001. According to these results, it was seen that the data structure was suitable for factor analysis.
Factor analysis provides information as to whether many variables are gathered under one or more headings (Alpar, 2016). After the exploratory factor analysis, the structural equation model (SEM) was created for the experimental data. Confirmatory factor analysis was used to evaluate that SEM is a good and adequate model. Chi-square is the most widely used statistic which can be regarded as an initial fit index. The fit between the data and the model is tested with chi-square test. As long as the calculated chi-square statistical value is small, the agreement is regarded as good. Although the value obtained with chi-square/degree of freedom in the literature is less than 5, the generally acceptable level is <3, which indicates a good fit. The χ2/df value obtained within the scope of this study was calculated as 2.031 and it was determined that the model showed good fit.
The NNFI is obtained by adding the degree of freedom of the model to the normed fit index (NFI). With this arrangement, the rejection of well-fitting models with small sample sizes is avoided. While 0.95 and above indicates good fit, 0.90 and above is interpreted as acceptable fit. Similarly, IFI has emerged to find solutions to the problems created by the wide variability in NNFI, the only difference is that the degree of freedom is not taken into account in the calculation of the index. As in NNFI, 0.95 and above can be interpreted as good fit, 0.90 and above as acceptable fit in IFI. The NNFI value of the SEM model created in this study was calculated as 0.934 and the IFI value as 0.981, and it was found that the model showed an acceptable fit.
The CFI, like other comparative indexes, is sensitive to sample size, but is less affected than NFI or NNFI when the sample is small. CFI 0.97 and above indicates good fit, 0.95 and above indicates acceptable fit. The CFI value obtained in the study was calculated as 0.980. This value was regarded to be close to acceptable compliance levels.
The RMSEA varies between 0 and 1. A value equal to or less than 0,05 is considered a good fit, and a value equal to or <0.08 is an acceptable fit. The RMSEA value obtained in this study was above the acceptable fit with 0.102. The RMSEA tends to exhibit heightened sensitivity to sample size. In cases of larger samples, even minor disparities between the model and observed data can yield statistically significant results. If the sample size is relatively small, this could be a contributing factor to the elevated RMSEA. In this study, we think that the sample size affects the RMSEA value.
The GFI varies between 0 and 1 and 0.90 and above is considered a good fit (Zekioğlu et al., 2018). Based on the GFI value of 0.978 calculated as a result of the CFA, the evaluation for the explainability of the model showed acceptable fit.
Although the SEM result (Structural Equation Modelling Results) of the scale p-value <0.001 significance level showed that the data set and the model established were different from each other based on the result of chi-square fit test of Confirmatory Factor analysis, the chi-square test is not the only valid statistical measurement. In addition to this test, there are important fit indices, and the model shows an acceptable fit based on these. In addition, each of the regression coefficients in the model has a p-value <0.05 and the correlation/covariance coefficients established between the variables, p-value<0.05 are small and significant.
The Cronbach’s alpha coefficient, which is the most widely used reliability method, takes a value between 0 and 1. If the coefficient is 0.7 and above, the reliability of the scale is considered to be good. The Cronbach’s alpha value of the A-DIVA Scale was α = 0.708 in the study. This result shows that the scale has moderate reliability. The Cronbach’s alpha value of the Dutch version of the A-DIVA Scale is 0.78 (Kılıç, 2016). The Cronbach’s alpha value of the scale was found to be 0.75 in Türkiye in the study of Psychometric Properties of the Turkish Version of the DIVA Scale for Children (Gerçeker et al., 2017).
For internal consistency, the item-total score correlation of each item is expected to be at least r = 0.30 (Alpar, 2016). If the item-total correlation is low, it means that this item does not measure the same construct as the other scale items. In this study, the item-total score correlation of the scale was above r = .30, which means that the whole scale measures the same quality. In conclusion, item reliability analysis of A-DIVA is at an acceptable level.
Almost all patients are in the intermediate-high risk group for DIVA in this study. DIVA is common in the emergency department (Shokoohi et al., 2020). Since the study was conducted in the emergency department, the percentage of patients considered to have DIVA is high.
Conclusion
It was determined that the Turkish version of the A-DIVA scale is a valid and reliable scale. The scale consists of five items in total. It is recommended to use this scale to determine the risk of difficult intravenous access in patients before catheterisation. The practical use of this scale by healthcare professionals will enable earlier diagnosis of patients with difficult vascular access. With the use of the scale in practice, it will contribute to nursing practices in order to increase the effectiveness of the patient’s IV treatment, reduce complications and reduce the costs caused by repeated trials.
Key points for policy, practice and/or research.
Difficult intravenous access decreases the success rate at the first attempt, causes repeated attempts and leads to serious complications.
The Turkish version of the Adult Difficult Intravenous Access Scale is valid and reliable.
Nurses can use this scale to determine the risk of difficult intravenous access in patients before catheterisation.
The use of the scale in the clinic will contribute to the identification of patients with difficult vascular access in the early period.
Identifying the patient with a difficult vascular access will contribute to the use of additional methods in the early period and to reduce both complications and costs.
Biography
Oğuzhan Taşkin completed a master’s degree from Bakircay University, Graduate Education Institute in 2022. She has been working as a nurse for 9 years in Manisa City Hospital. Taşkın’s research interests include nursing care and nursing process.
Elif Günay Ismailoğlu graduated from Ege University Nursing School in 2008. She completed the doctorate programme from Ege University Health Sciences Institute in 2015. She is a faculty member at Bakircay University, Faculty of Health Sciences, Department of Nursing, Fundamentals of Nursing Department. Her research interests include nursing care, nursing process, nursing basic skills and simulation in nursing.
Footnotes
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical approval: Written permissions were obtained from the Clinical Research Ethics Committee of a university (decision dated 08/04/2021 and numbered 238) and from hospital (Decision no: E-79593712-799). The patients were informed, and their consent was obtained. Permission was obtained from Van Loon, who developed the scale.
ORCID iD: Elif Günay İsmailoğlu 
https://orcid.org/0000-0002-9152-3469
Contributor Information
Oğuzhan Taşkın, Nurse, Kocaeli State Hospital, İzmir, Turkey.
Elif Günay İsmailoğlu, Associate Professor, Nursing Department, Health Sciences Faculty, Izmir Bakircay University, İzmir, Turkey.
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