Abstract
Aim
To develop and psychometrically test an instrument to assess nurses' evidence‐based knowledge and self‐efficacy regarding insertion and management of venous access devices (short peripheral catheter (SPC), long peripheral catheter/midline (LPC) and PICC) and the management of totally implantable central venous catheter (Port) in adult patients.
Design
Multicenter cross‐sectional observational study with questionnaire development and psychometric testing (validity and reliability).
Methods
An evidence‐based instrument was developed including a 34‐item knowledge section and an 81‐item self‐efficacy section including four device‐specific parts. Nineteen experts evaluated content validity. A pilot study was conducted with 86 nurses. Difficulty and discrimination indices were calculated for knowledge items. Confirmatory factor analyses tested the dimensionality of the self‐efficacy section according to the development model. Construct validity was tested through known group validity. Reliability was evaluated through Cronbach's alpha coefficient for unidimensional scales and omega coefficients for multidimensional scales.
Results
Content validity indices and results from the pilot study were excellent with all the item‐content validity indices >0.78 and scale‐content validity index ranging from 0.96 to 0.99. The survey was completed by 425 nurses. Difficulty and discrimination indices for knowledge items were acceptable with most items (58.8%) showing desirable difficulty and most items (58.8%) with excellent (35.3%) or good (23.5%) discrimination power, and appropriate to the content. The dimensionality of the model posited for self‐efficacy was confirmed with adequate fit indices (e.g., comparative fit index range 0.984–0.996, root mean square error of approximation range 0.054–0.073). Construct validity was determined and reliability was excellent with alpha values ranging from 0.843 to 0.946 and omega coefficients ranging from 0.833 to 0.933. Therefore, a valid and reliable tool based on updated guidelines is made available to evaluate nurses’ competencies for venous access insertion and management.
Keywords: central venous catheters, nurses, peripheral catheterization, psychometric properties, questionnaire, vascular access devices
1. INTRODUCTION
Venous access device (VAD) placement and management are among the most common nursing procedures performed in healthcare worldwide, and approximately 90% of hospitalized patients have at least one VAD (Fernández‐Ruiz et al., 2014). They are required for intravenous drugs and fluid administration, blood sampling and diagnostic and therapeutic procedures in a variety of healthcare settings and patient populations. Because of their invasive nature, VADs are associated with several risks, making it crucial to prevent them to ensure safe and high‐quality patient care (Morrell, 2020). Vessel health and preservation, prevention of complications and implementation of quality improvement strategies are pivotal to achieve quality nursing care, and desired patient outcomes including satisfaction (Nickel et al., 2024).
Venous access device‐related complications include phlebitis, catheter occlusion, dislodgement or accidental removal, infiltration or extravasation, leakage, thrombosis, catheter‐related bloodstream infection and exit site infection that can increase morbidity, mortality and costs (Alexandrou et al., 2018; Austin et al., 2016; Lafuente Cabrero et al., 2023). Their overall rate in adult patients ranges from 5% to 32% depending on the specific VAD (Badger, 2019; de Vasconcelos Pina et al., 2023; Marsh et al., 2018). Such complications can arise due to inadequate VAD management (Buchanan et al., 2023; Matey & Camp‐Sorrell, 2016). Challenges include suboptimal implementation of evidence‐based practices in clinical settings (Buchanan et al., 2023; Fiorini et al., 2021), and many barriers have been identified including nurses' VAD management (Jeffery & Pickler, 2014; Piredda et al., 2019). Previous research has identified gaps in nurses' knowledge and competencies regarding the care and maintenance of intravenous access (Hunter et al., 2018; Xu et al., 2020). Skilled nurses, with core competencies in both catheter insertion and maintenance, play a vital role in promoting appropriate utilization in clinical practice. Their expertise enhances successful catheter placement, enables timely recognition and treatment of early signs of complications and ensures the drugs' administration safety, catheter maintenance and patients' satisfaction (Hunter et al., 2018).
2. BACKGROUND
Adequate training and competency of nurses in VAD management can decrease complications such as bloodstream, exit site infection, thrombosis and catheter dislodgement (Aloush, 2018; Roslien & Alcock, 2009; Yousif et al., 2017) and are associated with improved patient satisfaction (Cooke et al., 2018). Skilled nurses show higher success rates for VAD insertion and improve patient outcomes (Piredda et al., 2017; Van Loon et al., 2019).
To adequately develop and assess competencies, it is crucial to focus not only on observable behaviours and knowledge but also on self‐efficacy that can influence actions and perceptions (Bandura et al., 1999). Bandura et al. (1999) use the term self‐efficacy to describe people's belief in their ability to successfully execute the behaviours required to produce a certain outcome. The term self‐confidence has often been used interchangeably with self‐efficacy to describe people's perceived ability to accomplish a certain level of performance. Bandura distinguishes between perceived self‐efficacy and self‐confidence. He prefers to use self‐efficacy to specify the level of perceived competence and the strength of the belief, while he uses self‐confidence referring to the strength of the belief without specifying the level of perceived competence (Bandura et al., 1999).
Appropriate levels of self‐confidence, aligned with the level of training and experience, and clinical complexity are required from healthcare professionals to provide safe and high‐quality care (Gottlieb et al., 2022). Accordingly, high levels of knowledge and self‐efficacy improve nurses' competencies in VAD management, including accurate placement, prevention of complications and management of patient pain (Meyer et al., 2020). For instance, a simulation study on peripheral VAD has improved the catheter first attempt success rate and dwell time by intervening in nurses' deficits regarding insertion and management knowledge and skills (Keleekai et al., 2016). This notwithstanding the level of knowledge and perceived self‐efficacy of nurses for VAD insertion and management is currently under‐studied (Raynak et al., 2020). Moreover, new scientific evidence and ongoing technological advancements in the field of intravenous access require continuous updating of these competencies (Raynak et al., 2020). In particular, following the recent update of the guidelines by the Infusion Nursing Society—INS (Gorski et al., 2021; Nickel et al., 2024), which have upgraded the recommendations for VAD insertion and management, it is important to investigate their reception and application by nurses, as they significantly impact on clinical practice and the quality of care provided to patients (Cooke et al., 2018).
Existing questionnaires regarding venous access device management and insertion are specifically developed for single intravenous access types, such as short peripheral catheters—SPCs (Osti et al., 2019), peripherally inserted central catheters—PICCs (Xu et al., 2020), ports (Raña‐Rocha et al., 2020) or central venous catheters—CVCs (Sharour, 2018). Research also focuses on VAD for paediatric patients, who require insertion procedures and management different from those of adults (Indarwati et al., 2022; Indarwati et al., 2023). Some questionnaires have been developed, focusing on routine management procedures, such as the difficult intravenous access scale (Van Loon et al., 2019) or to assess competences related to specific VAD‐related complications such as bloodstream infection (Cicolini et al., 2014; Esposito et al., 2017; Labeau et al., 2008). Additionally, they often only assess either knowledge or self‐efficacy, are based on outdated scientific evidence compared to the latest guideline recommendations and lack complete and satisfactory psychometric testing (Buchanan et al., 2023; Raynak et al., 2020). Among measures of nurses' self‐efficacy, a simple and clear 10‐item tool was developed by Roslien and Alcock (2009) based on Bandura et al. (1999). However, it was limited to peripherally inserted central catheters (PICCs) and not validated.
To ensure patients' quality of care and safety, especially considering the high‐risk nature of VAD and infusion therapy (Gorski et al., 2021; Nickel et al., 2024), healthcare organizations should assess and document the competencies of nurses, who are responsible for some VAD insertion and management of all of them. The development and validation of a comprehensive instrument aimed to measure both knowledge and self‐efficacy, based on the latest INS guidelines (Gorski et al., 2021; Nickel et al., 2024) and focused on their recommended sections, such as VAD insertion, complications' detection and prevention/management, is necessary to effectively evaluate nurses' competencies. Such an instrument will help identify competency gaps and facilitate the planning of targeted interventions to enhance their clinical performances, thereby improving patients' safety and quality of care.
3. THE STUDY
3.1. Aim
The objective of this study is therefore to develop and psychometrically test an instrument to assess nurses' evidence‐based knowledge and self‐efficacy regarding the insertion and management of venous access devices (short peripheral catheter (SPC), long peripheral catheter/midline (LPC) and PICC) and the management of totally implantable central venous catheter (port) in adult patients.
4. METHODS
4.1. Design
This was a multicentre cross‐sectional observational study with questionnaire development and psychometric testing. It followed the methodology for instrument development by Brancato et al. (2006) including the phases of questionnaire design (literature review, writing and sequencing the questions) and testing (pre‐field test with experts for content validity, revision and field test as pilot study). Consensus‐based Standards for the selection of health status Measurement Instruments (COSMIN) checklist was followed for conducting and reporting this research (Mokkink et al., 2010).
4.2. Questionnaire design
Several questionnaires investigating nurses' knowledge of venous access devices were identified through a literature review (e.g. Cicolini et al., 2014; Esposito et al., 2017; Raña‐Rocha et al., 2020). They were scrutinized to determine the research domains most closely aligned with the study requirements, which aimed to apply the updated recommendations of the standards of practice for venous access of the Infusion Nursing Society (Gorski et al., 2021; Nickel et al., 2024). Although none of the existing questionnaires as such were suitable for this study, we took some of their items and wording as suggestions for building the new instrument.
In this study, nurses' self‐efficacy was defined as their beliefs in their own capabilities to effectively manage venous access devices and perform insertion of SPC, LSC/midlines and PICCs (Bandura et al., 1999). To assess nurses' self‐efficacy, the questionnaire by Roslien and Alcock (2009) regarding peripherally inserted central catheters (PICCs) was modified to include short peripheral catheters (SPCs), long peripheral catheters/midline (LPCs/midlines) and totally implantable central venous catheters (ports).
An expert panel including two nurse researchers with PhDs and two clinical nurse members of infusion teams developed the instrument through several in‐person meetings held in June and July 2021. The first draft included a 37‐item section regarding nurses' knowledge of venous access insertion and management (general part, SPC, LPC/midline, PICC and port), and an 86‐item section on nurses' perceived self‐efficacy in venous access devices insertion and management (SPC, LPC/midline, PICC and port).
4.3. Content validity
To evaluate content validity, the draft instrument was sent by email in two rounds to 19 nurses expert in venous access insertion and management other than those on the expert panel, serving in three university hospitals. They were either part of vascular access teams/PICC teams or held post‐graduate specialization in vascular access management. The experts were asked to rate each item for relevance on a 4‐point Likert scale from 1 (not relevant) to 4 (highly relevant), to evaluate item clarity and instrument completeness and to provide suggestions for potential improvement. Based on their ratings, content validity indices (CVI) were computed both for each item (I‐CVI) and for the whole scale (S‐CVI). The I‐CVI was calculated from the ratio between the number of experts who rated the item as 3 or 4 and the total number of experts. To adjust for chance agreement among ratings, 0.78 was used as the cut‐off point for excellent I‐CVI (Polit et al., 2007). In the first round (September and October 2021), 7/37 items of the knowledge section received an I‐CVI score below the cut‐off (0.78), and suggestions for reviewing the wording were provided for 2 more items. After reviewing these 9 items in comparison with the INS guidelines (Gorski et al., 2021), 3 items were removed, the wording of 4 items and the response format of 2 items were modified to add clarity. Almost all the items (81/86) of the self‐efficacy section received excellent I‐CVI (>0.9). Only 5 were removed because of low relevance. The final number of valid items was 34 for knowledge and 81 for self‐efficacy, accounting for a total of 115 items. In the second round (November 2021), the instrument was sent back to the experts who approved all the items, yielding the following scores: all I‐CVI >0.78; a range of S‐CVIs for knowledge section = 0.96–0.98; and a range of S‐CVIs for self‐efficacy section = 0.97–0.99 (Supplementary File 2).
4.4. Instrument
The final draft of the instrument was labelled ‘Nurses' Knowledge and Self‐efficacy on Venous Access Devices’ (INVAD) and included 1) a knowledge section (in 5 parts: general, SPC, LPC/midline, PICC and port), with 34 items (32 items with 4 closed answers, only 1 of them correct; and 2 items with only 2 answers, only 1 of them correct); and 2) a self‐efficacy section divided into 4 device‐specific parts: SPC (21 items), LPC/midline (21 items), PICC (22 items) and port (17 items) with responses on a 4‐point Likert scale from 1 (not self‐confident) to 4 (highly self‐confident). Each of the SPC, LPC/midline and PICC parts of the self‐efficacy section included three dimensions: insertion, detection of complications and prevention/management of complications of SPC; the port part included two dimensions, namely detection and management of complications and prevention of complications. Participants' socio‐demographic, educational and organizational data were also collected. An online Google form was created for the administration of the instrument.
4.5. Pilot study
The final draft was piloted with nurses attending a master's degree to identify any possible issues regarding the questionnaire or its administration procedure. They were provided with information about the study procedures and objectives and asked to complete the questionnaire and provide feedback if they noted any problems. Eighty‐six nurses completed the online form between January and February 2022. They were mostly female (78%), mean age of 32.7 years, clinical experience ranging from 2 months to 26 years, with a bachelor's degree (86%) and hospital based (79%). Preliminary psychometric testing was encouraging, with Cronbach's alpha coefficients for the device‐specific dimensions of self‐efficacy ranging from 0.839 to 0.957. No further modifications were suggested after the pilot study and the final version of the instrument then proceeded to wider psychometric testing.
4.6. Study setting and sampling
Confirmatory factor analyses (CFAs) were planned only for the four device‐specific parts of the self‐efficacy section of the instrument, whose items range from 17 to 22. Therefore, a sample size of 220 participants was considered adequate, but a sample of more than 400 participants was sought to allow tests of known group validity (MacCallum et al., 1999). A convenience sample of nurses was recruited through personal contacts of nurses who were attending a Master's degree with students throughout the whole country, to reach a broad range of settings (hospital and community), clinical areas (including medical, surgical, critical care, outpatient and home care), professional characteristics (work experience, specialist training in venous access, etc.) and cities from the north, centre and south of Italy.
4.7. Inclusion and exclusion criteria
The inclusion criteria for the sample were nurses providing care to adult patients both in hospital and community settings. Nurses caring for paediatric patients were excluded.
4.8. Data collection for final validation
The link to the online Google form of the INVAD was sent via email to potential participants between March and June 2022. They were provided with information about the study procedures and objectives and asked to complete the questionnaire and to share the link with colleagues if they wished.
4.9. Data analysis
Descriptive analyses were conducted for participants' socio‐demographic variables and instrument items. Correct responses for items of the knowledge section were rated as score 1 and incorrect responses as score 0. The mean scores for each part (general, SPC, LPC/midline, PICC, port) of the knowledge section were computed by adding up all the item scores and dividing by the number of items in the part. Frequencies and percentages were calculated for the scores of the ordered categorical self‐efficacy items.
The index of difficulty (DIF I)/facility and the discrimination index (DI) were calculated for the items of the INVAD knowledge section to test their capability to distinguish between participants with different abilities or levels of competence. The DIF I indicates item difficulty/facility calculated by dividing the number of participants who answered the question correctly by the total number of participants. It can range from 0 to 1, where 0 indicates that no participant answered correctly, and 1 indicates that all participants answered correctly. For instance, a 25% correct response yields a DIF I of 0.25. Usually, values ranging from 0.30 to 0.70 are considered acceptable difficulty levels, values <0.30 suggest higher difficulty and values >0.70 indicate easier items. However, for four‐option items, the optimal average difficulty is (0.25 + 1.00) / 2 = 0.63, and for two‐option items (0.50 + 1.00)/2 = 0.75. The discrimination index measures the item's ability to discriminate between high‐ and low‐achieving participants. The DI is calculated by subtracting the number of correct answers recorded in the upper extreme (number of students in the high range who answered the item correctly) by the number of correct answers recorded in the lower extreme (number of students in the low range who answered the item correctly), divided by the number of subjects in each group. Each extreme includes 25% of respondents. DI values range from −1 to +1, where −1 signifies that individuals with lower abilities are more likely to answer correctly, +1 indicates that those with higher abilities are more likely to answer correctly and 0 indicates no discrimination between participants with different abilities. Discrimination power is excellent for DI values ≥0.35, good for DI 0.25–0.34, marginal for DI 0.15–0.24 and poor for values <0.15. DI <0 suggests that low achievers outperform high achievers, potentially due to unclear item wording or ineffective distractors (Guilbert, 1981; Matlock‐Hetzel, 1997).
According to classical test theory (Raykov, 2012), we tested the dimensionality of the self‐efficacy section of INVAD with confirmatory factor analyses (CFAs). This approach is recommended when instrument developers assume a theory‐based model, as in our case. Thus, we performed CFAs to confirm the dimensionality of the scales. Specifically, four CFAs, one for each device, were conducted by posing a three‐factor model (insertion, detection of complications and prevention/management of complications) for the SPC (21 items), LPC/midline (21 items) and PICC (22 items), and a two‐factor model (detection of complications and prevention/management of complications) for port (17 items). Second‐order models were also specified and tested with CFAs. As the items were ordered categorically instead of continuous variables, the CFAs were performed using robust weighted least squares with standard errors and mean‐ and variance‐adjusted chi‐square test statistics (WLS‐MV) as parameter estimators (Muthén & Muthén, 2012). According to recommendations by Hoyle (1995) and to a multifaceted approach to model fit testing (Bentler & Hu, 1998), we employed the root mean square error of approximation—RMSEA; the comparative fit index—CFI; the Tucker and Lewis index—TLI; and the standardized root mean square residual—SRMR. A good fit is indicated by values of RMSEA ≤0.06; RMSEA with 90% confidence intervals ≤0.05 to ≤0.08, RMSEA test of close‐fit examining the probability that the approximation error is low p > 0.05; CFI/TLI >0.95; and SRMR ≤0.08 (Browne & Cudeck, 1992; Hu & Bentler, 1999). The χ 2 statistics were computed and interpreted along with the above indices. Factor loadings > |0.30| were considered adequate (Tabachnick & Fidell, 2019).
To test construct validity, known group validity was assessed by testing the hypotheses that scores at self‐efficacy will be higher (1) in respondents with specific training in venous access management and insertion, than in those with no specific education, and (2) in nurses who frequently care for people with each type of VAD. To detect such differences between scores, χ 2 statistics were calculated.
The reliability in terms of internal consistency of each dimension of the device‐specific parts of the self‐efficacy section was assessed with Cronbach's alpha and ordinal omega for reliability coefficients (Revelle & Zinbarg, 2009). Evaluation of the internal consistency was deemed not appropriate for the different parts of the knowledge section, in accordance with previous literature (Cicolini et al., 2014; Keleekai et al., 2016; Simonetti et al., 2019). They included items focusing on specific procedures, some of them already well‐known and others recently modified according to new evidence (Gorski et al., 2021; Nickel et al., 2024). Therefore, knowledge of one of them may be independent from that of another, even regarding the same device. Statistical significance was set at <0.05. SPSS software v.26.00 (IBM Corp. Armonk, NY) and Mplus v.8.8 (Muthén & Muthén, Los Angeles, CA, USA) were used for statistical and psychometric analyses, and R for ordinal omega reliability coefficients.
4.10. Ethics statement
The study was approved by the Campus Bio‐Medico di Roma University' (PAR 20.21‐OSS) Ethics Committee on 23rd February 2021. Confidentiality of participant identity was guaranteed as data were collected anonymously and described in an aggregated way, in compliance with current data protection regulations and the ethical principles of the Helsinki Declaration (World Medical Association, 2013). Consent to participate was understood as provided by the fact of completing and returning the questionnaire.
5. RESULTS
5.1. Characteristics of the sample
The survey was completed by 425 nurses who were mostly female (68%) and hospital based (82.4%), with a mean age of 34 years and work experience of 8.8 years. They provided care to adult patients in different clinical areas in 16 regions of Northern, Central and Southern Italy. Some of them had received specific courses on insertion and management of SPC (22.6%), PICC/LPC/midline (16%) and management of CVC/port (20.7%). Further data on participants' characteristics are provided in Table 1.
TABLE 1.
Participants' characteristics (n = 425 nurses).
| Variable | N (%) | Mean ± SD (range) |
|---|---|---|
| Gender | ||
| Female | 289 (68) | |
| Male | 136 (32) | |
| Age (years) | 34 ± 9.51 (22–66) | |
| Experience (years) | 8.8 ± 8.515 (0–40) | |
| Postgraduate education completed | ||
| University course (1 year) | 146 (34.4) | |
| Master's degree (2 years) | 46 (10.8) | |
| None | 233 (54.8) | |
| Current postgraduate education | ||
| University course (1 year) | 86 (20.2) | |
| Master's degree (2 years) | 49 (11.5) | |
| Doctorate (3 years) | 2 (0.5) | |
| None | 288 (67.8) | |
| Clinical setting | ||
| Hospital | 350 (82.4) | |
| Community | 75 (17.6) | |
| Clinical area | ||
| Medicine | 100 (23.5) | |
| Surgery | 48 (11.3) | |
| Critical care | 85 (20) | |
| Emergency | 62 (14.6) | |
| Oncology/haematology/palliative care | 22 (5.2) | |
| Operating room | 20 (4.7) | |
| Other a | 88 (13.9) | |
| Advanced courses on SPC | 96 (22.6) | |
| Advanced courses on PICC/LPC/Midline | 68 (16.0) | |
| Advanced courses on CVC/Port | 88 (20.7) | |
| SPC placed/week | 14 ± 19.12 (0–103) | |
| LPC‐midline placed/week | 1.5 ± 6.44 (0–100) | |
| PICCs placed/week | 0.39 ± 1.87 (0–20) | |
| Patients with PICC/month | 9.68 ± 54.07 (0–600) | |
| Patients with port/month | 3.06 ± 15.45 (0–250) | |
Abbreviation: SD, standard deviation.
Other clinical areas include: outpatient clinics, home care and other services both hospital and community base.
5.1.1. Knowledge section
Index of difficulty/facility (DIF I) and discrimination index (DI)
Frequencies and percentages of correct responses for each item of the knowledge section are provided in Table 2. Overall analysis of DIF I values showed that most items (20; 58.8%) were of desirable difficulty (5 of which were excellent), 7 (20.6%) were too difficult and 7 (20.6%) too easy (Table 3).
TABLE 2.
Items of the knowledge section and participants' responses (n = 425 nurses).
| Item | Question | Correct responses N (%) |
|---|---|---|
| 1 GEN | How is it recommended to perform hand hygiene before VAD insertion? | 273 (64) |
| 2 GEN | How is it recommended to perform site disinfection before VAD insertion? | 227 (79) |
| 3 GEN | What dressings are recommended for VAD insertion site? | 177 (42) |
| 4 GEN | When should the gauze and adhesive dressing at the insertion site be changed? | 186 (44) |
| 5 GEN | When should the semi‐permeable transparent dressing at the insertion site be changed? | 254 (60) |
| 6 GEN | What syringe gauge and correct technique are recommended for VAD flushing? | 327 (77) |
| 7 GEN | What is the correct way to prevent blood reflux within the system? | 223 (52) |
| 8 GEN | What is recommended before blood sampling from a VAD? | 56 (13) |
| 1 SPC | What are the indications for inserting a short peripheral catheter? | 130 (31) |
| 2 SPC | Where should insertion be avoided when selecting a vein to cannulate? | 254 (60) |
| 3 SPC | In which veins is the insertion of a short peripheral catheter recommended for non‐emergency situations and therapies lasting a few days? | 297 (70) |
| 4 SPC | Can steel‐winged devices (such as butterfly) be used for drug administration? | 60 (14) |
| 5 SPC | Is blood sampling from a short peripheral catheter recommended? | 54 (10) |
| 6 SPC | Is drawing blood cultures from a short peripheral catheter recommended? | 162 (38) |
| 7 SPC | Is routinely replacing the short peripheral catheter recommended? | 136 (32) |
| 8 SPC | Is routinely replacing the short peripheral catheter that was inserted under emergency (or non‐aseptic) conditions recommended? | 129 (30) |
| 1 LPC | What are the indications for inserting a LPC/Midline? | 186 (44) |
| 2 LPC | In which veins is the insertion of a Midline recommended? | 341 (80) |
| 3 LPC | Where should the tip of a Midline terminate for proper positioning? | 204 (48) |
| 4 LPC | Where should the tip of a LPC terminate for proper positioning? | 85 (20) |
| 5 LPC | Does blood sampling from a LPC/Midline follow the same recommendations as short peripheral catheters? | 241 (60) |
| 1 Port | What type of infusions can be performed through a Port? | 363 (85) |
| 2 Port | Which needle should be used to puncture the septum of a Port? | 199 (47) |
| 3 Port | What is recommended during the flushing and locking of a Port? | 328 (77) |
| 4 Port | How and how often should non‐used Ports be flushed (locked) to maintain their patency? | 56 (13) |
| 5 Port | How often should Ports connected to a Huber needle but not in use be flushed (locked) to maintain their patency? | 62 (15) |
| 1 PICC | In which veins is it recommended to place a PICC? | 159 (37) |
| 2 PICC | Where should the tip of the PICC reach for proper placement? | 296 (70) |
| 3 PICC | What is the best method to assess the correct placement of the PICC tip? | 49 (10) |
| 4 PICC | What is the correct sequence for dressing a PICC? | 316 (74) |
| 5 PICC | What safety devices should be used to secure the PICC in place? | 309 (70) |
| 6 PICC | What is the correct sequence for drawing blood from a PICC? | 273 (60) |
| 7 PICC | Which actions can cause PICC occlusion? | 241 (57) |
| 8 PICC | How can PICC occlusion be prevented? | 352 (79) |
Abbreviations: GEN, general knowledge; LPC, knowledge of long peripheral catheter insertion and management; PICC, knowledge of peripherally inserted central catheter insertion and management; Port, knowledge of port management; SPC, knowledge of short peripheral catheter insertion and management.
TABLE 3.
Indices of difficulty/facility for device‐specific knowledge items (n = 425).
| Too difficult (DIF I < 0.30) | Good/acceptable (DIF I 0.30–0.70) | Excellent (DIF I 0.58–0.68, 4‐option item; DIF I 0.70–0.80: 2‐option item) | Too easy (DIF I > 0.70) | ||
|---|---|---|---|---|---|
| Knowledge section (number of items) | DIF I mean ± DS (range) | N items (%) | N items (%) | N items (%) | |
| General (8) | 0.54 ± 0.21 (0.13–0.79) | 1 (12.5) | 5 (62.5) | 2 (25) | 2 (25) |
| SPC (8) | 0.35 ± 0.21 (0.1–0.7) | 2 (25) | 6 (75) | 1 (12.5) | 0 |
| LPC/midline (5) | 0.52 ± 0.25 (0.2–0.88) | 1 (20) | 3 (60) | 1 (20) | 1 (20) |
| PICC (8) | 0.57 ± 0.23 (0.1–0.79) | 1 (12.5) | 5 (62.5) | 1 (12.5) | 2 (25) |
| Port (5) | 0.47 ± 0.34 (0.13–0.85) | 2 (40) | 1 (20) | 0 | 2 (40) |
| Total (34) | 7 (20.6) | 20 (58.8) | 5 (14.7) | 7 (20.6) |
Abbreviations: DIF I, index of difficulty/facility; LPC, long peripheral catheter; PICC, peripherally inserted central catheter; SPC, short peripheral catheter.
Overall analysis of DI values showed that most items (58.8%) had excellent (n = 12, 35.3%) or good (n = 8, 23.5%) discrimination power, while 5 (14.7%) and 9 (26.5%) had marginal or poor discrimination power, respectively (Table 4).
TABLE 4.
Discrimination Indices for device‐specific knowledge items.
| Poor (DI < 0.15) | Marginal (DI 0.15–0.24) | Good (DI I 0.25–0.34) | Excellent (DI ≥0.35) | ||
|---|---|---|---|---|---|
| Knowledge section (number of items) | DI mean ± DS (range) | N items (%) | N items (%) | N items (%) | |
| General (8) | 0.36 ± 0.17 (0.1–0.59) | 1 (12.5) | 0 | 4 (50) | 3 (37.5) |
| SPC (8) | 0.24 ± 0.11 (0.14–0.42) | 2 (25) | 4 (50) | 0 | 2 (25) |
| LPC/midline (5) | 0.22 ± 0.17 (0.1–0.41) | 2 (40) | 0 | 1 (20) | 2 (40) |
| PICC (8) | 0.31 ± 0.17 (0.08–0.49) | 2 (25) | 1 (12.5) | 1 (12.5) | 4 (50) |
| Port (5) | 0.25 ± 0.20 (0.06–0.55) | 2 (40) | 0 | 2 (40) | 1 (20) |
| Total (34) | 9 (26.5) | 5 (14.7) | 8 (23.5) | 12 (35.3) |
Abbreviations: DI, discrimination index; LPC, long peripheral catheter; PICC, peripherally inserted central catheter; SPC, short peripheral catheter.
5.1.2. Self‐efficacy section
Descriptive statistics (with frequencies and percentages of participants selecting the different responses) for the items of the self‐efficacy section are provided in Table 5.
TABLE 5.
Item descriptive statistics of self‐efficacy about VAD insertion and management (n = 425 nurses).
| Item number | Item | CAT 1, N (%) | CAT 2 , N (%) | CAT 3, N (%) | CAT 4, N (%) | Item loadings | ||
|---|---|---|---|---|---|---|---|---|
| Short peripheral catheter | F1 SPC | F2 SPC | F3 SPC | |||||
| 1 SPC | Choosing the appropriate device calibre | 37 (8.7) | 46 (10.8) | 135 (31.8) | 207 (48.7) | 0.855 | ||
| 2 SPC | Choosing the appropriate venipuncture site | 35 (8.2) | 42 (9.9) | 136 (32.0) | 212 (49.9) | 0.879 | ||
| 3 SPC | Inserting the VAD with a single venipuncture | 35 (8.2) | 50 (11.8) | 162 (38.1) | 178 (41.9) | 0.785 | ||
| 4 SPC | Evaluating the VAD correct placement | 30 (7.1) | 37 (8.7) | 120 (28.2) | 238 (56.0) | 0.909 | ||
| 5 SPC | Identifying a patient with DIVA | 38 (8.9) | 43 (10.1) | 122 (28.7) | 222 (52.2) | 0.920 | ||
| 6 SPC | Performing disinfection and dressing | 25 (5.9) | 36 (8.5) | 113 (26.6) | 251 (59.1) | 0.939 | ||
| 7 SPC | Identifying complications: Infection | 29 (6.8) | 43 (10.1) | 134 (31.5) | 219 (51.5) | 0.937 | ||
| 8 SPC | Identifying complications: Extravasation | 33 (7.8) | 47 (11.1) | 106 (24.9) | 239 (56.2) | 0.923 | ||
| 9 SPC | Identifying complications: Phlebitis | 32 (7.5) | 36 (8.5) | 125 (29.4) | 232 (54.6) | 0.912 | ||
| 10 SPC | Identifying complications: Externalization | 32 (7.5) | 53 (12.5) | 129 (30.4) | 211 (49.6) | 0.887 | ||
| 11 SPC | Identifying complications: Dislocation | 33 (7.8) | 37 (8.7) | 120 (28.2) | 235 (55.3) | 0.928 | ||
| 12 SPC | Identifying complications: Rupture | 45 (10.6) | 54 (12.7) | 136 (32.0) | 190 (44.7) | 0.861 | ||
| 13 SPC | Identifying complications: Occlusion | 26 (6.1) | 45 (10.6) | 122 (28.7) | 232 (54.6) | 0.926 | ||
| 14 SPC | Managing complications | 23 (5.4) | 41 (9.6) | 155 (36.5) | 206 (48.5) | 0.917 | ||
| 15 SPC | Drawing blood | 52 (12.2) | 46 (10.8) | 102 (24.0) | 225 (52.9) | 0.889 | ||
| 16 SPC | Preventing extravasation | 37 (8.7) | 38 (8.9) | 156 (36.7) | 194 (50.4) | 0.909 | ||
| 17 SPC | Preventing infections | 28 (6.6) | 41 (9.6) | 142 (33.4) | 214 (50.4) | 0.940 | ||
| 18 SPC | Preventing dislocation or rupture | 28 (6.6) | 55 (12.9) | 156 (36.7) | 186 (43.8) | 0.895 | ||
| 19 SPC | Preventing occlusion | 21 (4.9) | 52 (12.2) | 153 (36.0) | 199 (46.8) | 0.947 | ||
| 20 SPC | Maintaining patency | 21 (4.9) | 45 (10.6) | 146 (34.4) | 213 (50.1) | 0.929 | ||
| 21 SPC | Performing pulsatile flushing | 29 (6.8) | 38 (8.9) | 115 (27.1) | 243 (57.2) | 0.910 | ||
| Long peripheral catheter/Midline | CAT 1, N (%) | CAT 2, N (%) | CAT 3, N (%) | CAT 4, N (%) | F1 LPC | F2 LPC | F3 LPC | |
| 1 LPC | Choosing the appropriate device calibre | 97 (22.8) | 140 (32.9) | 134 (31.1) | 54 (12.7) | 0.652 | ||
| 2 LPC | Choosing the appropriate venipuncture site | 94 (22.1) | 110 (25.9) | 153 (36.0) | 68 (16.0) | 0.732 | ||
| 3 LPC | Inserting the VAD with a single venipuncture | 157 (36.9) | 121 (28.5) | 109 (25.6) | 38 (8.9) | 0.504 | ||
| 4 LPC | Evaluating the VAD correct placement | 78 (18.4) | 105 (24.7) | 136 (32) | 106 (24.9) | 0.896 | ||
| 5 LPC | Identifying a patient with DIVA | 84 (19.8) | 108 (25.4) | 134 (31.5) | 99 (23.3) | 0.818 | ||
| 6 LPC | Identifying complications: Infection | 22 (5.2) | 66 (15.5) | 170 (40.0) | 167 (39.3) | 0.833 | ||
| 7 LPC | Identifying complications: Extravasation | 25 (5.9) | 102 (24.0) | 160 (37.6) | 138 (32.5) | 0.785 | ||
| 8 LPC | Identifying complications: Phlebitis | 32 (7.5) | 86 (20.2) | 160 (37.6) | 147 (34.6) | 0.809 | ||
| 9 LPC | Identifying complications: Externalization | 37 (8.7) | 110 (25.9) | 156 (36.7) | 122 (28.7) | 0.819 | ||
| 10 LPC | Identifying complications: Dislocation | 37 (8.7) | 90 (21.2) | 178 (41.9) | 120 (28.2) | 0.857 | ||
| 11 LPC | Identifying complications: Rupture | 58 (13.6) | 123 (28.9) | 145 (34.1) | 99 (23.3) | 0.763 | ||
| 12 LPC | Managing complications | 39 (9.2) | 101 (23.8) | 184 (43.3) | 101 (23.8) | 0.847 | ||
| 13 LPC | Identifying complications: Occlusion | 22 (5.2) | 70 (16.5) | 147 (34.6) | 186 (43.8) | 0.865 | ||
| 14 LPC | Performing disinfection and dressing | 23 (5.4) | 58 (13.6) | 134 (31.5) | 210 (49.4) | 0.853 | ||
| 15 LPC | Drawing blood | 26 (6.1) | 64 (15.1) | 138 (32.5) | 197 (46.4) | 0.860 | ||
| 16 LPC | Preventing extravasation | 30 (7.1) | 81 (19.1) | 176 (41.4) | 138 (32.5) | 0.869 | ||
| 17 LPC | Preventing infections | 17 (4.0) | 57 (13.4) | 165 (38.8) | 186 (43.8) | 0.909 | ||
| 18 LPC | Preventing dislocation or rupture | 25 (5.9) | 91 (21.4) | 172 (40.5) | 137 (3.2) | 0.898 | ||
| 19 LPC | Preventing occlusion | 24 (5.6) | 62 (14.6) | 165 (38.8) | 174 (40.9) | 0.900 | ||
| 20 LPC | Maintaining patency | 17 (4.0) | 52 (12.2) | 112 (26.4) | 239 (56.2) | 0.877 | ||
| 21 LPC | Performing pulsatile flushing | 22 (5.2) | 52 (12.2) | 112 (26.4) | 239 (56.2) | 0.870 | ||
| α: 0.861 | α: 0.912 | α: 0.945 | ||||||
| ω: 0.843 | ω:0.899 | ω: 0.933 | ||||||
| PICC | CAT 1, N (%) | CAT 2, N (%) | CAT 3, N (%) | CAT 4, N (%) | F1 PICC | F2 PICC | F3 PICC | |
| 1 PICC | Choosing the appropriate device calibre | 119 (28) | 120 (28.2) | 117 (27.5) | 69 (16.2) | 0.629 | ||
| 2 PICC | Choosing the appropriate venipuncture site | 106 (24.9) | 107 (25.2) | 133 (31.3) | 79 (18.6) | 0.662 | ||
| 3 PICC | Inserting the VAD with a single venipuncture | 180 (42.4) | 99 (23.3) | 107 (25.2) | 39 (9.2) | 0.547 | ||
| 4 PICC | Evaluating the VAD correct placement | 86 (20.2) | 91 (21.4) | 132 (31.1) | 116 (27.3) | 0.942 | ||
| 5 PICC | Identifying a patient with DIVA | 80 (18.8) | 116 (27.3) | 131 (30.8) | 98 (23.1) | 0.825 | ||
| 6 PICC | Identifying complications: Extravasation | 31 (7.3) | 94 (22.1) | 174 (40.9) | 126 (29.6) | 0.741 | ||
| 7 PICC | Identifying complications: Phlebitis | 37 (8.7) | 78 (18.4) | 170 (40.0) | 140 (32.9) | 0.784 | ||
| 8 PICC | Identifying complications: Externalization | 40 (9.4) | 102 (24.0) | 158 (37.2) | 125 (29.4) | 0.764 | ||
| 9 PICC | Identifying complications: Dislocation | 35 (8.2) | 111 (26.1) | 168 (39.5) | 111 (26.1) | 0.841 | ||
| 10 PICC | Identifying complications: Rupture | 56 (13.2) | 120 (28.2) | 163 (38.4) | 86 (20.2) | 0.714 | ||
| 11 PICC | Managing complications | 39 (9.2) | 112 (26.4) | 183 (43.1) | 91 (21.4) | 0.828 | ||
| 12 PICC | Identifying complications: Infection | 23 (5.4) | 69 (16.2) | 165 (38.8) | 168 (39.5) | 0.805 | ||
| 13 PICC | Performing disinfection and dressing | 26 (6.1) | 48 (11.3) | 141 (33.2) | 210 (49.4) | 0.855 | ||
| 14 PICC | Identifying complications: Occlusion | 18 (4.2) | 63 (14.8) | 158 (37.2) | 186 (43.8) | 0.866 | ||
| 15 PICC | Drawing blood | 20 (4.7) | 58 (13.6) | 134 (31.5) | 213 (50.1) | 0.871 | ||
| 16 PICC | Preventing extravasation | 31 (7.3) | 76 (17.9) | 185 (43.5) | 133 (31.3) | 0.851 | ||
| 17 PICC | Preventing infections | 19 (4.5) | 63 (14.8) | 156 (36.7) | 187 (44.0) | 0.917 | ||
| 18 PICC | Preventing dislocation or rupture | 26 (6.1) | 79 (18.6) | 189 (44.5) | 131 (30.8) | 0.876 | ||
| 19 PICC | Preventing occlusion | 23 (5.4) | 50 (11.8) | 179 (42.1) | 173 (40.7) | 0.905 | ||
| 20 PICC | Maintaining patency | 15 (3.5) | 54 (12.7) | 167 (39.3) | 189 (44.5) | 0.892 | ||
| 21 PICC | Performing pulsatile flushing | 20 (4.7) | 42 (9.9) | 121 (28.5) | 242 (56.9) | 0.873 | ||
| 22 PICC | Anchoring with sutureless fixation device | 30 (7.1) | 69 (16.2) | 130 (30.6) | 196 (46.1) | 0.668 | ||
| α: 0.855 | α: 0.879 | α: 0.946 | ||||||
| ω: 0.833 | ω:0.856 | ω: 0.932 | ||||||
| Port | CAT 1, N (%) | CAT 2, N (%) | CAT 3, N (%) | CAT 4, N (%) | F1 Port | F2 Port | ||
| 1 Port | Managing complications | 64 (15.1) | 121 (28.5) | 165 (38.8) | 75 (17.6) | 0.815 | ||
| 2 Port | Identifying complications: Extravasation | 46 (10.8) | 116 (27.3) | 149 (35.1) | 114 (26.8) | 0.775 | ||
| 3 Port | Identifying complications: Phlebitis | 49 (11.5 | 96 (22.6) | 158 (37.2) | 122 (28.7) | 0.759 | ||
| 4 Port | Identifying complications: Dislocation | 65 (15.3) | 118 (27.8) | 147 (34.6) | 95 (22.4) | 0.828 | ||
| 5 Port | Identifying complications: Rupture | 81 (19.1) | 119 (28.0) | 151 (35.5) | 74 (17.4) | 0.741 | ||
| 6 Port | Identifying complications: Occlusion | 37 (8.7) | 66 (15.5) | 164 (38.6) | 158 (37.2) | 0.376 | 0.512 | |
| 7 Port | Identifying complications: Infection | 31 (7.3) | 84 (19.8) | 170 (40.0) | 140 (32.9) | 0.732 | ||
| 8 Port | Performing disinfection and dressing | 30 (7.1) | 66 (15.5) | 144 (33.9) | 185 (43.5) | 0.780 | ||
| 9 Port | Drawing blood | 50 (11.8) | 69 (16.2) | 127 (29.9) | 179 (42.1) | 0.855 | ||
| 10 Port | Preventing extravasation | 52 (12.2) | 79 (18.6) | 171 (40.2) | 123 (28.9) | 0.833 | ||
| 11 Port | Preventing infections | 31 (7.3) | 64 (15.1) | 152 (35.8) | 178 (41.9) | 0.839 | ||
| 12 Port | Preventing dislocation or rupture | 51 (12.0) | 85 (20.0) | 167 (39.3) | 122 (28.7) | 0.845 | ||
| 13 Port | Preventing occlusion | 40 (9.4) | 62 (14.6) | 167 (39.3) | 156 (36.7) | 0.848 | ||
| 14 Port | Maintaining patency | 29 (6.8) | 60 (14.1) | 161 (37.9) | 175 (41.2) | 0.869 | ||
| 15 Port | Performing pulsatile flushing | 31 (7.3) | 53 (12.5) | 118 (27.8) | 223 (52.5) | 0.803 | ||
| 16 Port | Inserting a Huber needle | 60 (14.1) | 81 (19.1) | 141 (33.2) | 143 (33.6) | 0.509 | ||
| 17 Port | Removing a Huber needle | 47 (11.1) | 85 (20.0) | 141 (33.2) | 152 (35.8) | 0.559 | ||
| α: 0.888 | α: 0.933 | |||||||
| ω: 0.862 | ω: 0.899 | |||||||
Abbreviations: CAT 1–4, frequencies and percentages of participants endorsing each response category; DIVA, difficult intravenous access; F1–F3, factors of each device‐specific section; LPC, self‐efficacy for long peripheral catheter and midline insertion and management; PICC, self‐efficacy for peripherally inserted central catheter insertion and management; Port, self‐efficacy for port management; SPC, self‐efficacy for short peripheral catheter insertion and management; VAD, Vascular Access Device; α, Cronbach's alpha coefficient; ω, Ordinal omega reliability coefficient.
5.2. Structural validity
5.2.1. SPC
To test the structural validity of the self‐efficacy section in the insertion and management of short peripheral catheters (SPCs), we specified a three‐factor confirmatory model: SPC Insertion measured by six items (#1 to #6), SPC Detection of complications measured by seven items (#7 to #13) and SPC Prevention and management of complications measured by eight items (#14 to #21). The fit indices were good: χ 2(186, N = 425) = 610.883, p < 0.0001; RMSEA = 0.073 (IC 90% 0.067–0.080), p < 0.001; CFI = 0.991; TLI = 0.990; SRMR = 0.022. Following inspection of the modification indices (MI), we specified the covariance of several items (#1 with #2 and #3; #2 with #3 and #4; #3 with #4; #6 with #7; #12 with #13 and #14; #17 with #18 and #20 with #21). The fit indices for this model were excellent: χ 2(176, N = 425) = 396.309, p < 0.0001; RMSEA = 0.054 (IC 90% 0.047–0.061), p < 0.157; CFI = 0.996; TLI = 0.995; SRMR = 0.017. Since the three factors were all highly correlated (mean r = 0.942, p < 0.001), a second‐order model was hypothesized, which yielded the same excellent fit indices. The SPC self‐efficacy scale is multidimensional at the level of primary factors and unidimensional at the level of the second‐order factor. All the items showed loadings >0.7 and p values <0.001 (Figure 1).
FIGURE 1.
Confirmatory factor analysis—self‐efficacy SPC. SPC, short peripheral catheter; Q1–Q21, items of self‐efficacy short peripheral catheter.
5.2.2. LPC/midline
For the self‐efficacy section regarding insertion and management of LPC/midline a three‐factor confirmatory model was specified: LPC/midline insertion measured by five items (#1 to #5), LPC/midline detection of complications measured by seven items (#6 to #12) and LPC/midline prevention and management of complications measured by nine items (#13 to #21). The fit indices identified a misfit: χ 2(186, N = 425) = 944.369, p < 0.001; RMSEA = 0.098 (IC 90% 0.092–0.104) p < 0.001; CFI = 0.965; TLI = 0.961; SRMR = 0.058. Following inspection of the MI, the covariance of several items (#1 with #2 and #3; #3 with #2 and #4; #14 with #5 and #6; #7 with #6 and #8; #13 with #8 and #10; #11 with #10 and #12; #12 with #16; and #20 with #19 and #21) was specified. The above model yielded the following adequate fit indices: χ 2(171, N = 425) = 520.311, p < 0.001; RMSEA = 0.069 (IC 90% 0.063–0.076) p < 0.001; CFI = 0.984; TLI = 0.980; SRMR = 0.041. All the items showed loadings ≥0.3 (range 0.504–0.909) and p < 0.001 (Figure 1). Since the three factors were highly correlated (mean r = 0.687, p < 0.001), a second‐order factor was tested but not confirmed (Figure 2).
FIGURE 2.
Confirmatory factor analysis—self‐efficacy LPC. LPC/Midline, long peripheral catheter/midline; Q1–Q21, items of self‐efficacy long peripheral catheter/midline.
5.2.3. PICC
For the self‐efficacy section regarding PICC insertion and management, a three‐factor confirmatory model was specified: PICC Insertion measured by five items (#1 to #5), PICC detection of complications measured by 6 items (#6 to #11) and PICC prevention and management of complications measured by 11 items (#12 to #22). The fit indices found a misfit: χ2(206, N = 425) = 1087.303, p < 0.0001; RMSEA = 0.100 (IC 90% 0.094–0.106) p < 0.001; CFI = 0.955; TLI = 0.950; SRMR = 0.070. Following an inspection of the MI, the covariance of several items (#1 with #2 and #3; #2 with #3; # 5 with #8 and #9; #6 with #7; #10 with #9 and #11; #11 with #16; #12 with #6 and #7; and #20 with #19 and #21) was specified. The above model yielded the following adequate fit indices: χ 2(193, N = 425) = 633.116, p < 0.0001; RMSEA = 0.073 (IC 90% 0.067–0.080) p < 0.001; CFI = 0.978; TLI = 0.973; SRMR = 0.051. All the items showed loadings >0.3 (range 0.544–0.923) and p < 0.001 (Figure 1). Since the three factors were highly correlated (mean r = 0.638, p < 0.001), we tested a second‐order factor, but this model was not confirmed (Figure 3).
FIGURE 3.
Confirmatory factor analysis—self‐efficacy Port. Port, totally implantable central venous catheter; Q1–Q17, items of self‐efficacy totally implantable central venous catheter.
5.2.4. Port
For the self‐efficacy section regarding port management, a two‐factor confirmatory model was specified: port detection and management of complications measured by 5 items (#1 to #5) and port prevention of complications measured by 12 items (#6 to #17). The fit indices for this model found a poor fit: χ 2(116, N = 425) = 581.181, p < 0.0001; RMSEA = 0.097 (IC 90% 0.089–0.105) p = 0.150; CFI = 0.970; TLI = 0.965; SRMR = 0.044. Following inspection of the MI, item #6 loaded in both factors and the covariance of several items (#3 with #4; #5 with #1 and #4; #1 with #10; #8 with #16 and #17; #11 with #12, #13 and #14; #12 with #13; #14 with #11, #13 and #15; and #16 with #17) was specified. The above model yielded the following excellent fit indices: χ 2(102, N = 425) = 236.569, p < 0.0001; RMSEA = 0.056 (IC 90% 0.046–0.065) p = 0.150; CFI = 0.991; TLI = 0.988; SRMR = 0.028. All the items showed loadings >0.3 (range 0.506–0.862) and p < 0.001 (Figure 1). Since the two factors were highly correlated (r = 0.843, p < 0.001), we tested a second‐order factor, but this model was not confirmed (Figure 4).
FIGURE 4.
Confirmatory factor analysis—self‐efficacy PICC. PICC, peripherally inserted central catheter; Q1–Q22 = items of self‐efficacy peripherally inserted central catheter.
5.2.5. Construct validity
We assessed known group validity by testing the hypotheses that scores at self‐efficacy will be higher (1) in respondents with specific training in venous access management and insertion, than in those with no specific education, and (2) in nurses who frequently care for people with each type of VAD. Statistically significant differences were found in the distribution of scores for (a) SPC self‐efficacy of nurses (n = 96) who reported specific training in SPC (p < 0.001); (b) self‐efficacy of nurses (n = 68) who reported specific training in LPC/midline and PICC (LPC/midline insertion, p < 0.001; LPC/midline detection of complications, p = 0.001; PICC insertion, p < 0.001; PICC detection of complications, p < 0.001; PICC prevention and management of complications, p = 0.003); (c) self‐efficacy of nurses (n = 88) who reported specific training in port management (port detection and management of complications, p = 0.008; port prevention of complications, p = 0.016) compared with those who did not report such training.
Moreover, statistically significant differences were found in the distribution of self‐efficacy scores regarding (a) LPC/midline insertion (p = 0.031), LPC/midline detection of complications (p < 0.001) and LPC/midline prevention and management of complications (p < 0.001) according to the number of patients with LPC/midline or PICC cared for monthly; (b) PICC detection of complications (p < 0.01) and PICC prevention and management of complications (p < 0.001) according to the number of patients with PICC cared for monthly; and (c) port prevention of complications (p = 0.003) according to the number of patients with port cared for monthly. The differences in the remaining self‐efficacy scores (i.e. for SPC, PICC insertion and port detection and management of complications) were not statistically significant according to the number of patients cared for with the specific device.
Overall, the hypotheses posed to test known group validity were confirmed. In addition, no significant difference was found in the distribution of any self‐efficacy score according to nurses' work experience, age, settings (hospital or community) and clinical areas (e.g. critical care, onco‐haematology, emergency, medicine and surgery).
5.2.6. Reliability
To evaluate internal consistency, we computed Cronbach's alpha coefficients (alpha) for the second‐order factor of the scale SPC (0.977) and each factor of the four self‐efficacy scales. Alpha values ranged from 0.861 to 0.945 for factors of LPC/midline, 0.855 to 0.946 for PICC and 0.888– to 0.9303 for port. Omega coefficient values ranged from 0.843 to 0.933 for factors of LPC/midline, 0.833 to 0.932 for PICC and 0.862 to 0.899 for port. Both alpha and omega coefficients showed excellent internal consistency (Table 5).
6. DISCUSSION
This study aimed to develop and psychometrically test INVAD, an instrument to assess nurses' evidence‐based knowledge and self‐efficacy regarding the insertion and management of venous access devices (SPC, LPC and PICC) and the management of port in adult patients. INVAD is a valid and reliable instrument with two sections, knowledge (with five parts, general and device specific) and self‐efficacy (with four device‐specific parts).
The scoring of each part of the knowledge section is computed by totalling the number of correct responses and standardizing the total to 100 to allow comparison between parts with different numbers of items. For each part, higher scores indicate higher levels of nurses' knowledge.
As regards self‐efficacy for LPS/midline, PICC and port, which are multidimensional scales, the score of each factor should be calculated separately. For SPC, a total score can be calculated, in addition to single‐factor scores. The scoring of each factor is calculated by totalling the item scores and standardizing them to 100. Specific formulae to assist in the calculation of standardized scores are provided in Supplementary File 1. For every factor of each device‐specific scale, higher scores mean higher levels of nurses' self‐efficacy.
Compared with previous tools developed for single venous access devices (Osti et al., 2019; Raña‐Rocha et al., 2020; Roslien & Alcock, 2009; Sharour, 2018; Xu et al., 2020) and lacking satisfactory psychometric testing (Buchanan et al., 2023; Raynak et al., 2020), this study provides a valid and reliable measure of both knowledge and self‐efficacy of nurses in the management of four different venous devices.
Overall, most items of the knowledge section were of desirable difficulty and some of them were even excellent. However, several knowledge items were rated as too difficult. This difficulty can be explained by some of them (e.g. #8 General knowledge, technique of discard during blood venous withdrawal; Port #4 and #5, frequencies of flushing and locking; PICC #3, detection of catheter tip localization) because they included new recommendations from the updated guideline (Gorski et al., 2021). Another ‘difficult’ item (#4) was highly specific as it regarded LSPC/midline localization of the catheter tip. In contrast, the difficult items of the SPC section regarding the indications for the use of steel‐winged devices (#4) and the indications for blood withdrawal, which is a controversial issue in Italy, mostly regulated by local policies, (#5) help to identify areas for improvement in nurses' basic knowledge of SPC management. Analysis of the ‘too easy’ items showed that they regarded fundamental notions (e.g. choice of the vein, disinfection, dressing and flushing) that cannot be omitted when evaluating nurses' knowledge of VAD insertion and management, in line with Labeau et al. (2008).
Discrimination power was also excellent or good for most knowledge items. Low discrimination power was shown for the same items classified as too difficult and therefore can be explained by the same reasons related to lack of updated knowledge. In addition, six of eight knowledge items of SPC had low discrimination power and an overall low proportion of correct answers. Although these results are aligned with previous literature (Indarwati et al., 2022; Keleekai et al., 2016; Labeau et al., 2008), it may seem surprising as SPCs are widely used by nurses in most clinical settings. A possible explanation may be linked precisely to the nurses' experience in SPC insertion and management, which, in Italy usually begins in undergraduate practical training, which might lead them to believe they do not need to upgrade their knowledge. This was also shown by the high SPC self‐efficacy scores reported by nurses in this study mirroring the dissonance between objective knowledge and perceived self‐efficacy found in previous studies (Indarwati et al., 2022; Keleekai et al., 2016). These findings underline the usefulness of applying INVAD within healthcare organizations for routine assessments of nurses' competencies and skills about VAD, to maintain or to identify the need to update their knowledge levels by planning targeted interventions for specific areas shown to be lacking.
The structural validity of the self‐efficacy section was confirmed following the model on which it was developed through four CFAs with adequate fit indices and high and significant loadings.
For the self‐efficacy scale regarding port, the item ‘Detection of occlusion’ loaded close to the item ‘Prevention of occlusion’ in both subscales ‘Detection and management of complications’ and ‘Prevention of complications’. This can be explained by nurses' attitudes towards the safety of their patients with VADs (Alanazi et al., 2022), in particular, to prevent occlusion of the VADs that can stay in place for months (Moureau & Chopra, 2016). For SPC, a higher structural factorial model was confirmed, meaning that self‐efficacy for all the procedures regarding SPC is highly correlated. Therefore, it is possible to compute an overall score for self‐efficacy in SPC insertion and management.
Construct validity was also determined as the hypotheses posed to test known group validity, namely that the self‐efficacy of nurses with specific training in VAD management and insertion and of those with extensive experience in caring for patients with VADs would be higher than in nurses with no specific training and with less experience, were confirmed. Excellent reliability was shown for all the factors of the self‐efficacy section through the evaluation of internal consistency.
Therefore, robust validity and reliability testing support the use of INVAD, either in its complete version with four different venous access devices or in a version focused on one or more of the included devices.
6.1. Implications for policy and practice
This new instrument offers notable opportunities for healthcare and nurse managers to evaluate the nurses' competencies and skills in VAD insertion and management (Supplementary File 3). INVAD offers the added value of measuring both knowledge and self‐efficacy in the management of different venous access devices. The new instrument will aid in pinpointing competency gaps and enable the planning of targeted interventions aimed at enhancing clinical performance, thus advancing quality of care and patients' satisfaction (Cooke et al., 2018). The INVAD is also useful to measure effectiveness of educational interventions, allowing an objective comparison of the acquired competencies and skills before and after a professional training course, for instance, within staff development programmes.
By integrating the INVAD into clinical practice, healthcare institutions can provide comprehensive assessments of their nurses' knowledge and self‐efficacy regarding several aspects of venous access, ensuring that nursing performance is proficient and aligned to the recently updated evidence (Gorski et al., 2021; Nickel et al., 2024).
The comprehensiveness and length of the questionnaire may raise concerns regarding its utility. However, the questionnaire's structure and format were intentionally designed to assist and guide users. Extensive feedback from experts and end‐users during the processes of content validity, face validity and pilot testing confirmed that the tool was user friendly and easy to complete.
Moreover, as the device‐specific sections of the INVAD are scored separately, they can be used in a modular way allowing knowledge and self‐efficacy of one or more devices to be assessed, instead of the entire INVAD. For instance, this can be the case for wards or services where a particular VAD is principally used or a new device has been introduced, and nurse managers want to assess the need for training or the effect of an educational course on that VAD.
The Infusion Nursing Society launched an updated version of the standards of VAD in January 2024, when this manuscript was almost ready for publication and we could check and ensure that the specific content included within our tool does not need to be modified as it was not updated (Nickel et al., 2024). The clinical use of this instrument, in line with the recent standards of VAD care (Gorski et al., 2021; Nickel et al., 2024), offers the possibility of improving patient care, raising both individual nurse performance and overall quality of care.
6.2. Strengths and limitations of the study
The strengths of this study were the methodological steps followed for the instrument development (Brancato et al., 2006) and the solid statistical analyses performed. The INVAD was based on a literature review, VAD international guidelines (Gorski et al., 2021) and expert consensus, thus ensuring the inclusion of the most relevant and most recently upgraded VAD management aspects. Besides, the multimodal statistical analysis approach used for its validation, such as the DIF/I, DI and CFA, demonstrates the accuracy of the new instrument in measuring nurses' competencies and skills related to VAD insertion and management.
Some limitations should be considered when interpreting the results of this study. The study was conducted at a national level with a convenience sample that, although representing nurses with heterogeneous individual and organizational characteristics, might not be representative of the entire nursing population. Because the data were collected online, it was not possible to ensure that the knowledge score accurately reflected the nurses' actual knowledge. Consequently, this factor could have influenced the validity and reliability findings of the knowledge questionnaire. However, the low knowledge scores obtained, especially for the items about procedures updated according to recent guidelines, suggest that respondents answered autonomously based on their knowledge. Moreover, the responsiveness of the instrument to changes, for instance, after educational courses, and the stability of the instrument over time, were not assessed.
6.3. Recommendations for further research
Further studies are desirable to test the effectiveness of educational courses about VAD insertion and management through pre–post designs, and stability through test–retest reliability, to further test the psychometric properties of INVAD. International studies are also warranted for cross‐cultural validation of the new instrument.
7. CONCLUSION
This study has developed and psychometrically tested the INVAD, an instrument for assessing nurses' evidence‐based knowledge and self‐efficacy regarding the insertion and management of peripheral and central venous access devices in adult patients. The new instrument shows adequate validity and reliability in investigating the nurses' knowledge and self‐efficacy related to the latest evidence about VAD management, released by the INS (Gorski et al., 2021; Nickel et al., 2024). The study provides healthcare organizations with a useful assessment tool for identifying gaps in nurses' knowledge related to VAD management. INVAD can become a useful guide for continuous educational programmes, orienting the implementation of targeted interventions for identified gaps to improve patients' safety and quality of care.
AUTHOR CONTRIBUTIONS
Michela Piredda: Conceptualization, methodology, investigation, data curation, formal analysis, writing–original draft, writing–review & editing and visualization. Marco Sguanci: Writing–original draft, writing–review & editing and visualization. Maddalena De Maria: Methodology, formal analysis, writing–review & editing and visualization. Giorgia Petrucci: Validation, writing–original draft and visualization. Matteo Usai: Investigation, data curation and visualization. Jacopo Fiorini: Methodology, validation, writing–review & editing and visualization. Maria Grazia De Marinis: Conceptualization, supervision and visualization.
CONFLICT OF INTEREST STATEMENT
The authors have declared no conflict of interest.
STATISTICS
The statistics were checked prior to submission by an expert statistician, namely Dr. Diana Giannarelli, email: diana.giannarelli@policlinicogemelli.it.
Supporting information
Supplementary File 1.
Supplementary File 2.
Supplementary File 3.
ACKNOWLEDGEMENTS
This research received a grant from the Center of Excellence for Nursing Scholarship, CECRI, Rome, Italy (grant number 2.21.14).
Piredda, M. , Sguanci, M. , De Maria, M. , Petrucci, G. , Usai, M. , Fiorini, J. , & De Marinis, M. G. (2024). Nurses' evidence‐based knowledge and self‐efficacy in venous access device insertion and management: Development and validation of a questionnaire. Nursing Open, 11, e2177. 10.1002/nop2.2177
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
REFERENCES
- Alanazi, F. K. , Sim, J. , & Lapkin, S. (2022). Systematic review: Nurses' safety attitudes and their impact on patient outcomes in acute‐care hospitals. Nursing Open, 9(1), 30–43. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Alexandrou, E. , Ray‐Barruel, G. , Carr, P. J. , Frost, S. A. , Inwood, S. , Higgins, N. , Lin, F. , Alberto, L. , Mermel, L. , & Rickard, C. M. (2018). Use of short peripheral intravenous catheters: Characteristics, management, and outcomes worldwide. Journal of Hospital Medicine, 13(5), E1–E7. [DOI] [PubMed] [Google Scholar]
- Aloush, S. (2018). Educating intensive care unit nurses to use central venous catheter infection prevention guidelines: Effectiveness of an educational course. Journal of Research in Nursing, 23(5), 406–413. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Austin, E. D. , Sullivan, S. B. , Whittier, S. , Lowy, F. D. , & Uhlemann, A.‐C. (2016). Peripheral intravenous catheter placement is an underrecognized source of Staphylococcus aureus bloodstream infection. Open Forum Infectious Diseases, 3(2), 1–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Badger, J. (2019). Long peripheral catheters for deep arm vein venous access: A systematic review of complications. Heart & Lung, 48(3), 222–225. [DOI] [PubMed] [Google Scholar]
- Bandura, A. , Freeman, W. H. , & Lightsey, R. (1999). Self‐efficacy: The exercise of control. Journal of Cognitive Psychotherapy, 13(2), 158–166. [Google Scholar]
- Bentler, P. M. , & Hu, L. (1998). Fit indices in covariance structure modeling: Sensitivity to underparameterized model misspecification. Psychological Methods, 3(4), 424–453. [Google Scholar]
- Brancato, G. , Macchia, S. , Murgia, M. , Signore, M. , Simeoni, G. , Blanke, K. , Korner, T. , Nimmergut, A. , Lima, P. , Paulino, R. , & Jürgen, H.‐Z. (2006). Handbook of recommended practices for Questionnarie development and testing in European statistical systems European Commission Grant Agreement. In European Statistical System.
- Browne, M. W. , & Cudeck, R. (1992). Alternative ways of assessing model fit. Sociological Methods & Research, 21(2), 230–258. [Google Scholar]
- Buchanan, C. , Burt, A. , Moureau, N. , Murray, D. , & Nizum, N. (2023). Registered nurses' Association of Ontario (RNAO) best practice guideline on the assessment and management of vascular access devices. The Journal of Vascular Access, 1–14. [DOI] [PubMed] [Google Scholar]
- Cicolini, G. , Simonetti, V. , Comparcini, D. , Labeau, S. , Blot, S. , Pelusi, G. , & Di Giovanni, P. (2014). Nurses' knowledge of evidence‐based guidelines on the prevention of peripheral venous catheter‐related infections: A multicentre survey. Journal of Clinical Nursing, 23(17–18), 2578–2588. [DOI] [PubMed] [Google Scholar]
- Cooke, M. , Ullman, A. J. , Ray‐Barruel, G. , Wallis, M. , Corley, A. , & Rickard, C. M. (2018). Not “just” an intravenous line: Consumer perspectives on peripheral intravenous cannulation (PIVC). An international cross‐sectional survey of 25 countries. PLoS One, 13(2), e0193436. [DOI] [PMC free article] [PubMed] [Google Scholar]
- de Vasconcelos Pina, T. , da CunhaCosta, N. C. , Barros Ferreira, E. , & Silva Rocha, P. R. (2023). Complications of peripherally inserted central catheter: Integrative review. Revista de Enfermagem UFPE on Line, 17(1): 210–228. [Google Scholar]
- Esposito, M. R. , Guillari, A. , & Angelillo, I. F. (2017). Knowledge, attitudes, and practice on the prevention of central line‐associated bloodstream infections among nurses in oncological care: A cross‐sectional study in an area of southern Italy. PLoS One, 12(6), 1–11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Fernández‐Ruiz, M. , Carretero, A. , Díaz, D. , Fuentes, C. , González, J. I. , García‐Reyne, A. , Aguado, J. M. , & López‐Medrano, F. (2014). Hospital‐wide survey of the adequacy in the number of vascular catheters and catheter lumens. Journal of Hospital Medicine, 9(1), 35–41. [DOI] [PubMed] [Google Scholar]
- Fiorini, J. , Piredda, M. , Zaghini, F. , Venturini, G. , Colella, S. , Conti, F. , Denton, A. , & Sili, A. (2021). Vessel health and preservation: Development and validation of a proactive instrument. Collegian, 28(5), 528–533. [Google Scholar]
- Gorski, L. A. , Hadaway, L. , Hagle, M. E. , Broadhurst, D. , Clare, S. , Kliedon, T. , Meyer, B. M. , Nickel, B. , Rowley, S. , Sharpe, E. , & Alexander, M. (2021). 2021 infusion therapy standards of practice updates. Journal of Infusion Nursing, 44(4), 189–190. [DOI] [PubMed] [Google Scholar]
- Gottlieb, M. , Chan, T. M. , Zaver, F. , & Ellaway, R. (2022). Confidence‐competence alignment and the role of self‐confidence in medical education: A conceptual review. Medical Education, 56(1), 37–47. [DOI] [PubMed] [Google Scholar]
- Guilbert, J. J. (1981). Educational handbook for health personnel. Revised edition. WHO Offset Publication, 35, 1–330. [PubMed]
- Hoyle, R. H. (1995). The structural equation modeling approach: Basic concepts and fundamental issues. In I. SAGE Publications Inc., Structural equation modeling: Concepts, issues, and applications (pp. 1–15). [Google Scholar]
- Hu, L. T. , & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling, 6(1), 1–55. [Google Scholar]
- Hunter, M. R. , Vandenhouten, C. , Raynak, A. , Owens, A. K. , & Thompson, J. (2018). Addressing the silence: A need for peripheral intravenous education in North America. Journal of the Association for Vascular Access, 23(3), 157–165. [Google Scholar]
- Indarwati, F. , Munday, J. , & Keogh, S. (2022). Nurse knowledge and confidence on peripheral intravenous catheter insertion and maintenance in pediatric patients: A multicentre cross‐sectional study. Journal of Pediatric Nursing, 62, 10–16. [DOI] [PubMed] [Google Scholar]
- Indarwati, F. , Munday, J. , & Keogh, S. (2023). Peripheral intravenous catheter insertion, maintenance and outcomes in Indonesian paediatric hospital settings: A point prevalence study. Journal of Pediatric Nursing, 73(February), 106–112. [DOI] [PubMed] [Google Scholar]
- Jeffery, A. D. , & Pickler, R. H. (2014). Barriers to nurses' adherence to central venous catheter guidelines. JONA: The Journal of Nursing Administration, 44(7/8), 429–435. [DOI] [PubMed] [Google Scholar]
- Keleekai, N. L. , Schuster, C. A. , Murray, C. L. , King, M. A. , Stahl, B. R. , Labrozzi, L. J. , Gallucci, S. , LeClair, M. W. , & Glover, K. R. (2016). Improving nurses' peripheral intravenous catheter insertion knowledge, confidence, and skills using a simulation‐based blended learning program. Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, 11(6), 376–384. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Labeau, S. , Vereecke, A. , Vandijck, D. M. , Claes, B. , & Blot, S. I. (2008). Critical care nurses' knowledge of evidence‐based guidelines for preventing infections associated with central venous catheters: An evaluation questionnaire. American Journal of Critical Care, 17(1), 65–71. [PubMed] [Google Scholar]
- Lafuente Cabrero, E. , Terradas Robledo, R. , Civit Cuñado, A. , García Sardelli, D. , Hidalgo López, C. , Giro Formatger, D. , Lacueva Perez, L. , Esquinas López, C. , & Tortosa Moreno, A. (2023). Risk factors of catheter‐ associated bloodstream infection: Systematic review and meta‐analysis. PLoS One, 18(3), e0282290. [DOI] [PMC free article] [PubMed] [Google Scholar]
- MacCallum, R. C. , Widaman, K. F. , Zhang, S. , & Hong, S. (1999). Sample size in factor analysis. Psychological Methods, 4(1), 84–99. [Google Scholar]
- Marsh, N. , Webster, J. , Larsen, E. , Cooke, M. , Mihala, G. , & Rickard, C. M. (2018). Observational study of peripheral intravenous catheter outcomes in adult hospitalized patients: A multivariable analysis of peripheral intravenous catheter failure. Journal of Hospital Medicine, 13(2), 83–89. [DOI] [PubMed] [Google Scholar]
- Matey, L. , & Camp‐Sorrell, D. (2016). Venous access devices: Clinical rounds. Asia‐Pacific Journal of Oncology Nursing, 3(4), 357–364. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Matlock‐Hetzel, S. (1997). Basic concepts in item and test analysis. Annual Meeting of the Southwest Educational Research Association, 1–22. [Google Scholar]
- Meyer, B. M. , Berndt, D. , Biscossi, M. , Eld, M. , Gillette‐Kent, G. , & Malone, A. (2020). Vascular access device care and management: A comprehensive organizational approach. Journal of Infusion Nursing, 43(5), 246–254. [DOI] [PubMed] [Google Scholar]
- Mokkink, L. B. , Terwee, C. B. , Patrick, D. L. , Alonso, J. , Stratford, P. W. , Knol, D. L. , Bouter, L. M. , & de Vet, H. C. W. (2010). The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: An international Delphi study. Quality of Life Research, 19(4), 539–549. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Morrell, E. (2020). Reducing risks and improving vascular access outcomes. Journal of Infusion Nursing, 43(4), 222–228. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Moureau, N. L. , & Chopra, V. (2016). Indications for peripheral, midline and central catheters: Summary of the MAGIC recommendations. British Journal of Nursing, 25(8), S15–S24. [DOI] [PubMed] [Google Scholar]
- Muthén, L. K. , & Muthén, B. (2012). Mplus user's guide (version 7.0). Los Angeles: Muthén & Muthén10. [Google Scholar]
- Nickel, B. , Gorski, L. , Kleidon, T. , Kyes, A. , DeVries, M. , Keogh, S. , Meyer, B. , Sarver, M. J. , Crickman, R. , Ong, J. , Clare, S. , & Hagle, M. E. (2024). Infusion therapy standards of practice, 9th Edition. Journal of Infusion Nursing, 47(1S), S1–S285. [DOI] [PubMed] [Google Scholar]
- Osti, C. , Khadka, M. , Wosti, D. , Gurung, G. , & Zhao, Q. (2019). Knowledge and practice towards care and maintenance of peripheral intravenous cannula among nurses in Chitwan Medical College Teaching Hospital, Nepal. Nursing Open, 6(3), 1006–1012. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Piredda, M. , Biagioli, V. , Barrella, B. , Carpisassi, I. , Ghinelli, R. , Giannarelli, D. , & De Marinis, M. G. (2017). Factors affecting difficult peripheral intravenous cannulation in adults: A prospective obervational study. Journal of Clinical Nursing, 26(7), 1074–1084. [DOI] [PubMed] [Google Scholar]
- Piredda, M. , Fiorini, J. , Facchinetti, G. , Biagioli, V. , Marchetti, A. , Conti, F. , Iacorossi, L. , Giannarelli, D. , Matarese, M. , & De Marinis, M. G. (2019). Risk factors for a difficult intravenous access: A multicentre study comparing nurses' beliefs to evidence. Journal of Clinical Nursing, 28(19–20), 3492–3504. [DOI] [PubMed] [Google Scholar]
- Polit, D. F. , Beck, C. T. , & Owen, S. V. (2007). Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Research in Nursing & Health, 30, 459–467. [DOI] [PubMed] [Google Scholar]
- Raña‐Rocha, R. , López‐de‐Ullibarri, I. , Movilla‐Fernández, M.‐J. , & Carvajal, C. C. (2020). Validation of a questionnaire of knowledge and attitudes about the subcutaneous venous reservoir in nursing. Revista Latino‐Americana de Enfermagem, 28, 1–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Raykov, T. (2012). Scale construction and development using structural equation modeling. In Handbook of structural equation modeling (pp. 472–492). Guilford Press. [Google Scholar]
- Raynak, A. , Paquet, F. , Marchionni, C. , Lok, V. , Gauthier, M. , & Frati, F. (2020). Nurses' knowledge on routine care and maintenance of adult vascular access devices: A scoping review. Journal of Clinical Nursing, 29(21–22), 3905–3921. [DOI] [PubMed] [Google Scholar]
- Revelle, W. , & Zinbarg, R. E. (2009). Coefficients alpha, beta, omega, and the glb: Comments on sijtsma. Psychometrika, 74(1), 145–154. [Google Scholar]
- Roslien, J. , & Alcock, L. (2009). The effect of an educational intervention on the RN's peripherally inserted central catheters knowledge, confidence, and psychomotor skill. Journal for Nurses in Staff Development (JNSD), 25(3), E19–E27. [DOI] [PubMed] [Google Scholar]
- Sharour, L. A. (2018). Oncology nurses' knowledge about central line catheter: Caring, complications, and applications among cancer patients—A cross‐sectional study. Journal of Vascular Nursing, 36(3), 145–148. [DOI] [PubMed] [Google Scholar]
- Simonetti, V. , Comparcini, D. , Miniscalco, D. , Tirabassi, R. , Di Giovanni, P. , & Cicolini, G. (2019). Assessing nursing students' knowledge of evidence‐based guidelines on the management of peripheral venous catheters: A multicentre cross‐sectional study. Nurse Education Today, 73(November 2018), 77–82. [DOI] [PubMed] [Google Scholar]
- Tabachnick, B. G. , & Fidell, L. S. (2019). Using multivariate statistics. In Pearson education, Inc (7th ed.). Springer US. [Google Scholar]
- Van Loon, F. H. J. , van Hooff, L. , de Boer, H. , Koopman, S. , Buise, M. , Korsten, H. , Dierick‐van Daele, A. , & Bouwman, A. (2019). The modified A‐DIVA scale as a predictive tool for prospective identification of adult patients at risk of a difficult intravenous access: A multicenter validation study. Journal of Clinical Medicine, 8(2), 144. [DOI] [PMC free article] [PubMed] [Google Scholar]
- World Medical Association . (2013). Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA: The Journal of the American Medical Association, 310(20), 2191–2194. [DOI] [PubMed] [Google Scholar]
- Xu, B. , Zhang, J. , Hou, J. , Ma, M. , Gong, Z. , & Tang, S. (2020). Nurses' knowledge of peripherally inserted central catheter maintenance and its influencing factors in Hunan province, China: A cross‐sectional survey. BMJ Open, 10(5), e033804. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Yousif, K. , Abu‐Aisha, H. , & Abboud, O. (2017). The effect of an educational program for vascular access care on nurses' knowledge at dialysis centers in Khartoum state, Sudan. Saudi Journal of Kidney Diseases and Transplantation, 28(5), 1027–1033. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary File 1.
Supplementary File 2.
Supplementary File 3.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.