The Impact of a Collaborative Learning Intervention on Nurses' Knowledge and Practice in Hemodialysis Vascular Access Care: A Randomized Controlled Trial

ABSTRACT

Background and Aim

Hemodialysis vascular access is a critical requirement for patients with End Stage Kidney Disease. Hemodialysis nurses play a crucial role in maintaining the quality and efficiency of vascular access care. Structured educational interventions are crucial for enhancing nurses' knowledge and practice in providing safe care. This study aimed to evaluate the effectiveness of an educational intervention based on the Collaborative Approach and Learning Cooperatives (CALC) Model on nurses' knowledge and practice in hemodialysis vascular access care.

Methods

This single‐blinded randomized controlled trial (RCT) was conducted in 2021 at two major teaching hospitals affiliated with Urmia University of Medical Sciences. In this study, a total of 50 hemodialysis nurses were recruited using convenience sampling and randomly allocated to either an intervention group (n = 25) or a control group (n = 25). Data were collected at three time points: before, 1 month and 2 months after the intervention using a demographic questionnaire, a nurses' knowledge of vascular access questionnaire and a checklist of vascular access care techniques. The intervention group received education based on the CALC model. The chi‐square test, independent t‐test, paired t‐test, and repeated measure ANOVA were used to analyze the data.

Results

Analysis of variance revealed a significant difference in the mean practice scores 1 month and 2 months after the educational intervention based on the CALC model between the intervention and control groups (p < 0.001). Similarly, a significant difference was found in the mean knowledge scores at 1 month and 2 months after the intervention between the two groups (p < 0.001). However, no significant differences in average practice and knowledge scores were observed between the two groups before the intervention.

Conclusion

This study highlights the efficacy of the CALC model as an educational intervention in enhancing nurses' knowledge and practice regarding to hemodialysis vascular access care. Consequently, the implementation of this approach in clinical nursing education is recommended to promote evidence‐based practice and support continuous professional development.

1. Introduction

Chronic kidney disease (CKD) is a progressive condition characterized by structural and functional alterations in renal physiology [1]. It is one of the leading noncommunicable diseases globally, with an estimated prevalence that is continuously increasing, ranging from 11% to 13% [2]. It is projected to be the fifth leading cause of years of life lost by 2040, with mortality from the disease increasing steadily to 14 deaths per 100,000 in the general population by 2030 [3, 4] The prevalence of CKD in the United States increased from 12.8% (1280 per million) in 2000% to 23.8% (2382 per million) in 2018 [5] and in Iran, its prevalence is 10.83 per million [6].

Hemodialysis (HD) has emerged as a standard and life‐saving therapeutic modality for individuals with End‐Stage Kidney Disease (ESKD) [7]. Due to the increasing prevalence of CKD and the growing emphasis on patient safety and care quality, nephrology nurses are required to uphold professional responsibility by maintaining competence to deliver consistently high standards of care. Regarding specific core competencies for nephrology nurses, these can be divided into four domains: inpatient and pre‐dialysis, hemodialysis, peritoneal dialysis, and transplantation [8]. In the context of hemodialysis, one of the key competencies is comprehensive management of vascular access [9], including aspects such as cannulation of fistulas and grafts, accessing central lines, dressings, medications, intravenous push medications, intravenous insertion/infusion, and removing temporary central venous catheters [10]. The successful implementation of HD necessitates the establishment and maintenance of vascular access [11]. hemodialysis vascular access care has a profound impact on the patients' dialysis and overall quality of life [12]. Vascular access assessment constitutes a central responsibility for hemodialysis nurses, who play a unique role in preserving the functionality and safety of hemodialysis vascular access [13]. Therefore, the delivery of appropriate and standardized nursing care is imperative to preserve vascular access functionality and mitigate potential complications [14]. Also, insufficient nursing knowledge regarding preventive measures and infection control can lead to adverse patient outcomes, including heightened infection rates, increased mortality, and prolonged hospital stays [15]. Consequently, advanced training for hemodialysis nurses is indispensable for improving clinical outcomes for patient with CKD across various levels and clinical settings [8]. Particularly, ongoing nursing education programs tailored to vascular access care are important for enhancing nurses' knowledge and skill. Innovative educational methods by prioritizing the optimization of nursing care practices are effective in improving the knowledge and practice of nurses in hemodialysis vascular access care and can improve patient outcomes, enhance quality of life, and minimize the burden of complications associated with vascular access. These educational initiatives should be well‐structured, readily accessible within hemodialysis units, and equipped with appropriate educational resources [16]. The Collaborative Approach and Learning Cooperatives (CALC) model is one of the collaborative educational methods that can be fundamental for nursing and clinical education by promoting the knowledge of evidence‐based care and plays a significant role in updating the knowledge of nurses and providing safe care for patients. This systematic, calculated approach promotes a two‐way learning method and facilitates a cooperative learning environment involving the knowledge of evidence based practice for both nursing students and nurses [17].

In conclusion, the CALC model represents a distinct and purposeful evolution of traditional collaborative learning methods in nursing education. By introducing a systematic, phase‐based structure, centering the application of evidence‐based practice as the primary outcome, and establishing formalized, bidirectional learning between academic nursing students/faculty and practicing clinical nurses, CALC transcends conventional, often unstructured or single‐group collaborative approaches.

Most importantly, it directly addresses a critical and previously persistent gap in the literature: the absence of collaborative educational interventions that simultaneously engage university and hospital stakeholders to enhance evidence‐based knowledge and clinical practice in specialized, high‐risk areas such as hemodialysis vascular access care.

Therefore, CALC is not merely a collaborative pedagogy, but a replicable, theory‐driven implementation model specifically designed to accelerate the translation of evidence into practice, bridge the persistent academic–clinical divide, and ultimately improve patient safety and clinical outcomes.

The quality of nursing care and the depth of nurses' knowledge are critical determinants of hemodialysis vascular access survival and functional efficacy. While collaborative learning is increasingly recognized as an effective pedagogical strategy within nursing education to address such clinical challenges, a review of the literature revealed a significant gap: no studies were identified that utilized a collaborative learning approach engaging both university nursing faculty and hospital clinical staff to enhance evidence‐based knowledge in vascular access care. This gap is particularly salient given the clinical observations of the primary researcher, a nephrology nurse, who noted frequent vascular access complications. Therefore, this study aimed to determine the impact of an educational intervention based on the Collaborative Approach and Learning Cooperatives (CALC) Model on nurses' knowledge and practice in hemodialysis vascular access care.

2. Methodology

2.1. Study Design and Setting

This single‐blinded, randomized controlled trial was conducted in two major teaching hospitals (Imam Khomeini and Taleghani) affiliated with Urmia University of Medical Sciences in Urmia, Iran in 2021.

2.2. Participants and Sample Size

This study utilized a convenience sampling method. The required sample size was determined using data from Bahram Nejad & NematiKhah [18] 2017, which reported mean scores (±SD) of 11.69 ± 1.59 (intervention group) and 10.85 ± 1.47 (control group). With a 95% confidence interval and test power, the minimum sample size per group was calculated as 20 using the specified formula:

(α = 0.05, 1‐ β = 0.8,$\mu ₁-\mu ₂=$ 1.31, δ = 1.415)

$$\mathrm{n}=\frac{2{\delta }^2{(Z_{1-\frac{\alpha }{2}}+Z\mathrm{₁}\mathrm{₋}\beta )}^2}{{(\mu \mathrm{₁}-\mu \mathrm{₂})}^2}$$

$${\mathrm{n}}_1={\mathrm{n}}_2=\frac{2\times {(1·415)}^2{(1·96+0·84)}^2}{{(1·31)}^2}\cong 20$$

Regarding the attrition rate of 25%, the final sample size was considered to be 25 per group.

2.3. Inclusion and Exclusion Criteria

The inclusion criteria were as follows: (1) willingness to participate in the study, (2) a minimum of 3 months of work experience in the hemodialysis unit, (3) having a bachelor's (BSN) degree or higher, (4) direct responsibility for patient care. Nurses with the following characteristics were excluded from the study: (1) participant reluctance to continue cooperation for any reason and (2) transfer out of the hemodialysis unit during the study period.

2.4. Data Collection

Data were collected using three instruments: a demographic questionnaire, a nurses' knowledge of hemodialysis vascular access questionnaire, and a checklist of vascular access care techniques.

2.5. Demographic Questionnaire

This questionnaire collected data on age, gender, marital status, education level, work experience, and work experience in the hemodialysis departments.

2.6. Researcher‐Made Questionnaire on Nurses' Knowledge of Vascular Access

A questionnaire measuring nurses' knowledge of vascular access was constructed based on the clinical practice guidelines for vascular access [19]. It consisted of 30 multiple‐choice questions, with 15 questions related to arteriovenous fistula, 6 questions related to central venous catheter, 4 questions related to arteriovenous graft, and 5 questions related to infection control in vascular access. Each correct answer received 1 point, and each wrong answer received 0 points. Thus, scores ranged from 0 to 30. Scores were categorized as undesirable (0−10), moderate (11–20), or desirable (21–30). The average scores were of interest in this study.

To determine the scientific validity of the questionnaire on nurses' knowledge of hemodialysis vascular access, qualitative content validity and quantitative content validity methods were used. It was confirmed by 10 experts, including 6 faculty members of the School of Nursing and Midwifery who had experience working in hemodialysis and nephrology units, 2 nurses from the hemodialysis departments (managers of the hemodialysis centers of Imam Khomeini and Taleghani hospitals with over 10 years of work experience), and 2 nephrologists. Internal consistency reliability, calculated using the Kuder‐Richardson formula 20 (KR‐20) coefficient, was 0.85, indicating high reliability [20].

2.7. Checklist for Vascular Access Care Techniques

The checklist includes 14 items about vascular access care techniques while connecting the patients to the machine, such as observing aseptic technique, wearing gloves, wearing a mask, heparin bolus injection, appropriate priming, closing the end of the venous line while connecting the patient to the machine, adjusting the correct dose of heparin based on the physician's order, closing one line while washing the other line, closing the end of arterial catheter while disconnecting the patient from the machine, using a sterile dressing on the catheter site, the rate of blood flow at the start of hemodialysis, the distance of needle entrance from fistula, correct needling, and needling of the aneurysm. Four of the above mentioned items were related to AVF (the rate of blood flow at the start of the hemodialysis, the distance of needle entrance from fistula, correct needling and needling of the aneurysm) and four items were related to CVC (closing one line while washing the other line, closing the end of arterial catheter while disconnecting the patient from the machine, closing the end of the venous line while connecting the patient to the machine, using a sterile dressing on the catheter site). The first six items were observed for the both groups. A score of 1 was allocated for a “yes” response (indicating correct performance), and a score of 0 for a “no” response (indicating the care was not performed or was performed incorrectly). The score range for both types of vascular access was 0–10. The minimum score was 0, and the maximum score was 10. Care quality was divided into desirable, average, and undesirable categories. Obtaining a score of 0%–50% represented undesirable care quality, 51%–75% represented average care quality, and 76%–100% represented desirable care quality [21]. In the current study, the practice score for each nurse was based on their average scores in three observations of vascular access care techniques.

The content validity of the care techniques checklist was confirmed in a previous study [21] by 10 professors of the Nursing School and 6 trainers, nurses, and experienced physicians from the hemodialysis units in Kashan and Isfahan, and its reliability was confirmed through inter‐rater reliability with a value of 0.96. Furthermore, the content validity of the modified checklist was approved in the other study [22] by eight faculty members of Nursing Faculty of Kashan, Iran, and two experienced nurses of hemodialysis unit of Kashan. Moreover, to evaluate the interrater reliability of this instrument, two nurses (researcher and another trained nurse) filled out the checklist for four patients. In the current study, inter‐rater reliability was estimated to be 0.85‐1 (mean = 0.92) for each item of the checklist.

2.8. Ethical Considerations

All stages of this study involving human participants adhered to the principles outlined in the Declaration of Helsinki. Ethical approval for conducting the research was obtained from the Research Ethics Committee of Urmia University of Medical Sciences, under approval code IR. UMSU. REC.1400.010. The study was also registered in the Iranian Registry of Clinical Trials (IRCT) (Registration No: IRCT20161008030214N3).

Participation in this study was entirely voluntary and written informed consent was obtained from nurses after they were thoroughly informed about the study's objectives and procedures. Furthermore, they were assured of the confidentiality and anonymity of personal information.

2.9. Intervention Protocol

From the total of 55 nurses working in the hemodialysis wards of Imam Khomeini and Taleghani hospitals who met the study's inclusion criteria, 50 nurses were selected. Participants were then randomly allocated to either the control or intervention group. Each eligible nurse was assigned a unique number ranging from 1 to 50. These numbers were placed into an opaque envelope. The researcher then randomly drew one number from the envelope at a time, alternately assigning the selected nurse to the control group and the next to the intervention group. This process continued until 25 nurses were assigned to each group (Figure 1).

Figure 1.

Flow diagram of the study selection process.

2.10. The Intervention was Conducted in Three Phases

Stage 1: After introducing themselves and outlining the objectives and methodology to the participants, the researcher obtained written consent from them to participate in the study. At this stage, the pre‐test questionnaires, which included a demographic information questionnaire and nurses' knowledge of vascular access, were explained to the nurses in the control group, and then the questionnaires were completed in the presence of the researcher. The observation of vascular access care practice for three patients per nurse during different work shifts was conducted by the observer (researcher) utilizing the checklist for vascular access care techniques. In other words, each nurse was observed three times during different work shifts. Additionally, to account for the potential influence of the researcher's presence on the nurses' practice, the observer remained present in the department for extended periods and across different work shifts, ensuring continuous observation of the nurses' actual practice while simultaneously to minimize and account for any potential Hawthorne effect (where behavior changes due to observation). The control group was not provided with any education and post‐test questionnaires were completed one and 2 months after the pre‐tests.

Stage 2: Following the initial data collection from the control group, the intervention phase commenced with the nurses in the intervention group. Initially, the pre‐test questionnaires, which included the demographic questionnaire and nurses' knowledge of vascular access, were explained to the intervention group nurses and completed in the presence of the researcher. The observation of vascular access care practice, using the same checklist as the control group, was also carried out. Subsequently, the intervention began in this group, based on the “CALC” model.

The CALC Model is designed to foster collaboration between faculty and hospital administrators, enhance small‐group learning for undergraduate nursing students, and promote evidence‐based care knowledge among nurses. The implementation of this model proceeded as follows:

Under the nursing internship program, undergraduate nursing students in the seventh and eighth terms were divided into groups of 7 to 8 members. Each group attended four training sessions held in one of the classrooms at Imam Khomeini Hospital, with each session lasting from 1.5 to 2 h. The workshop instructors consisted of the researcher, a faculty advisor, and two members of the nursing faculty. In the first session, the discussion focused on the importance of vascular access care in hemodialysis patients with chronic kidney disease and the role of nursing students as individuals who can provide safe care based on the latest scientific evidence. The second session emphasized the importance of evidence‐based nursing. The steps of evidence‐based nursing practice, search strategies in online databases and the use of guidelines and how to design a focused clinical question using the PICOT approach were also taught to the students. In the third session, students were divided into small groups of 3 to 4 individuals to enhance cooperative learning. Each group was assigned a clinical issue, derived from real clinical cases discussed by hemodialysis nurses regarding the care of vascular access. They were asked to design a clinical question using the PICOT approach. Consequently, four clinical questions were designed in the field of preventing bloodstream infections related to central venous catheters, proper cannulation of AV fistula and physical examination of AV fistula by nurses. Over the following 2 weeks, students conducted a literature search using relevant PICOT keywords based on the latest evidence presented in scientific texts. After critically evaluating the obtained studies, they summarized, synthesized, and critically appraised the findings, creating a comprehensive literature review which was then summarized into a standardized poster format. The fourth session was conducted for all student groups, where a total of eight posters were prepared. Each group presented their latest evidence related to their clinical question, which was then discussed and reviewed collectively. In this way, the best evidence in the care of vascular access in hemodialysis was shared among the student groups (Table 1).

Table 1.

Content and Structure of the Educational Intervention for Nursing Students.

Session	Educational stages	Objectives	Content & Activities
1	Introduction & Orientation	✓ Establish learning objectives ✓ Highlight the critical role of evidence‐based nursing care in vascular access for chronic kidney disease patients ✓ Emphasize nursing students’ capacity in integrating current evidence into safe practice	Introduction to the course and participants Discussion on the significance of nursing care for vascular access Explanation of students’ role in accessing, appraising, and applying latest evidence Q&A session
2	Knowledge Building & Skill Development	✓ Introduce evidence‐based nursing (EBN) principles ✓ Teach steps of EBN and efficient search strategies in online databases ✓ Instruct students on formulating clinical questions using PICOT framework	Lecture and interactive discussion on EBN Demonstration of database search techniques Practical workshop on PICOT question development Q&A session
3	Collaborative Learning & Application	✓ Facilitate small‐group work and clinical question design ✓ Promote collaborative learning and critical thinking	Division into small groups (3–4 students) Assignment of vascular access‐related clinical topics Group development of PICOT questions Facilitated Q&A and guidance
4	Self‐Directed Learning & Synthesis	✓ Enable independent literature search and evidence synthesis ✓ Foster skills in critical appraisal and scientific communication	Two‐week period for independent research Student‐led search using keywords from PICOT questions Critical appraisal and summary of findings Preparation of a scientific poster
5	Knowledge Sharing & Consolidation	✓ Share and discuss evidence findings across groups ✓ Promote collective learning and integration of best evidence	Group presentations of poster findings Critical discussion and comparison of evidence Identification and agreement on best evidence for vascular access care Reflective Q&A

Note: PICOT = Population, Intervention, Comparison, Outcome, Time framework; EBN = Evidence‐Based Nursing.

After completing the training sessions for nursing students, the posters prepared by the student groups regarding the care of vascular access in hemodialysis were reviewed and evaluated in a session attended by two members of the nursing faculty and educational supervisors from selected hospitals. The posters were evaluated and scored by the faculty and supervisors using a standardized checklist. Finally, four posters with the highest scores according to the checklist criteria were selected as the top four posters. Subsequently, to disseminate the latest evidence in vascular access care to hemodialysis nurses, top four posters were displayed in the hemodialysis departments of Imam Khomeini and Taleghani hospitals.

The nurses in the intervention group were divided into groups of 7–8 members. Four training sessions were held for each group over the course of 1 week. The training sessions took place between the connection and disconnection of the patient from the hemodialysis device. Each training session lasted for 45–60 min. In each group, the content of the posters prepared by nursing students based on the latest scientific evidence based regarding the care of hemodialysis vascular access, supplemented with additional evidence and clinical insights on the same topics, were presented to the nurses using a participatory learning approach.

Stage 3: 1 month after the implementation of the intervention based on the CALC model, knowledge was assessed in the intervention group using the vascular access questionnaire, and practice was evaluated using the care techniques checklist. Additionally, a follow‐up evaluation was conducted 2 months after the intervention to assess the sustainability of knowledge and the quality of care for vascular access using the same tools. Upon completion of the study, the same educational intervention was provided to nurses in the control group.

2.11. Data Analysis

All data were entered into IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, N.Y., USA). The Kolmogorov–Smirnov test was used to examine the normality of data distribution. Data were analyzed using descriptive and inferential statistics. In descriptive statistics, we used the frequency and percentage for analyzing qualitative variables and the mean and standard deviation for describing normally distributed quantitative variables. For inferential statistics, the chi‐squared (χ²) test and Fisher's exact test were applied to assess group homogeneity. Finally, the repeated measure analysis of variance (RM‐ANOVA) was used for in‐group comparisons of normally distributed parameters. A p‐value of less than 0.05 was considered statistically significant for all analyses.

3. Results

3.1. Demographic Characteristics

According to the results of this study, the mean age of participations in the control group was 36.48 ± 8.75 years, while the mean age in the intervention group was 33.36 ± 6.48 years. The results of the χ² test and independent t‐test showed that there was no statistically significant difference between the two groups in terms of quantitative and qualitative demographic characteristics (p < 0.05). In other words, both groups were homogeneous in terms of demographic characteristics (Table 2) All participating nurses held a bachelor's degree.

Table 2.

Comparison of demographic characteristics of the Nurses in the study groups.

Variables		Groups		Results of the Chi‐squared test
		Control n (%)	Intervention n (%)
Gender	Male	6 (37.5)	10 (62.5)	χ2 = 1.471 p‐value = 0.23
	Female	19 (55.9)	15 (44.1)
Marital status	Single	9 (47.4)	10 (52.6)	χ2 = 0.085 p‐value = 0.77
	Married	16 (51.6)	15 (48.4)
Age		Control	Intervention	Results of the Independent sample t‐test t = 1.432 p‐value = 0.16
		Mean ± SD	Mean ± SD
		36.48 ± 8.75	33.36 ± 6.48
Work Experience		13.00 ± 8.24	9.96 ± 6.51	t = 1.447 p‐value = 0.15
Work experience in the hemodialysis ward		7.64 ± 6.13	6.60 ± 4.67	t = 0.675 p‐value = 0.50

Abbreviations: SD, Standard Deviation, χ2, Chi‐squared test.

3.2. Nurses' Hemodialysis Vascular Access Competencies (Knowledge, Practice)

The results of the Kolmogorov–Smirnov test indicated that the scores for knowledge and practice were normally distributed across all measurement time points (p > 0.05).

In the intervention group the mean scores of nurses' knowledge of vascular access in hemodialysis at baseline, 1 month and 2 months after the intervention were 18.00 ± 2.30, 27.32 ± 1.86, and 27.32 ± 1.85 and in the control group were 17.04 ± 2.63, 17.12 ± 2.10, and 17.04 ± 2.05 (Table 3).

Table 3.

Mean scores of nurses’ knowledge and practice in the control and intervention groups at before intervention,1 month after, and 2 months after the intervention.

Variable	Groups	Before the intervention	One month afterthe intervention	Two months after the intervention
		Mean ± SD	Mean ± SD	Mean ± SD
Knowledge	Control	17.04 ± 2.63	17.12 ± 2.10	17.04 ± 2.05
	Intervention	18.00 ± 2.30	27.32 ± 1.86	27.32 ± 1.85
Practice	Control	5.68 ± 0.67	5.94 ± 0.50	5.95 ± 0.58
	Intervention	6.00 ± 0.56	8.45 ± 0.45	8.53 ± 0.39

Abbreviation: SD, Standard Deviation.

To examine the mean score of nurses' knowledge of vascular access in hemodialysis at three time points between the control and intervention groups, repeated measures ANOVA was used. The results of this analysis showed a significant difference in the mean scores of nurses' knowledge of vascular access in hemodialysis between the intervention and control groups at the three time points (p < 0.001). The main effect of the intervention was significant, F (1, 48) = 222.47, p < 0.001, ηp² = 0.823, indicating a large difference between groups. The main effect of time was also significant, F (2, 96) = 136.80, p < 0.001, ηp² = 0.740, showing scores changed across measurements. Importantly, the time × intervention interaction was significant, F (2, 96) = 134.47, p < 0.001, ηp² = 0.737, meaning the pattern of change over time differed between groups. According to Cohen's criteria, all effect sizes were very large (Table 4).

Table 4.

Comparison of nurses’ knowledge scores between the two groups at three measurement time points based on the repeated measures ANOVA.

Mean scores of nurses’ knowledge	RSS	df	MSE	F	p value	ηp²
The main effect of time	730.120	2	365.06	136.798	< 0.001	0.740
Group × time interaction effect	717.693	2	385.84	134.469	< 0.001	0.737
Error term (time)	256.187	96	2.66	—	—	—
The main effect of the intervention	1915.307	1	1915.307	222.466	< 0.001	0.823
Error term (intervention)	413.253	48	8.609	—	—	—

Abbreviations: ANOVA, Analysis of Variance; df, Degrees of Freedom; MSE, Mean Squared Error; RSS, Residual Sum of Squares; ηp², partial eta‐squared.

In the intervention group the mean scores of nurses' practice in the care of vascular access in hemodialysis at baseline, 1 month and 2 months after the intervention were 6.56 ± 2.30, 8.45 ± 0.45, and 8.53 ± 039 and in the control group were 5.68 ± 0.67, 5.94 ± 0.50, and 5.95 ± 0.58 (Table 3). The results of the repeated measures ANOVA (RM‐ANOVA) test revealed a significant difference in the mean scores of nurses' practice in the care of vascular access in hemodialysis between the intervention and control groups at three measurement time points (p < 0.001). The main effect of the intervention was significant, F (1, 48) = 250.61, p < 0.001, ηp² = 0.865, indicating a large difference between groups. The main effect of time was also significant, F (2, 96) = 138.26, p < 0.001, ηp² = 0.742, showing scores changed across measurements. Importantly, the time × intervention interaction was significant, F (2, 96) = 89.77, p < 0.001, ηp² = 0.652, meaning the pattern of change over time differed between groups. According to Cohen's criteria, all effect sizes were very large (Table 5).

Table 5.

Comparison of nurses’ practice scores between the two groups at three measurement time points based on the repeated measures ANOVA.

Mean scores of nurses’ practice	RSS	df	MSE	F	p value	ηp²
The main effect of time	63.528	2	31.764	138.26	< 0.001	0.742
Group × time interaction effect	41.251	2	20.62	89.77	< 0.001	0.652
Error term (time)	22.054	96	0.230	—	—	—
The main effect of the intervention	122.402	1	122.402	250.605	< 0.001	0.865
Error term (intervention)	19.078	48	0.397	—	—	—

Abbreviations: ANOVA: Analysis of Variance; RSS: Residual Sum of Squares; df = Degrees of Freedom; MSE: Mean Squared Error; ηp²: partial eta‐squared

3.3. Summary of Statistical Tests and Software

Normality of continuous data was evaluated using the Kolmogorov‐Smirnov test. Descriptive statistics are reported as mean ± standard deviation (SD) for continuous variables and as number (percentage) for categorical variables. Inter‐group comparisons were performed using the independent‐samples t‐test for continuous measures and the chi‐square test for categorical measures. To compare the mean scores of nurses' knowledge and practice between the control and intervention groups across three time points (before, 1 month, and 2 months after), a two‐way repeated‐measures ANOVA was employed.”.

All tests were two‐sided and a p value < 0.05 was considered statistically significant. Data analyses were performed using SPSS Statistics software (version 25.0, (IBM Corp., Armonk, N.Y., USA).

4. Discussion

While no prior studies have specifically evaluated the Collaborative Approach and Learning Cooperatives (CALC) model in the context of hemodialysis vascular access care, the findings of this study align with a robust body of evidence demonstrating that structured educational interventions significantly improve nurses' knowledge and practice in this domain.

The results of the present study showed that the average scores of nurses' knowledge of hemodialysis vascular access did not have a significant difference between the intervention and control groups before the intervention. However, the average scores of nurses' knowledge in the intervention group significantly increased after the implementation of a training intervention based on CALC model. Therefore, it seems that the use of the CALC method can improve nurses' knowledge in caring for hemodialysis vascular access. In line with the findings of the present study, the findings of Deshmukh and Shinde (2014) indicate that structured educational interventions significantly improve nurses' knowledge about vascular access care [23]. The low scores of nurses' knowledge before the intervention were observed in the study by Nagamatsu et al (2014) [24] and also in this study. The baseline knowledge deficit observed in this and other studies may be attributed to insufficient initial training or the natural decay of knowledge over time without reinforcement. The significant improvement post‐intervention underscores the critical need for continuous, structured education to maintain clinical competency. The present study supports the findings of Azmandian (2013) and Lobo (2010) regarding the effectiveness of education in increasing nurses' knowledge [25, 26]. Zeyada et al. (2021) in their study stated that the average scores of nurses' knowledge before, immediately after, and 2 months after the implementation of nursing educational guidelines had a significant improvement, and the implementation of nursing educational guidelines not only improved the knowledge and practice of nurses in central venous catheter care but also had a positive impact on reducing bloodstream infections related to it [27], which is consistent with the findings of the present study. In this regard, the study by Yousif et al. (2017) also showed that implementing a clinical practical guideline‐based educational program for caring for vascular access for hemodialysis had a significant impact on dialysis nurses' knowledge in caring for vascular access in hemodialysis patients [28]. These results are consistent with the present study, as the average scores of nurses' knowledge of vascular access for hemodialysis significantly increased one and 2 months after the implementation of the CALC model. Also, the study by Mohamed et al. (2015) showed a significant difference in nurses' knowledge scores regarding vascular access care before and after the implementation of educational sessions [29]. The findings of Wright's study (2017) also indicated that high knowledge of nurses for managing vascular access for hemodialysis based on evidence‐based guidelines can improve their practice and patient outcomes [30], which aligns with our results. On the other hand, the study by Mahmood & Khudur (2020) also indicated that the average scores of nurses' knowledge regarding the management of patients with vascular access significantly increased after the implementation of an educational program, which was considered as a positive effect of the educational program [16], which is consistent with the findings of the present study.

The results of the present study showed that there was no significant difference in the mean practice scores of nurses in caring for hemodialysis vascular accesses between the intervention and control groups before the intervention. However, the mean practice scores of nurses in the intervention group significantly increased after the implementation of the CALC model. Therefore, it appears that the use of the CALC method can improve the practice of nurses in caring for hemodialysis vascular accesses. In line with these findings, the study conducted by Bahramnejad and Nematikhah (2017) demonstrated a statistically significant difference in the practice score changes regarding the care of central venous catheters between the intervention and control groups after the participatory‐based educational intervention, while no statistically significant difference was observed in the pre‐test phase between the two groups [18], which is consistent with the current study. A key methodological similarity with the study by Bahramnejad and Nematikhah [18] is the use of a participatory learning approach, actively engaging nurses in the educational process. Additionally, both studies facilitated comparison between the conventional nursing education method and the participatory approach by including a control group. Another strength of these two studies was that the impact of the educational intervention on the nurses' practice in caring for hemodialysis vascular accesses was assessed through observation. In general, the increase in the practice scores of nurses in the intervention group compared to the control group in the present study indicates that the implementation of an educational intervention based on Collaborative Approach and Learning Cooperatives is a pathway to enhance the practice of nurses in caring for hemodialysis vascular accesses. In fact, the foundation of this model is crucial to assist hemodialysis nurses, who have a heavy workload and limited time to participate in courses and training sessions, in utilizing the best scientific evidence in clinical practice and achieving positive and significant changes in their practice, thereby improving the quality of care provided to hemodialysis patients. Similarly, the findings of Bayoumi & Mahmoud's study (2017) demonstrated an improvement in the practice of nurses who received evidence‐based guideline training programs on the maintenance and care of central venous catheters [31]. Another common point in these studies and the present study is the importance of continuous education on evidence‐based guidelines for nurses in updating and renewing their knowledge and improving the care provided in hemodialysis units. Mohamed et al. (2015) also found an increase in the overall practice score of nurses in caring for hemodialysis vascular accesses after the educational intervention [29]. In this regard, Osman et al. (2021) stated that nursing educational interventions had a positive and significant impact on improving the overall practice of nurses in infection control in hemodialysis units [32]. Abdo et al. (2020) emphasized the importance of implementing an educational program in increasing the practice score of hemodialysis nurses in the care and prevention of central venous catheters related bloodstream infections [33]. The results of Raafat Mahdy et al. (2022) indicated that the majority of nurses showed satisfactory practice in caring for arteriovenous fistula after the implementation of educational guidelines, and there was a significant statistical difference between the pre‐test and post‐test results, concluding that educational guidelines are effective in enhancing the practice of nurses in the care of arteriovenous fistula [34]. Furthermore, Saleh et al. (2018) found that the majority of nurses (80%) showed satisfactory practice after the educational intervention, and there was a significant statistical difference between the pre‐test and post‐test results [35]. Both of these studies are in accordance with the findings of the present study.

4.1. Study Limitations

This study has some limitations. First, its small sample size, a consequence of the limited population of hemodialysis nurses. This restricts the generalizability of the findings. To enhance the validity of future results, it is recommended that researchers conduct studies with larger sample sizes and different follow‐up periods. Second limitation was that participants in control group didn't receive any education. It is recommended that in future studies, the control group be provided with general education or at least educational materials and the other limitation of this study was the constrained ability to assess the impact of the knowledge and skills gained through the educational intervention on patient outcomes. Therefore, it is recommended that a study be designed to identify and evaluate patient care outcomes associated with collaborative approaches.

5. Conclusion

The results of the present study showed that the average scores of nurses' knowledge and practice in caring for vascular access for hemodialysis did not have a significant difference between the intervention and control groups before the intervention. However, the average scores of nurses' knowledge and practice in the intervention group significantly increased after the implementation of a collaborative approach and learning cooperatives. Therefore, it seems that the use of the CALC method can improve nurses' knowledge and practice in caring for vascular access for hemodialysis.

Author Contributions

All authors have read and approved the final version of the manuscript. Negin Azizi: conceptualization, investigation, data curation, writing – original draft, writing – review and editing, resources. Leyla Alilu: conceptualization, writing – original draft, methodology, supervision, project administration. Vahid Alinejad: software, formal analysis. Hossein Jafarizadeh: conceptualization, validation, review and editing, supervision.

Funding

The authors received no specific funding for this work.

Conflicts of Interest

The authors declare that there are no conflicts of interest or personal affiliations that might be perceived as influencing this study.

Transparency Statement

The lead author Jafarizadeh Hossein affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

The corresponding author had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.