ORIGINAL ARTICLE

Nurses’ knowledge of evidence-based guidelines on the prevention of

peripheral venous catheter-related infections: a multicentre survey
Giancarlo Cicolini*, Valentina Simonetti*, Dania Comparcini, Sonia Labeau, Stijn Blot, Gilda Pelusi
and Pamela Di Giovanni

Aims and objectives. To evaluate nurses’ knowledge of guidelines for preventing

infections associated with peripheral venous catheters. What does this paper contribute
Background. Guidelines for the prevention of intravascular catheter-related infec- to the wider global clinical
tions are an important tool to help healthcare professionals minimise the risk of infec- community?
tion. However, they are not always applied by nurses. The literature on this topic is • A low level of nurses’ education
limited, and no study examined this matter for peripheral venous catheters. is a risk factor for patient safety.
Design. This cross-sectional study was carried out from November 2011–June 2012. • The results should sensitise
healthcare managers to improve
Methods. The nurses’ knowledge of peripheral venous catheter guidelines and its
nursing training and education,
association with gender, experience, education and the ward membership was according to clinical risk man-
assessed using a validated questionnaire. agement perspectives.
Results. Sixteen hospitals from six regions of Italy participated, and 933 question- • The mission of an efficient health
naires were collected. Most participants were female (70
1%), undergraduate policy should be oriented
(51
8%), worked in medical (35
8%) and surgical departments (28
0%), and had towards the improvement of the
quality and the safety of health
>10 years of experience (55
0%). The median score on 10 questions was 6 of 10.
care provided from nurses.
A majority of nurses knew it is recommended to replace peripheral venous
catheters routinely (90
0%), to perform an aseptic technique during connecting/
disconnecting the infusive lines (55
2%), and to replace the administration set
<24 hour when lipid emulsions have been infused (88
4%). Of note, 52
6% of
nurses advocated the use of steel needles, a potentially dangerous practice.
In multivariate analysis, a higher level of education and the area of work
were associated with better test scores.
Conclusion. The sample of nurses’ knowledge to some recommendations is
frequently low. This could be a potential risk factor for patient safety. The results
should sensitise healthcare managers to improve nursing training and education,
according to clinical risk management perspectives.
Relevance to clinical practice. These data request for more emphasis on interna-
tional guidelines in infection prevention initiatives.

Authors: Giancarlo Cicolini, PhD, RN, MSN, Nurse Director,
Department of Medicine and Science of Aging, “G. d’Annunzio”
University of Chieti, Chieti; Valentina Simonetti, RN, MSN, PhD
student, Department of Medicine and Science of Aging, “G. d’An-
nunzio” University of Chieti, Chieti; Dania Comparcini, RN,
MSN, PhD student, Department of Medicine and Science of Aging,
“G. d’Annunzio” University of Chieti, Chieti, Italy; Sonia Labeau,
MNSc, PhD, RN, Professor, Faculty of Education, Health and
Social Work, University College Ghent, Ghent; Stijn Blot, MNSc,
PhD, RN, Professor, Department of Internal Medicine, Ghent Uni-
versity, Ghent, Belgium; Gilda Pelusi, RN, MSN, Chief Director,
University of Ancona, Ancona; Pamela Di Giovanni, MD, Assistant
Professor, Department of Pharmacy, “G. d’Annunzio” University
of Chieti, Chieti, Italy
Correspondence: Giancarlo Cicolini, PhD, RN, MSN, Center of
Excellence on Aging, Clinical Research Center CRC-CeSI – Univer-
sity of “G. d’Annunzio” – Chieti, Via dei Vestini 31, 66013 Chieti
Scalo, Italy. Telephone: +39 0871 541355.
E-mail: g.cicolini@unich.it
*These authors equally contributed to the present study.

© 2013 John Wiley & Sons Ltd

2578 Journal of Clinical Nursing, 23, 2578–2588, doi: 10.1111/jocn.12474
Original article
Key words: cross-sectional design, evidence-based guidelines, guidelines, nurses’
knowledge, peripheral venous catheter-related infection, prevention
Accepted for publication: 4 August 2013
Introduction
Peripheral venous catheters (PVCs) and central venous cath-
eters (CVCs) are widely used devices in patients requiring
infusion therapy, in various healthcare settings (Mermel
2000, Parker 2002).
However, PVCs and CVCs are frequently associated with
phlebitis, a condition leading to an increased risk of cathe-
ter-related bloodstream infection (CRBSI) (Pratt et al.
2007).
Phlebitis is mainly influenced by a number of factors such
as catheter material (Sheth et al. 1983, Maki & Ringer
1991), site of insertion (Maki & Ringer 1991, Lundgren
et al. 1993, Bregenzer et al. 1998, Karadeniz et al. 2003,
Uslusoy & Mete 2008, Cicolini et al. 2009, Forni et al.
2010), principles of asepsis (Pittet et al. 2000, Boyce & Pit-
tet 2002), time of catheter replacement (Bregenzer et al.
1998, Homer & Holmes 1998, Lai 1998, White 2001,
Cornely et al. 2002, Webster et al. 2008, 2010, Van Donk
et al. 2009), replacement of administration set (Gillies et al.
2005), type of infusate (Hanna & Raad 2001) and the
patient’s own risk profile (Tagalakis et al. 2002, O’Grady
et al. 2011).
Background
Compliance with international guidelines for the prevention
of intravascular catheter-related infections is extremely
important to improve patient outcomes, to reduce health
care costs (O’Grady et al. 2011), to support clinical deci-
sions (Lohr & Field 1992) and to reduce adverse events
(Eiman et al. 2008). Unfortunately, they are not always
observed by healthcare professionals (Grol & Grimshaw
2003).
Various studies investigated the reasons why healthcare
professionals sometimes deviate from guidelines (Cabana
et al. 1999, Johansson et al. 2009, Abrahamson et al.
2012). It has been commonly assumed that principal barri-
ers to evidence-based clinical practice, such as lack of
knowledge, skills and negative attitudes, operate at the
individual professional level in association with factors
derived from healthcare system levels: organisational and
structural barriers, peer group and operator–patient inter-
action barriers (Grimshaw et al. 2004). A systematic
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2578–2588
Nurses’ knowledge and prevention of PVC infections
review to identify barriers to physicians’ adherence of
guidelines revealed that lack of awareness, familiarity,
agreement, self-efficacy, outcome expectancy, the inertia
of previous practice and external barriers can affect a
physician’s ability to execute recommendations (Cabana
et al. 1999). Although several physician-oriented
researches exist, the adherence and the effectiveness of
implementation of guidelines in nursing context are rela-
tively little known (Frigerio et al. 2012). However, the
full adherence to recommendations is an important issue
related to the quality of nursing care, and in particular,
in Italy, PVC management represents an important nurs-
ing task (Frigerio et al. 2012). Knowledge of guidelines
remains a priority for personnel who manage CVCs, par-
ticularly for nurses who provide most of the manipulation
and care of the patients’ intravenous infusions (Uslusoy &
Mete 2008).
The latest CDC guidelines (O’Grady et al. 2011) stressed
the importance of the staff’s experience and knowledge to
prevent CRBSI and to improve clinical performance by
recommending education programmes and periodical
knowledge assessment of the personnel.
Given the pivotal role on learning as an essential activ-
ity for ongoing professional development, knowledge
gained from research and learning needs surveys could be
used to promote self-awareness of operators on the need
to achieve practice changes (Kent et al. 2009). All
practitioners should be aware that it is their responsibility
to maintain their practice and keep up to date (Trim
2005).
The literature on the knowledge of recommendations for
preventing infections associated with peripheral intravascu-
lar catheters by health professionals is, however, limited
and presented limitations related to the validity and reliabil-
ity of instruments used that are not supported by current
updated guidelines (Karadeniz et al. 2003, Walker et al.
2006).
Only one study (Labeau et al. 2009) investigated this
issue on a population of intensive care unit nurses, using a
validated questionnaire, albeit in relation to CVCs.
Recently, a new instrument was validated to test nursing
students’ knowledge and skills when performing venepunc-
ture and inserting a peripheral venous catheter (Ahlin et al.
2013), showing a discrete inter-rater reliability. However,
2579
G Cicolini et al.
until now, no study evaluated nurses’ knowledge of current
updated CDC guidelines for preventing infections associ-
ated with PVCs using a specific questionnaire.
The aims of this study were to evaluate the knowledge of
current recommendations for preventing infections associ-
ated with PVCs by nurses and to investigate potential
predictors associated with nurses’ knowledge.
Methods
Design
This multicentre cross-sectional survey was carried out
from November 2011–June 2012.
Participants and setting
We asked participation of sixteen structures within the
national healthcare system located in six Italian regions. No
restrictions in terms of number of beds and/or complexity
were applied.
We used a convenience sample. All nurses of the surgical
and medical departments, critical wards, maternal child
health sections, primary healthcare services and managerial
nursing staff who signed the informed consent were
included.
Nurses who did not accept to participate or did not sign
the informed consent were excluded from the study.
Sample size
The study was designed to evaluate nurses’ knowledge of
current recommendations for preventing infections associ-
ated with PVCs. Estimating that the total number of nurses
eligible for participation was 1200 and based on a 71%
response rate identified in the literature (Labeau et al.
2008b, 2009), we expected to recruit a sample size of about
800 nurses.
Data collection procedures
In each participating hospital, a previously trained
researcher, employed in the facility, recruited the potential
participants and personally delivered a validated and self-
reported multiple-choice questionnaire of Labeau et al.
(2008a,b).
The researcher asked the nurses to fill out and return the
questionnaires within 15 minutes in person. To guarantee
the confidentiality and anonymity, participants resubmitted
the questionnaire in an envelope inside a special urn.
2580
Measures
Instrument
In this study, we used an adapted version of a previous val-
idated 10-item questionnaire that assessed nurses’ knowl-
edge of guidelines for preventing CVC-related infections
(Labeau et al. 2008a,b). A preliminary forward–back trans-
lation procedure of this original version of the instrument
(Labeau et al. 2008a,b) was performed to establish seman-
tic and conceptual equivalence with Italian context. Subse-
quently, the questions of the original instrument were
modified and adapted on the basis of the updated CDC
guidelines (O’Grady et al. 2011), to measure nurses’ knowl-
edge on the prevention of infections associated with PVCs.
The new instrument included a few items collecting infor-
mation on the healthcare structure, nurses’ gender, years of
experience (categorised in four periods: <1 year, 1–5 years,
6–10 years and more than 10 years), level of education and
10 questions related to PVC management, selected from
CDC guidelines (O’Grady et al. 2011) on the basis of rele-
vance for nursing practice: (1) PVC replacement; (2) hand
hygiene; (3) aseptic technique; (4) selection of catheters; (5)
catheter site dressing regimens (time of replacement); (6)
catheter site dressing regimens (type of dressing); (7) skin
preparation; (8) catheter site dressing regimens (antibiotic
ointment); (9) replacement of administration sets (lipid
emulsion infusions); and (10) replacement of administration
sets (neither lipid emulsions and nor blood product infu-
sions). Responses to each question included one correct
answer (given one point), two distractors or alternative
responses and the answering option ‘I do not know’, to
avoid guessing. The latter option and the alternative
responses were assigned 0 points. The maximum score
value was 10 and the minimum was 0, indicating the higher
and lower knowledge of guidelines, respectively.
Questionnaire’s face validity has been preliminarily eval-
uated by a panel of 10 Italian expert nurses in this field, to
determine the clarity of the questions. Also, the panel was
asked to determine the relevance of each items by assessing
them on a 3-point Likert scale ranging from 1–3 (1 = not
relevant, 2 = relevant but not necessary, 3 = absolutely
necessary). The expert panel recommended to rewrite item
number 7 to avoid misinterpretation. After appropriate
revision, the experts unanimously expressed overall agree-
ment with questionnaire’ clarity and content. In addition,
we pilot-tested the revised questionnaire on a population of
30 nurses, and we conducted an item analysis to determine
the difficulty level (difficulty index) and the discriminating
power (discrimination index) (Haladyna, 1999; Thorndike
et al. 1991). Detailed interpretation criteria of item analyses
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2578–2588
Original article Nurses’ knowledge and prevention of PVC infections

have been previously published (Labeau et al. 2008a,b).
Overall, difficulty index ranged from 0
4–0
8, showing sat-
isfactory values, except for item no. 1 (PVC replacement)
and item no. 9 (replacement of administration set for lipid
emulsions) (value = 0
97 and value = 0
93, respectively).
Although these results indicated that the items were very
easer for responders, they were included in the final version
of the instrument because of the importance of the themes
explored by the questions. Most of the items reported an
excellent discrimination index (value ≥0
35), item no. 7 and
item no. 9 reported a good index (ranged from 0
25–0
34),
while item no. 1 reported a critical value (0
10). However,
the interpretation of this result must take into account the
relationship between item’s difficulty index and discrimina-
tion index: no. 1 was not likely to be very discriminating
because it was very easy.
Ethical considerations
The study was approved by the independent ethics commit-
tee (the initial approval was granted from the coordinating
centre). Anonymity was granted to all participants.
The total of eligible participants was 1167, and the final
sample consisted of 933 nurses who completed the question-
naire (79
94% response rate). Most participants were female
(70
1%), were undergraduate (51
8%), had >10 years of
work experience (55
0%) and worked in medical and surgi-
cal departments (35
8 and 28
0%, respectively). Demograph-
ics and participants’ characteristics are summarised in
Table 1.
Knowledge of guidelines
Multiple-choice questions, response possibilities and respec-
tive answers are shown in Table 2. Among options of the
questionnaire, none achieved 100% correct answers, and
only one nurse of the total sample responded correctly to
all items of the survey.
By analysing the 10 answers to the questionnaire, a high
rate of incorrect answers can be observed related to the
questions about antiseptic hand wash before PVC insertion
(73
7%), steel needles for drug infusion (58
9%), gauze or
polyurethane catheter dressing (59
1%), chlorhexidine
concentration for disinfecting the insertion site (49
6%),

Data analysis Table 1 Overall characteristics of the sample

Continuous variables were summarised as median and Characteristics N (%)

nterquartile range (IQ). Categorical variables were summar-
Overall sample 933 (100)
ised as frequencies and percentages. Kolmogorov–Smirnov
Region
test was used to verify normal distribution of the observed Umbria 150 (16
1)
data. Our data were non-normally distributed. Significance Molise 134 (14
4)
of differences in score value between different categories was Basilicata 130 (13
9)
evaluated with Mann–Whitney U-test or Kruskall–Wallis Abruzzo 212 (22
7)
Campania 122 (13
1)
test, as appropriate. After Kruskall–Wallis test, post hoc
Marche 185 (19
8)
analysis was performed by Mann–Whitney U-test on each Gender
pair of categories adjusting the p value with the Bonferroni Female 654 (70
1)
method. After testing that the distribution of the total score Male 279 (29
9)
is not skewed, the relationship with data collected through Years of experience
<1 23 (2
5)
the questionnaire was assessed by multiple linear regression
1–5 135 (14
5)
analysis, assuming as dependent variable the total score and
6–10 262 (28
0)
as independent variables gender, years of experience, level of >10 513 (55
0)
education and healthcare setting. The statistical significance Level of education
was set at p value <0
05. All statistical analyses were Undergraduate 483 (51
8)
performed with SPSS® 13.0 (SPSS Inc, Chicago, IL, USA). Graduate 396 (42
4)
Postgraduate 54 (5
8)
Healthcare setting
Results Medical 334 (35
8)
Surgical 261 (28
0)
Critical wards 116 (12
4)
Characteristics of the sample Managerial nursing staff 40 (4
3)
Maternal child health sections 65 (7
0)
Sixteen public hospitals from six regions of central and
Primary healthcare services 117 (12
5)
southern Italy accepted to participate.

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 2578–2588 2581
G Cicolini et al.

Table 2 Nurses’ answers to multiple-choice questions regarding Table 2 (Continued)

prevention of peripheral venous catheter-related infections
Item % of answers
Item % of answers
B.* No, because it causes antibiotic resistance 30
1
1. It is recommended to replace peripheral venous catheters (PVCs) C. No, because it does not decrease the risk for 55
1
routinely… catheter-related infections
A. Yes, every 24 hours 8
3 D. I do not know 6
2
B. Yes, every 12 hours 0
6 9. When lipid emulsions are administered through a PVC, it is
C.* Yes, every 72–96 hours 90
0 recommended to replace the administration set…
D. I do not know 1
1 A.* Within 24 hours 88
4
2. It is recommended to perform an antiseptic hand wash before B. Every 72 hours 6
5
insertion of PVCs… C. Every 96 hours 1
9
A.* No, it’s sufficient to wash hands with 25
9 D. I do not know 3
2
a nonantimicrobial soap 10. When neither lipid emulsions nor blood products are
B. No, you do this only for invasive procedures 7
0 administered through a PVC, it is recommended to
C. Yes, always 66
7 replace the infusion set…
D. I do not know 0
4 A. Every 24 hours 27
5
3. It is recommended to use an aseptic technique during B. Every 72 hours 24
8
connecting/disconnecting the infusive lines (i.e. no touch C.* Every 96 hours 45
4
technique)… D. I do not know 2
3
A.* Yes, always 55
2
B. No, it’s sufficient to wash hands with 42
9 *Correct answer according to CDC guidelines.
an antimicrobial soap
antibiotic ointments on insertion sites (69
9%) and change
C. No, because it increases the risk of infection 1
5
D. I do not know 0
4
of infusion lines every 96 hours when neither lipids nor
4. It is recommended to use steel needles (butterfly type) for the blood products are administered (54
6%). On the other
administration of drugs… hand, more than 50% of respondents correctly answered
A.* No, because they might cause tissue 41
1 the questions about using an aseptic technique when (dis-)
necrosis if extravasation occurs connecting the infusion lines (55
2%) and which antiseptic
B. Yes, if I have to inject drugs for a short time 52
6
to use for disinfecting the insertion site (50
4%).
C. Yes, always 3
8
D. I do not know 2
5 The median score was 6 (IQ: 5–7) on 10 questions. There
5. It is recommended to change the dressing on the catheter were no statistically significant differences in scores between
insertion site… genders (p = 0
076) and in relation to the work experience
A. On a daily basis 8
6 stratified into four periods (p = 0
580). Differences in
B. Every 3 days 27
9
scores showed, however, were statistically significant when
C.* When indicated (soiled, loosened,…) 63
0
D. I do not know 0
5
related to the level of education (p < 0
001) and the area of
6. It is recommended to cover up the catheter insertion site with… work (p < 0
001) (Table 3). In particular, the median score
A. Polyurethane dressing (transparent, 44
6 increases with the level of education: 6 for undergraduate
semipermeable) and 7 for postgraduate nurses. Regarding the area of work,
B. Gauze dressing 13
0 nurses from managerial nursing staff scored significantly
C.* Both are recommended because the type of 40
9
higher than nurses from other areas. Multiple linear regres-
dressing does not affect the risk for catheter-
related infections sion analysis revealed that 3
7% of the variance in respon-
D. I do not know 1
5 dents’ test score was explained by nurses’ characteristics
7. It is recommended to disinfect the catheter insertion site with… (R2 = 0
037, F4,928 = 9
013, p < 0
001). The greatest con-
A.* 0
5% Chlorhexidine gluconate solution 50
4 tribution to respondents’ test score emerged from the level
with alcohol
of education (B = 0
449, p < 0
001) and healthcare setting
B. 2% Chlorhexidine gluconate solution with 40
2
alcohol
(B = 0
112, p < 0
001) (Table 4).
C. 10% alcohol 7
5
D. I do not know 1
9
8. It is recommended to apply an antibiotic ointment at the
Discussion
insertion site of a CVP… Guidelines for the management of PVCs have been pub-
A. Yes, because it decreases the risk for 8
6
lished to reduce rates of phlebitis, unnecessary suffering of
catheter-related infections
patients, prolongation of hospitalisation and associated

© 2013 John Wiley & Sons Ltd

2582 Journal of Clinical Nursing, 23, 2578–2588
Original article Nurses’ knowledge and prevention of PVC infections

Table 3 Median score (interquartile, IQ) on 10 questions according Even if the study of Labeau et al. (2008a,b) was carried
to nurses’ characteristics out specifically among intensive care nurses and on knowl-
Characteristics Median (IQ) K-W p-value edge of current recommendations for preventing infections
associated with CVCs, the results showed the same lack of
Total cohort 6 (5–7) —
knowledge as our study.
Gender
Female 6 (5–7) 0
076† We assume that both results could reflect a lack of
Male 6 (4–7) nurses’ adherence to CDC guidelines and negatively affect
Years of experience clinical practice with an increased risk for patients’ safety.
<1 6 (5–7) 0
580 When analysing the 10 items of the questionnaire, it
1–5 6 (5–7)
was observed that only for items number one (replace-
6–10 6 (4–7)
>10 6 (5–7)
ment of PVC), five (dressing changes) and nine (replace-
Level of education ment of administration set used for lipid emulsions
Undergraduate 6 (4–7) <0
001 infusion), the majority of nurses answered correctly. Par-
Graduate 6 (5–7) ticularly, regarding the recommendation to replace PVCs
Postgraduate 7 (6–8)* every 72–96 hours, our results are in agreement with
Healthcare setting
those of Karadeniz et al. (2003) who reported that almost
Medical 6 (4–7) <0
001
Surgical 6 (5–6) all of the nurses knew the duration of catheters’ dwelling
Critical wards 6 (5–7) time. On the contrary, the study of Walker et al. (2006)
Managerial nursing staff 7 (6–8)** investigating nurses’ knowledge and practice in the man-
Maternal child health sections 5 (5–6
5) agement of PVCs in three different countries (Australia,
Primary healthcare services 6 (5–7)
Tasmania and Greece) reported PVCs’ dwelling time over
†
Mann–Whitney U-test. 72 hours.
*p < 0
05 post hoc test vs. graduate and undergraduate. A large number (54
6%) believed that in patients not
**p < 0
05 post hoc test vs. medical, surgical, critical, maternal receiving blood, blood products or fat emulsions, adminis-
child.
tration sets should be replaced within 24 or 72 hours, while
this is only necessary after 96 hours. However, this time
Table 4 Multiple linear regression analysis to assess the relationship interval matches the maximal indwelling time of the PVC
between total score and nurses’ characteristics (question 1). As such, at this time, the catheter needs to be
Total score* removed as well. Labeau et al. (2008a,b) also reported that
67
8% of nurses consider it necessary to change administra-
Characteristics† b-estimate (95% CI) p-value
tion sets more frequently than 96 hours.
Gender 0
140 ( 0
361; 0
080) 0
211 Only 25
9% of nurses knew that a social hand washing
Years of experience 0
124 ( 0
025; 0
272) 0
102 is sufficient before the PVC insertion, but 66
7% thought
Level of education 0
449 (0
249; 0
650) <0
001
that an antiseptic hand wash is recommended. In fact, the
Healthcare setting 0
112 (0
054; 0
171) <0
001
latest CDC guidelines (O’Grady et al. 2011) recommend to
*Dependent variable. perform hand hygiene procedures, by washing hands either
†
Independent variables. with conventional soap and water or with alcohol-based
hand rubs. A potential explanation for these response errors
financial costs. Adequate knowledge and full adherence to could be that the term ‘conventional’ could be misunder-
published guidelines for the prevention of catheter-related stood by nurses. The previous CDC guidelines (O’Grady
infections remain an important target for all healthcare et al. 2002) clearly recommended an appropriate hand anti-
workers who manage these devices, particularly for nurses. sepsis using an antiseptic or a waterless alcohol-based gel
In this study, we evaluated the nursing knowledge of cur- or foam. Actually, studies supporting the actual CDC
rent recommendations for preventing infections associated guidelines (O’Grady et al. 2011) reiterated the importance
with PVCs. Our results showed that the majority of partici- of hand antisepsis (Pittet et al. 1999) with an alcohol-based
pants had a limited knowledge of the current guidelines on hand rub or hand washing with an antimicrobial soap
the prevention of peripheral venous catheter-related infec- (Boyce & Pittet 2002) to reduce bacterial contamination of
tion and a great variability in responses, in accordance with the hands.
Labeau et al. (2008a,b), who conducted a multicentre Only half of the respondents (55
2%) were aware that it
European survey on 3405 intensive care nurses. is always recommended to use an aseptic technique during

© 2013 John Wiley & Sons Ltd

Journal of Clinical Nursing, 23, 2578–2588 2583
G Cicolini et al.
the management of infusive lines. In fact, many of them
thought it would be sufficient to perform a hand antisepsis.
Also, the CDC guidelines (O’Grady et al. 2011) clearly
recommend to avoid the use of steel needles for the admin-
istration of fluids and medication that might cause tissue
necrosis if extravasation occurs. Only 41
1% reported the
correct answer, while 52
6% thought it was possible to use
them in case only a brief infusion was necessary. However,
this mistake could be due to a misconception of the recom-
mendation regarding the catheter material, as CDC guide-
lines (O’Grady et al. 2011) stated that steel needles used as
an alternative to catheters for peripheral venous access
reported the same rate of infectious complication as
Teflon® catheters.
While both sterile transparent dressing and sterile gauze
can be used to cover the catheter site, a majority (44
6%)
thought that the transparent material was preferred. This
finding is in accordance with the results of Labeau et al.
(2009) who reported a rate of 62
6% and might be
explained by nurses’ preferences in clinical practice. In
fact, Polyurethane® dressings allow continuous visual
inspection of the catheter site and require less frequent
changes than standard gauze and tape dressings (O’Grady
et al. 2011).
As for the skin preparation, 50
4% of nurses knew that
the recommended antiseptic is alcoholic 0
5% chlorhexidine
gluconate solution. Nevertheless, still 40
2% answered that
it is recommended to clean skin with 2% chlorhexidine
preparation with alcohol, a recommendation that relates to
skin preparation for the insertion of CVCs.
Moreover, our results highlighted some considerations
regarding the relationship between nurses’ characteristics
and knowledge of evidence-based guidelines on the manage-
ment of PVCs. First, higher level of education was predic-
tive of higher total test score. The median values are
significantly influenced by the level of education
(p < 0
001). Interquartile range shows a trend towards
increasing scores in relation to the degree obtained by the
participants. This could be associated with a difference
between undergraduate and graduate curricula, due to skills
acquired in graduated curricula, which are more oriented
towards knowledge and the use of evidence in clinical prac-
tice. However, the low number of postgraduate nurses
enrolled should be considered.
Second, working in managerial setting was a significant
predictor of higher test score. This could be due to the dif-
ference in rotating shiftwork. In particular, it is universally
recognised that working in the night shift forces the body
to operate counter to its circadian rhythm with bad effect
for health and sleep disorders (Karlsson et al. 2001,
2584
Clissold et al. 2002, Labyak et al. 2002, Ohayon et al.
2002, Fujino et al. 2006, Woo & Postolache 2008). Results
from a recent study (Jermendy et al. 2012) showed that
rotating shift workers spend less time sleeping, performing
sport activity and daily work. Because in Italy nurses from
Health Direction usually work on a daily shift, we suppose
that they could pay major attention to their training and
education. For these reasons, further research is necessary
to deepen this aspect. We have also observed that a great
number of nurses from managerial nursing staff were post-
graduate. These data further confirm the hypothesis that a
higher level of education is associated with better nurses’
knowledge.
Previous studies highlighted that there was poor compli-
ance with clinical recommendations even if nurses were
aware of guidelines (Walker et al. 2006, Biswas 2007) and
the mere knowledge were not sufficient to change clinical
practice (Charrier et al. 2008). Recent findings showed the
efficacy of continuing education courses on intravenous
infusions in improving the knowledge and skills of experi-
enced nurses regarding PVC management (Fakih et al.
2012, Lyons & Kasker 2012). However, to our knowl-
edge, this is the first study evaluating independent predic-
tors of nurses’ knowledge of guidelines for the prevention
of PVC-related infections. Our results may contribute to
enhancing the debate regarding the influence of knowledge
on nurses’ adherence to recommendations. Also, findings
could be useful to plan educational programmes based on
characteristics of the targeted groups and working area
that may predispose changes in clinical practice (NHS
1999).
Conclusions
In conclusion, several of the recommended procedures for
the management of PVC were not known by most of the
participating nurses. Our results suggest that potentially
nurses could partly adhere to clinical guidelines, in their
clinical practice, as reported by previous findings of Walker
et al. (2006) who concluded that differences in PVC clinical
management could be due to a poor-quality evidence on
which to base practice. This could lead to negative conse-
quences in the care of the patient. However, a higher level
of education seems to be associated with better nurses’
knowledge. This could represent a starting point for reflec-
tion for healthcare managers on the importance of nursing
training, education and continuous updating. In particular,
on which topics to take into major consideration in their
training courses (i.e. it is sufficient a social hand wash
before PVC insertion; do not use steel needles for drug
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2578–2588
Original article
administration; do not apply an antibiotic ointment at the
insertion site of a CVP). However, it is universally recogni-
sed that education alone is not sufficient to grant operators’
guidelines compliance (Cabana et al. 1999, Charrier et al.
2008, Johansson et al. 2009). In fact, training programmes
should be focused not only on learning content, but also on
the importance to follow recommendations for the patient
(i.e. to prevent phlebitis, discomfort, additional costs and
increase of length of stay).
Also, we identified some independent predictors of poor
knowledge, and according to our findings, the first actions
should be addressed to undergraduate nurses.
Given the importance of an accurate prevention of cathe-
ter-related bloodstream infections and phlebitis, major
attention is necessary to this topic to avoid patient’s
discomfort and additional costs.
Further research would be necessary to expand the
knowledge on this topic to compare the Italian context
with other international healthcare settings.
Study limitations
The strength of this study is the large sample size and the
multicentre healthcare setting. The data were collected by
equally trained researchers for each structure, thus decreas-
ing the information bias and increasing the generalisability
of the results in the Italian context.
However, the study has some limitations that should be
discussed.
Although all protocols adopted in each structure was
based upon the CDC guidelines (O’Grady et al. 2011), we
do not know whether periodical or different educational
programmes were in progress in these hospitals to grant
continuous professional updating on this topic. For this rea-
son, our results could be affected by potential heteroge-
neous educational contexts. However, if so, this confirms
the problem of dissemination failure of international guide-
lines as demonstrated in other fields of nursing practice as
well (Blot et al. 2007, Labeau et al. 2007, 2008a,b, Ful-
brook et al. 2012). Anyhow, results of this study could be
useful to healthcare agencies to establish corrective actions
specifically tailored to update internal hospital protocols
and disseminate international guidelines.
Another limitation of our study is the limited number of
respondents in the item analysis.
Further, our results may be affected by selection bias. It
is quite possible that those who did not agree to be sur-
veyed had even worse knowledge than responders. If so,
the results of the survey could be overestimated.
© 2013 John Wiley & Sons Ltd
Journal of Clinical Nursing, 23, 2578–2588
Nurses’ knowledge and prevention of PVC infections
In addition, the cross-sectional design of the study only
allows to determine associations and not casual relation-
ships in the analysis of predictors of nurses’ knowledge on
the prevention of PVC-related infections.
Relevance to clinical practice
A low level of nurses’ education could be a potential risk
factor for patient safety. These results should sensitise
healthcare managers to improve nursing training and edu-
cation, according to clinical risk management perspec-
tives.
The mission of an efficient health policy should be
oriented towards the improvement of the quality and the
safety of health care provided from nurses. These data
request for more emphasis on international guidelines in
infection prevention initiatives.
Also, the questionnaire used in this survey is a simple
and inexpensive instrument that could be periodically
applied in all clinical settings to assess nurses’ knowledge to
PVC recommendations to eventually identify training needs
and apply proper solutions.
Acknowledgements
The authors acknowledge the collaboration of the following
nurses and nursing students, the support of whom was
essential for data collection: A. Taddei, RN; G. Mastrogiorgio,
RN; M. Staffieri, RN; F. Gallone, RN; C. Masucci, RN;
A. Monteodorisio, RN.
Disclosure
The authors have confirmed that all authors meet the
ICMJE criteria for authorship credit (www.icmje.org/
ethical_1author.html), as follows: (1) substantial contribu-
tions to conception and design of, or acquisition of data or
analysis and interpretation of data, (2) drafting the article
or revising it critically for important intellectual content,
and (3) final approval of the version to be published.
Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
Conflicts of interest
No conflict of interest has been declared by the authors.
2585
G Cicolini et al.
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