Mary Martin was admitted to home care after a peripherally inserted central catheter (PICC) was placed for vancomycin therapy during her hospital stay. Catheter tip placement of the PICC was confirmed to be in the lower superior vena cava as evidenced by an x-ray report. Mary, 56, had osteomyelitis, the result of a recent leg injury. She had already been in the hospital for 2 weeks, and her arms were sore after many peripheral intravenous (IV) catheter placements. Frequent bouts of phlebitis caused by vancomycin had resulted in site changes every 24 to 48 hours during her hospital stay. The PICC catheter would stay in place for the remainder of her 6-week antibiotic therapy.
During her admission to home care Mary mentioned to the nurse that she has started feeling like her heart “was racing” at times. When asked by the nurse to describe this feeling in more detail, Mary stated she at times feels heart palpitations especially when in bed on her right side, adding it tended to go away when she turns over.
The admitting nurse recognized that the symptoms that Mary was describing could be due to PICC line migration and immediately called the medical doctor to report the patient's symptoms and her suspicion of the tip migration. Mary was then taken for a repeat chest x-ray and it was confirmed that the tip of the PICC line had migrated into the right atrium. The line was repositioned by the interventional radiologist at the hospital and repeat x-ray confirmed that the repositioned catheter was now in the distal superior vena cava. Mary no longer had symptoms and was able to finish her antibiotic therapy at home without complication.
The outcome for this patient could have been quite different without intervention. Infusion nurses must demonstrate accountability, technical knowledge, and critical thinking skills when providing care to patients (Dougherty, 2008). The importance of practicing infusion therapy within standards of practice is also essential for the quality outcomes for which clinicians strive (Scales, 2009).
Expanding Role of Infusion Therapy in Home Care
IV therapy in the home care setting has become well-accepted practice with the many advantages including cost saving, decreased length of hospital stays, care of patients surrounded by family and caregivers, and a lower risk of infection (O'Hanlon et al., 2008). Therapies that are frequently provided in the home setting include antibiotic therapy, chemotherapy, total parenteral nutrition (TPN), rehydration, and pain management. The most common diagnoses infusion therapy is prescribed for in the home setting include cellulitis, sepsis, osteomyelitis, urinary tract infections, pneumonia, multiple sclerosis, cancer, gastrointestinal diseases, dehydration, and immune deficiencies (National Home Infusion Association [NHIA], 2011). Home IV therapy allows patients and families to enjoy an increased quality of life, a sense of participation in the therapy, and a feeling of control over illness. Clinicians in the home care setting need to be competent to carry out the skills as well as educate patients and/or caregivers to manage, monitor, and sometimes self-administer therapy. The expanded role of IV therapy in the home setting will only continue to grow and how agencies and clinicians are prepared to adapt will make the difference in quality outcomes.
During the last decade, spurred by national initiatives and research, healthcare has increased their emphasis on safety and competence in practice. The Institute of Medicine (IOM) recommends that all healthcare agencies offer continuing education programs that impact quality clinical outcomes (IOM, 2010).
Although home IV therapy has tremendous benefits, it also carries a high risk to both the patient and clinician if not performed within standards of practice. To protect both the patient and the clinician, IV therapy must only be performed by clinicians who have the specialized educational and technical skills required. Practice that is evidence-based is required to meet quality standards, and is effective and efficient (Infusion Nurses Society [INS], 2010). Practice that is based on “how we have always done it” or based on skills picked up “on the job” can lead to misinformation and substandard care (INS, 2010). Quality education programs are essential to correct misinformation and teach evidence-based practice.
Competence is defined as the individual's capacity or potential to perform his or her own job (Billings & Halstead, 2009). Accrediting bodies such as The Joint Commission (THC) look at competence as part of the process of maintaining a high-quality work force (THC, 2012). Areas that are generally targeted for competency testing include the areas that are considered high risk or low volume. IV therapy is considered a high-risk procedure and some of the therapy used in the home care setting can also be considered low volume. Risks include infection, thrombosis, hypersensitivity, infiltration/extravasations, and vein inflammation. Clinicians should be expected to practice using standards of practice such as those published by the INS as well as infection control practice guidelines such as the Center for Disease Control and Prevention (CDC) (O'Grady et al., 2011). It is the responsibility of the organization and the practicing clinician to maintain these standards when providing IV therapy.
One Model of Collaboration
Eleven years ago, six community-based, not-for-profit home care agencies in New Hampshire and Vermont identified the growing need of IV services in their populations. With a united mission to provide excellence in IV therapy the six organizations progressively formed the Visiting Nurse Association Health System of Northern New England (VNAHSNNE) workgroup. This workgroup consists of representatives from each agency that include IV experts, education coordinators, and management representation.
The main objectives of this workgroup remain the same. They are to share best practices, maintain staff competence both upon hire and ongoing, and identify and prepare clinicians for new IV therapy practices as they occur in the home care setting. Clinical certification is also supported by this group and includes participants that are certified in infusion therapy by INS with the designation of CRNI. Each agency varies in job requirements for home care nurses; some require all staff to perform IV therapy, while others have specific IV teams within their organization based on the demand in each geographic region.
This workgroup identified the need to develop a clinical competency program aimed at providing evidence-based education on the fundamentals of home infusion therapy based on agency survey results. Although the participating six agencies performed competency testing in their own agencies based on the INS standards, a program that addressed both the theoretical knowledge and practical application was needed. This program would be used for clinicians new to home care as well for ongoing competency testing of staff members of the six participating agencies. This model also would have cost-saving implications for the participating organizations.
The cost to develop and implement this program was funded by the VNAHSNNE alliance. Cost considerations when developing were staff time, room space, supply costs, and curriculum development. The members of the workgroup created the presentation over several months of work and research. There is no charge for participating agencies to send staff to this program. Classroom size allows at least 20 participants to attend each course. Each agency with available space takes turns “hosting” the course, which also cuts down on costs.
The competency program, titled “Overview of Home Infusion Therapy” is a day-long course that consists of interactive lecture in the morning and skills sessions in the afternoon (Figure 1).
Methodology for Development of Course
When developing a competency program, it is first necessary to identify the learning needs of the audience (Billings & Halstead, 2009). Agencies in the workgroup completed surveys on the current number of IV staff and specific skills that clinicians had or were desired within each organization. Learning needs varied from agency to agency based on the volume of patients and types of IV therapy administered. For example, some agencies worked closely with local oncology clinics and perform frequent chemotherapy in the home, while some agencies see very little. This survey also helped the organizations establish the frequency of the course to meet everyone's needs.
It was decided that all IV nurses who were new to each agency or nurses new to IV therapy would be required to attend this course, regardless of their experience and background. Nurses new to home care have varied experience based on their previous settings and many have had limited exposure to various infusion access devices and therapies. The importance of validating both the technical skills and critical thinking skills of each clinician is necessary prior to providing quality patient care.
For experienced IV staff, it is also necessary to provide ongoing competency training. This course allows staff to meet their agency requirements for ongoing competency testing of basic IV skills. In addition, each agency has their own requirements with the frequency of ongoing competency testing based on the volume and types of IV therapy they provide.
When creating the course, it was important to understand the audience and how to meet their learning styles. Adults learn differently than younger people because of motivational differences, values, attitudes, and personal history (Westover, 2009). Important characteristics of adult learning include that adults relate learning to what they already know, they must be responsible for their own learning, and they are more likely to be actively involved (Billings & Halstead, 2009). It has been reported that they are not content centered; they are self-directed and problem centered (Nehls & Vandermause, 2004). Understanding how these characteristic are incorporated into an education plan is the biggest indicator of its success.
As IV therapy has multiple components from theory development, skill demonstration, as well as problem solving, using a combination of learning strategies was determined to be most effective. Learning needs were addressed by developing a program that included interactive lectures with case studies to engage staff and allow them to relate the information into their own practice (McKeachie & Svinicki, 2006). A demonstration portion with hands-on practice and application is also a component.
The lecture content was created by the participating members of the IV workgroup and based on INS standards of practice (INS, 2011a). Qualifications of the instructors include CRNI certification as well as an education background. Areas of clinical content include differences between infusion therapy in the home versus alternate settings, vascular access devices (VADs), their individual care and maintenance, and criteria for device selection. Identifying complications associated with access devices and appropriate nursing interventions, infection control, as well as legal liability associated with home infusion therapy and review of common therapies were also included. Fluid and electrolyte balance, pharmacology, and consideration for the pediatric and neonate population are also part of the curriculum. Case examples are used, and clinicians are encouraged to ask questions and bring up examples from their practice setting that are relevant. Clinicians are also given handouts that reinforce the information taught.
Clinicians are taught the importance of patient education when providing IV therapy in the home. Effective patient education is essential to the success of home care. Unlike other settings the patient is commonly required to infuse medications, monitor for signs of adverse reactions, and response to therapy. The ability of the clinician to assess the patient's readiness to learn, to provide education that individualized taking into consideration health literacy, functional limitations, anxiety, and the like, will have a better chance of success. The clinician must also be able to evaluate the effectiveness of the teaching and modify the education if needed (INS, 2011b).
Because this course is a basic overview of home infusion therapy, more complex therapies such as TPN therapy, chemotherapy, and pain management are also introduced. The expectation is that the staff takes further courses specific to each of these topics prior to being able to care for these complex cases in the home. It is up to individual agencies to identify the specialties staff needs and educate clinicians based on these needs.
The afternoon portion of the course is dedicated to “hands-on practice.” The skills identified and practiced during this portion are drawing blood off of a central venous access line, accessing and deaccessing an implanted vascular access, and changing a central VAD dressing. These skills have been identified as those used frequently in the home care setting and are basic skills in which clinicians must be competent. This portion of the course also includes participation by local IV vendors who bring infusion pumps for staff to practice using during the competency day. IV vendors who participate bring the equipment commonly used in home care, teaching about pump use, and programming. Written instructions/manuals are provided to all participants to use as reference.
Each skill is first demonstrated to the “students” by the instructor. Each clinician is given a copy of the Competency Checklist (Figure 2) as well as a copy of each procedure with step-by-step instructions to review and then are broken up into small groups.
Class sizes are limited to 20 participants. The groups rotate through each of the skill stations and are able to practice each skill using simulation arms and chests. For each skill the participants use new products (e.g., dressing change kits, needles) to make the simulation as realistic as possible. The use of IV simulation arms allows for interaction between clinicians, and clinicians and educators while practicing their skills (Etzel-Hardman, 2008). By allowing the clinicians to practice skills with each other, they can help each other gain confidence, problem solve, and troubleshoot (Krautscheid et al., 2008). Educators can also facilitate the interactions by asking clinical questions during the process and encourage collaboration. As clinicians are allowed to practice these skills in a safe environment that allows them to make mistakes and develop confidence (Billings & Halstead, 2009), the amount of comfort in asking question increases. Another benefit of the use of simulation is to provide consistent experiences for all clinicians and allow for reflection of the process (Bradshaw & Lowenstein, 2007). By the educator facilitating the clinicians to critically think and problem solve while learning physical skills, the level of interaction rises and the learning is further enhanced. Knowing that a patient is not going to be hurt by mistakes or errors, the clinician is able to feel comfortable taking more risks practicing and by asking questions with each other.
As clinicians go through each station and correctly demonstrate each procedure, the IV educators sign off on each completed skill. Clinicians bring the competency checklists back to their agencies to be filed.
After the course is completed, clinicians new to home IV therapy are next required to perform the skills demonstrated in the class in the patient's home. It is important for clinicians to be able to apply what they have learned into practice in a supervised manner. As home care IV therapy has a large teaching component, having clinicians practice not only the technical skills but teaching the patient how to care for their infusion device is important and will enhance the student and patient learning.
The skill stations are also used for existing staff that are due for their ongoing competency testing. This course allows agencies to send staff through on a regular basis and meet agency educational and quality requirements. Periodic reassessment is necessary to ensure that all IV clinicians are continuing to practice based on current practice guidelines.
The evaluation of learning is important to discover problems and improve learning outcomes. To provide the best education requires ongoing critical reflection of the objectives and how they are being met is important (Westover, 2009).
As the overall goal of the program is to produce competent clinicians that practice quality home IV therapy, several methods of evaluation are used to measure this goal. Staff satisfaction scores from evaluations (see Box 1) after the course are used to evaluate the course content and for future course revision of the course to best meet the needs of the learners on an ongoing basis.
Evaluating the learning objectives by each clinician demonstration at each skill station is one objective measure.
Looking at patient satisfaction scores and outcomes of care will help an organization know that the overall program is in congruence with the mission and purpose of the agency. Monitoring statistics such as infection control rates and rehospitalization rates is also important and provides objective data to measure the goals.
Staff satisfaction scores have been positive since the start of this program (see Figure 3). Clinicians feel “better prepared” and value the education as the foundation for quality clinical practice when starting to perform IV therapy in the home setting. Feedback has been used to modify the course and continue to make it more learner-centered and reflect the needs of the students.
Implications for Practice
Continuing education is essential to advance practice and ensure competency. The importance of active participation in infusion-related continuing education programs promotes evidence-based practice and quality (INS, 2011b). Ongoing competency assessment testing should be based on the needs of the agency and should be performed with constant reflection to ever-changing standards of practice. The agencies within the VNAHSNNE group require all clinicians who perform IV therapy to have competency assessment evaluations at a minimum of every 2 years. Specialty courses in TPN management, chemotherapy, and pain management are provided prior to any clinician performing those skills and on an ongoing basis to provide updates on changes in standards of practice to ensure clinicians are performing skills based on current evidence. Clinicians are accountable for maintaining their own personal and professional growth and maintaining knowledge and expertise based on current standards of practice. Agencies that promote ongoing education demonstrate a goal of providing quality evidence-based care as they seek to improve both patient and staff satisfaction.
Infusion therapy in the home care setting has become well-accepted practice with the many advantages including cost saving, decreased length of hospital stays, care of patients surrounded by family and caregivers and a lower risk of infection (Depledge & Gracie, 2006). As the goal of home infusion therapy is to provide safe evidence-based care, the importance of providing education that reflects standards of practice is crucial. Successful competency programs are learner-centered and address the both the theoretical knowledge and the practical applications necessary for safe practice. To protect both the patient's right to safe quality care and the clinician who performs the infusion therapy is the goal of successful competency programs.
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