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00124645-200909000-0001800124645_2009_25_273_schlief_development_5miscellaneous< 43_0_8_0 >Journal for Nurses in Staff Development (JNSD)© 2009 Lippincott Williams & Wilkins, Inc.Volume 25(5)September/October 2009pp 273-275Staff Development Story[DEPARTMENTS: Staff Development Stories]Schlief, Deborah P. MSN, RNC, IBCLCDeborah P. Schlief, MSN, RNC, IBCLC, is Clinical Educator for Pediatrics/PICU, NICU, and Medical/Surgical/Women's Health Units, NCH Healthcare System North Naples Hospital, and Clinical Associate, Edison State College, Naples, Florida.ADDRESS FOR CORRESPONDENCE: Deborah Schlief, 380 29th St. NW, Naples, FL 34120 (e-mail: rschlief@comcast.net).FROM PEDIATRICS TO PEDIATRIC INTENSIVE CARE UNIT: AN EDUCATION PROGRAM FOR NURSES ON THE CARE OF CENTRAL ACCESS CATHETERSThe pediatric department of a community hospital in southwest Florida was in the midst of a major transition. The unit was being moved to a newly constructed addition to the hospital, so instead of having 14 general pediatrics beds, it would now have 24 total beds, with 4 of the beds designated as pediatric intensive care unit (PICU). Increased acuity, increased census, and increased staff all added up to a challenge for the education department.The clinical educator for the pediatrics/PICU was charged with developing programs to increase both the confidence and competence of the nurses who would be caring for the patients in the PICU. The critical need was caring for patients with central access catheters. Prior to the unit's transition, patients requiring even a peripherally inserted central catheter (PICC) were transported to another hospital for placement, then returned to the unit. The staff had received basic education on dressing changes, flushing, and site assessment for the PICCs but had not cared for patients with either a femoral or subclavian central catheter. The nurses were also not familiar with treatment for sluggish or clotted lines, so program planning needed to include this aspect of central line care as well. When questioned about their education needs and preferences, the nurses were not shy about expressing their trepidation on caring for patients with central lines.PROGRAM DESIGNThe program design chosen by the clinical educator was one that would take a relatively short period of time because it would be conducted on the unit and attended by nurses who may be busy with a patient assignment. The program needed to include core competencies and be presented to aid retention of the new knowledge and skills. Adult learning principles were included in the design (Horton, 2007). The clinical educator representing the company that manufactured the central lines was contacted and arrangements were made for her to be a guest speaker at the education program. In addition, PICU educators from surrounding hospitals were contacted for collaboration on program design. Research documents that would validate the skills and competencies included in the program as evidence of best practice were obtained. An education packet including all available information was developed for each nurse attending.With the curriculum framework in place, the educator identified the expected program outcome and methods of evaluating the competencies of flushing, drawing blood samples, declotting, and changing dressings for central access catheters. Using the curriculum framework as a road map, the competencies were designated "mile markers" and outcomes as the destination (Billings & Halstead, 2005). Therefore, each competency will have to be completed by demonstrating knowledge of the procedure, ability to perform the procedure safely and correctly, and an understanding of the rationale for the procedure for the outcomes to be achieved. Competency checklists were developed using the Infusion Nurses Society (2006) checklist as a resource and will be completed for each participant at the program conclusion. The program outcomes to be achieved include the aforementioned increase in competence and confidence on the part of the nurses caring for patients with central lines, along with a decrease in the rate of infection through implementation of competencies. Outcomes will be measured during the summative evaluation process at the conclusion of the program and through ongoing evaluation during central line care on the unit.To increase interest in the subject and education program, an anticipatory set (Billings & Halstead, 2005) was created by posting flyers advertising the upcoming program in the break room and other areas on the unit frequented by the staff. The program was announced in staff meetings and the educator made a point of stimulating interest in the subject during unit rounds. As the date for the program approached, it was noted by the unit manager and the educator that the staff was actively discussing the upcoming program and was looking forward to the event.CLINICAL RELEVANCEWhereas improving competence and increasing confidence in central line care for the nurses were fundamental goals of this project, strategies for preventing catheter-related infections were also a major goal. The Centers for Disease Control (CDC, 2002) provides excellent information on guidelines for prevention of infection related to central line catheters and encourages well-organized programs for healthcare providers, citing education as a critical component in the success of their efforts. The pediatric nurses were dedicated to clinical excellence and were willing to make every effort to provide care that would reduce catheter-related blood stream infections in patients. The information from the CDC was a valuable source of information for them, and copies of the report were placed in the resource area of the unit.As an adjunct to the CDC report, information was also included in the program from the Institute for Healthcare Improvement (2007) and the 5 Million Lives Campaign How-to Guide on preventing central line infections. The guide contains information on implementation of the central line bundle, so the suggestions were compiled into a checklist. The checklist was copied and placed on a clipboard on the procedure cart so the nurses would have easy access to the list when assisting the physician with central line insertion. The copies were printed on color paper to improve visibility and act as a reminder to follow proper procedure during placement of the line.In addition, the American Academy of Pediatrics has published similar guidelines on the prevention of catheter-related infections (O'Grady et al., 2002). The guidelines were reprinted along with information on how to access the information online and were provided to the class participants as reference material.IMPLEMENTATION OF THE PROGRAMThe educator wanted to incorporate different domains of learning, including cognitive, affective, and psychomotor (Millhaem & Timm, 2007). The cognitive domain and knowledge dimension was to be addressed through lecture by both the central catheter company educator and the clinical educator. This part of the program would cover the basics of central lines, including evidence-based practice, hospital policy, introduction of the equipment, and procedures for insertion, maintenance, and assessment. Educational posters on central catheters had been mounted on the walls of the room, and the information packets were distributed to the participants. Information on items such as chlorhexidine-impregnated patches, flushing techniques, clotted lines, and declotting medication and techniques was also displayed throughout the room.Targeting the affective domain, the educators appealed to the participants' desire for clinical excellence and quality patient care. This was accomplished by reviewing case studies and stimulating discussion about the cases, encouraging the nurses to state their concerns, and working to improve their confidence level in their ability to care for patients with central lines.The psychomotor domain involves using fine and gross motor skills for learning. To address this domain, a baby patient simulator was set up in the room along with all necessary equipment to perform central line care. Simulation would allow the participant to ask questions during the procedure and to perform without fear of patient harm (Landry, Oberleitner, Landry, & Borazjani, 2006). Because the femoral insertion site is acceptable in pediatrics, the central line was secured at this site. After lecture and discussion, each nurse was given the opportunity to assess the site, do a dressing change, draw blood, flush all lumens, and declot a sluggish line. Participants were encouraged to repeat the procedures until they felt comfortable and were able to go through the procedures independently. Throughout this part of the program, the educators reviewed rationale for the procedures and encouraged questions and comments on the processes.Once the program was completed, each nurse received a completed checklist of competencies successfully performed for his/her personnel file.PROGRAM RESULTSThe program was well received, with over 90% of the staff attending. Upon entering the room and without prompting, many of the participants spent time reviewing the wall posters and displays on central line care. Once seated, they were attentive to the educators and engaged in discussion on the topics presented. While at the skills station, they paid rapt attention to the processes being performed and did help each other when the need arose for assistance. Emphasis was placed on the importance of how staff education has been shown to reduce the frequency of central line complications and improve patient outcomes (East & Jacoby, 2005). The company educator directed them through competencies, with several of the nurses asking to repeat procedures until they were confident that they understood the rationales and processes being conducted. It was quite impressive to witness the excitement and engagement on the part of the nurses as they moved through the program.Formative evaluation allowed the educators to change the program while in progress to meet the needs of each group of participants. Summative evaluation was conducted after the program to see if outcomes were met by means of a questionnaire with a Likert-type scale of 1-5, with the results indicating an increase in feelings of both confidence and competence when caring for pediatric patients with central lines. Ongoing evaluation on the unit conducted during central line placement and care indicated that the program outcome of implementing the competencies acquired during training and decreasing the infection rate had also been met.CONCLUSIONFrom inception to conclusion, this program was such a positive experience for educators, the unit manager, and the nurses. Nurses continue to comment on the program, and nurses who missed the program have been asking that the program be repeated.Plans for ongoing evaluation include audits of completed checklists for each central line placed on the unit and a review of rates of infection every 3 months. Annual skills events on the unit will offer a review of the program competencies and all new staff will be required to complete the competency checklist for care of central lines within their 90-day orientation timeframe.The unit educator and unit manager make it a priority to be available as a resource when patients require a central line. Ten femoral central lines have been placed on the unit using the checklist, allowing the nurses to document the correct steps used during the procedures. Several patients with PICCs have been cared for on the unit with no reports of infection or problems during procedures. To date, the nurses have needed minimal reinforcement to perform the care and have continued to express appreciation for the opportunity to participate in the central line education program.REFERENCESBillings, D. M., & Halstead, J. A. (2005). Teaching in nursing: A guide for faculty (2nd ed.). St. Louis, MO: Elsevier Saunders. [Context Link]Centers for Disease Control. (2002). Guidelines for the prevention of intravascular catheter-related infections. Morbidity and Mortality Weekly Report, 51(RR-10), 1-29. [Context Link]East, D., & Jacoby, K. (2005). The effect of a nursing staff education program on compliance with central line care policy in the cardiac intensive care unit. Pediatric Nursing, 31(3), 182-184. [Full Text] [Medline Link] [Context Link]Horton, B. B. (2007). Clinical staff development: Planning and teaching for desired outcomes. Journal for Nurses in Staff Development, 23(6), 260-268. [Context Link]Institute for Healthcare Improvement. (2007). Getting started kit: Prevent central line infections how-to guide. Retrieved July 18, 2007, from www.ihi.org/IHI/Programs/Campaign [Context Link]Infusion Nurses Society. (2006). Clinical competency validation program for infusion nurses. Philadelphia: Lippincott Williams & Wilkins. [Context Link]Landry, M., Oberleitner, M. G., Landry, H., & Borazjani, J. G. (2006). Education and practice collaboration: Using simulation and virtual reality technology to assess continuing nurse competency in the long-term acute care setting. Journal for Nurses in Staff Development, 23(4), 163-169. [Context Link]Millhaem, T. B., & Timm, K. (2007). Identifying the educational needs of nursing staff. Journal for Nurses in Staff Development, 23(6), 277-282. [CrossRef] [Full Text] [Medline Link] [Context Link]O'Grady, N. P., Alexander, M., Dellinger, E. P., Gerberding, J. L., Heard, S. O., Maki, D. G., et al. (2002). Guidelines for the prevention of intravascular catheter-related infections. Pediatrics, 110(5), 1-24. Retrieved on July 18, 2008, from www.pediatrics.org [Context Link]ovid.com:/bib/ovftdb/00124645-200909000-0001800006443_2005_31_182_east_compliance_|00124645-200909000-00018#xpointer(id(R3-18))|11065404||ovftdb|01217119-200505000-00004SL0000644320053118211065404P36[Full Text]01217119-200505000-00004ovid.com:/bib/ovftdb/00124645-200909000-0001800006443_2005_31_182_east_compliance_|00124645-200909000-00018#xpointer(id(R3-18))|11065405||ovftdb|01217119-200505000-00004SL0000644320053118211065405P36[Medline Link]16060581ovid.com:/bib/ovftdb/00124645-200909000-0001800124645_2007_23_277_millhaem_identifying_|00124645-200909000-00018#xpointer(id(R8-18))|11065213||ovftdb|00124645-200711000-00006SL0012464520072327711065213P41[CrossRef]10.1097%2F01.NND.0000300834.92277.9eovid.com:/bib/ovftdb/00124645-200909000-0001800124645_2007_23_277_millhaem_identifying_|00124645-200909000-00018#xpointer(id(R8-18))|11065404||ovftdb|00124645-200711000-00006SL0012464520072327711065404P41[Full Text]00124645-200711000-00006ovid.com:/bib/ovftdb/00124645-200909000-0001800124645_2007_23_277_millhaem_identifying_|00124645-200909000-00018#xpointer(id(R8-18))|11065405||ovftdb|00124645-200711000-00006SL0012464520072327711065405P41[Medline Link]18043336Staff Development StorySchlief, Deborah P. MSN, RNC, IBCLCDEPARTMENTS: Staff Development Stories525