Received: 20 January 2020 | Revised: 8 June 2020 | Accepted: 3 July 2020

DOI: 10.1111/jocn.15419

REVIEW

Nurses' knowledge on routine care and maintenance of adult

vascular access devices: A scoping review

Andrea Raynak RN, MPH(N), CVAA(c), VA-BC(tm) Clinical Nurse Specialist-Vascular Access1 |
2
France Paquet RN, MSc(N), CVAA(c), Nursing Practice Consultant | Caroline Marchionni RN,
MSc, Admin, MScA, Faculty Lecturer3 | Valerie Lok RN, MSc(A), Research Assistant4 |
Mélanie Gauthier N., BScN, M. Int. Care N., CNCC(C) Program Director BN(I), Faculty Lecturer5 |
Francesca Frati BFA, MLIS Assistant Librarian6

1
Thunder Bay Regional Health Sciences
Centre, Thunder Bay, ON, Canada
2
McGill University Health Centre, Montreal,
QC, Canada
3
Ingram School of Nursing, McGill
University, Montreal, QC, Canada
4
Ingram School of Nursing, Faculty of
Medicine, McGill University, Montreal, QC,
Canada
5 Objective: This scoping review examines the current state of practicing nurses
Ingram School of Nursing, McGill
University, Montréal, QC, Canada
6
McGill University Library, Montreal, QC,
Canada
Correspondence
Andrea Raynak, Thunder Bay Regional
Health Sciences Centre, Thunder Bay, ON,
Canada.
Email: raynaka@tbh.net
Funding information
This scoping review has no funding
associated.
Abstract
Background: Vascular access devices (VAD), centrally (CVAD) or peripherally (PIV)
located, are common in the nursing profession. A high proportion of admitted pa-
tients require a VAD to enable administration of intravenous treatments or diagnos-
tic modalities. As the primary caregivers for these patients, nurses are responsible for
ongoing care and maintenance of these devices.
knowledge around routine care and maintenance of adult VADs.
Methods: In the fall of 2018, the following databases were searched: Medline-Ovid
1946 to current, Embase-Ovid 1947 to current, Ebsco CINAHL Plus with full text and
ProQuest Nursing & Allied Health database, and articles were selected according
to the PRISMA-ScR checklist. Inclusion criteria: original research published in peer-
reviewed journals; in English or French; and focused on practising nurses’ knowledge
about the routine care and maintenance of adult VADs.
Results: Of the 4,099 abstracts identified, 36 full-text articles were included. Study
characteristics are reportedin addition to themes found in the literature: the rela-
tionship between demographic data and CVAD/PIV knowledge, the state of nurses’
CVAD/PIV knowledge and nurses’ CVAD/PIV knowledge scores. Overall, significant
gaps in nurses’ knowledge on the care and maintenance of VADs are noted.
Conclusion: The variability in nurses’ knowledge around both CVAD and PIV led the
authors to conclude that there is room for improvement in the educational prepara-
tion of nurses and a need for workplace training.
Relevance to Clinical Practice: This scoping review intends to highlight the knowl-
edge gap of nurses with regard to best practices for VAD routine care and mainte-
nance and demonstrate the need for education, both in educational and healthcare
institutions, to ensure high-quality care and improved patient outcomes.

J Clin Nurs. 2020;00:1–17. wileyonlinelibrary.com/journal/jocn© 2020 John Wiley & Sons Ltd | 1
2 |
KEYWORDS
care and maintenance, catheter, central venous catheters, infusion therapy, knowledge,
nurses, nurses’ role, peripheral intravenous catheter, vascular access devices
1 | I NTRO D U C TI O N
A significant portion of 35.1 million patients admitted to the hospital
each year in the United States requires the placement of a vascular
access device (VAD) for their treatment (Wuerz, 2016). VADs can
be categorised into two types of devices: peripherally inserted and
centrally inserted. Estimates show that 90% of these hospitalised
patients will require peripheral intravenous (PIV) therapy during
their admission, and 25% of these patients will go on to require a
central venous access device (CVAD) for a variety of clinical indica-
tions: antibiotic therapy, pain management, chemotherapy, total par-
enteral nutrition, fluid and/or blood product administration, dialysis,
apheresis blood draws and diagnostic imaging (American College
of Radiology, 2018; Deshmukh & Shinde, 2014; Ullman, Long, &
Rickard, 2014; Weinstein & Hagle, 2014).
Both PIVs and CVADs require significant nursing knowledge, skill
and clinical judgement to ensure positive patient outcomes (Hunter,
Vandenhouten, Raynak, Owens, & Thompson, 2018; Raynak,
Paquet, Ruck, & Wood, 2018). Literature published globally, in addi-
tion to anecdotal evidence, has identified gaps in nurses’ knowledge
regarding the care and maintenance of VADs. Inadequate nursing
knowledge with respect to routine care and maintenance of VADs
is associated with poor patient outcomes, including higher com-
plication rates (e.g. central line-associated bloodstream infections
and occlusions), an increase in morbidity and mortality, and longer
hospitalisation (Centres for Disease Control & Prevention, 2011;
Cicolini et al., 2013; Deshmukh & Shinde, 2014; Humphery, 2015;
Marschall et al., 2007; Paquet, Boucher, Valenti, & Lindsey, 2017;
Ullman et al., 2014).
However, a clear understanding of the depth and breadth of
nurse knowledge about VADs is lacking. Studies with nurses from a
variety of countries have revealed knowledge deficits (e.g. Alkubati,
Ahmed, Mohamed, Fayed, & Asfour, 2015; Banks, Gilmartin, & Fink,
2010; Lobo et al., 2010; Ozden & Caliskan, 2012), but to date, there
has been no comprehensive scoping review of nurses knowledge on
the routine care and maintenance of adult VAD’s published.
Scoping reviews are conducted for a variety of reasons, for ex-
ample, when it is difficult to determine a narrow review question,
when sources may have multiple study designs, when knowledge is
not published on the existing topic or when a quality assessment
of review sources is not essential (Arksey & O’Malley, 2005). Based
on the complexity of evaluating nurses’ knowledge of VADs, the
authors decided a scoping review would be an effective method to
examine the subject, synthesise new evidence and identify gaps in
the literature.
The objective of this scoping review is to address the following
question: What is the current state of nurses’ knowledge regarding
the routine care and maintenance of VADs in adults?
RAYNAK et al.
What does this paper contribute to the wider
global community?
• It is difficult for nurses to keep up with the rapidly evolv-
ing research world, leading to a gap in evidence-based
practice at the bedside.
• The complexity of care is continuously increasing, and
nurses are expected to perform as experts in all fields.
• It is imperative that academic institutions and health-
care organisations work together to support the knowl-
edge and ongoing professional development of their
students/employees.
2 | M E TH O DS
The data collection for this review was conducted in the fall of 2018.
The Joanna Briggs Institute Reviewers Manual (2017) was used to
guide the methods and map the findings (Aromataris & Munn, 2017).
Comprehensive searches were conducted on 15 October 2018 in
the following databases: Medline-Ovid 1946 to current, Embase-
Ovid 1947 to current, CINAHL Plus with full text and Nursing &
Allied Health database, limited to a publication date of 2005 on-
wards and to English and French language. The initial search strategy
was developed in Medline by a research librarian and peer-reviewed
by a second research librarian using the Peer Review of Electronic
Search Strategies checklist (McGowan, Sampson, & Lefebvre, 2010;
Appendix A1). This search was then translated to the other data-
bases, and duplicates were removed using a simplified method
based on Bramer, Giustini, de Jonge, Holland, and Bekhuis (2016).
After initial screening, articles meeting the criteria for inclusion
(Morris, Boruff, & Gore, 2016) were analysed using the Yale MeSH
Analyser to identify additional keywords or subject headings that
could be used to improve the original search (Grossetta Nardini &
Wang, 2017), resulting in a slight revision to the search strategy
(see Appendix A1 for final Medline search strategy), and all updated
searches were rerun on 5 August 2019. After duplicates and previ-
ously retrieved articles were removed, a second screening was con-
ducted. Reference lists from included articles were hand-searched,
and citing articles were reviewed using Google Scholar and Scopus
to identify additional relevant articles.
Articles included in this study included original research pub-
lished in peer-reviewed journals that focused on practising nurses’
knowledge about the routine care and maintenance of adult VADs.
The authors define VADs as any device that is inserted into an adult
patient's vein, whether it is peripheral or central. This includes PIV
RAYNAK et al. | 3

catheters, centrally inserted central catheters (CICC), totally im-
plantable vascular access devices (TIVAD), peripherally inserted
central catheters (PICC) and tunnelled catheters (e.g. Hickman®/
Broviac®). This review excludes haemodialysis and apheresis cath-
eters as they are often restricted to specialised nurses who have
received particular training on their usage (Craswell et al., 2019;
Neyrinck & Vrielink, 2019). Articles excluded from this scoping
review include the following: not original research in a peer-re-
viewed journal, studies in which the population in focus was not
nurses (ie. doctors, pharmacists, nursing assistants) or where
results specific to nurses were not available within the publication;
studies not related to VADs; studies focusing on haemodialysis
catheters, paediatric or neonatal patients as the sole sample; arti-
cles that examined how knowledge is put into practice (knowledge
translation); articles that provided recommendations/guidelines/
synthesis of best practices; articles that focused on the insertion
of VADs; and articles focusing on nursing students, as clinical skills
and scope of practice differs by geographical area and institution
(Figure 1). The included full-text articles were divided equally
and independently read by a minimum of two investigators.

Records identified through Additional records

searching databases (n = identified through other
9084) sources (n = 2)

Excluded full-text articles

Records after the removal of (n = 276)
-Miscellaneous (conference abstract,
duplications (n = 4099) editorial, thesis etc.) (n = 99)
-Synthesis of literature or guidelines
(n = 46)
-Evaluated the effect of an
intervention without presenting pre-
intervention knowledge (n = 35)
-Assessed knowledge translation
Articles screened (3789) (n = 27)
-Performed an assessment or audit of
nurses (n = 23)
-Included other professions besides
nurses (n = 15)
-Focused on the insertion of VAD’s
(n = 11)
-Sole population in study was
Full text articles assessed for pediatrics or neonates (n = 7)
eligibility (n = 310) -Primary language was not English or
French (n = 6)
-Examined haemodialysis catheters
(n = 3)
-Did not include VAD catheters (n = 2)
-Duplicate (n = 1)
-Article could not be retrieved for full
review (n = 1)

Articles included in the

synthesis (n = 36)

FIGURE 1 Scoping review flow diagram

4 |
Agreement between the reviewers was confirmed through joint
assessment of the selected literature. Any uncertainties were
discussed within the research team until consensus was reached.
Articles were selected according to the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses extension for Scoping
Reviews (PRISMA-ScR) guidelines (File S1).
An extraction table was developed by the primary author out-
lining relevant information to collect to ensure consistency among
reviewers (Appendix B1). The authors were assigned a subset of
articles and extracted the following: author(s), year of publication,
journal, country of origin, aims/purpose related to nurses’ knowl-
edge, study methodology, population, sample size, VAD studied, tool
utilised for knowledge assessment and outcomes/details. A second
author verified the extracted data. The reviewers did not appraise
the quality of the evidence. Results were further analysed through
inductive thematic analysis. This qualitative analytic approach al-
lowed the research team to provide a detailed account of the current
knowledge of practicing nurses by identifying, organising and report-
ing themes found within the data set. The generated themes, which
described patterns across qualitative and quantitative data, were
compared and contrasted regarding current knowledge of practicing
nurses. A review protocol was not created for this scoping review.
Knowledge scores presented in the following result section are
shown as percentages with standard deviations. Comparison be-
tween PIV and CVAD scores was done using a t test for compar-
ison of means with MedCalc for Windows, version 19.1 (Medcalc
Software, Ostend, Belgium).
3 | R E S U LT S
After the removal of duplicates, a total of 4,099 articles were
identified from the electronic database search. The articles were
screened based on title and abstract, and an additional 3,789 ar-
ticles were excluded based on the inclusion/exclusion criteria, re-
sulting in 310 remaining for full-text review. Of these 310 articles,
276 of these were excluded for the following reasons: miscella-
neous (conference abstract, editorial, thesis, poster etc.) (n = 99);
synthesis of literature or guidelines (n = 46); evaluated the effect
of an intervention without presenting pre-intervention knowledge
(n = 35); assessed knowledge translation (n = 27); performed an
assessment or audit of nurses’ performance (n = 23); included
other professions besides nurses (n = 15); focused on the inser-
tion of VADs (n = 11), paediatrics or neonates (n = 7); primary lan-
guage was not English or French (n = 6); examined haemodialysis
catheters (n = 3); did not include vascular access catheters (n = 2);
duplicate (n = 1); and 1 article could not be retrieved for full re-
view. Two additional articles were found through snowballing, re-
sulting in 36 full-text articles included in the scoping review. The
PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist
and Explanation was followed (Figure 1).
We report study characteristics and themes related to nurses’
knowledge of CVAD care and PIVs separately.
RAYNAK et al.
4 | S T U DY C H A R AC TE R I S TI C S
4.1 | Location
The majority of the articles included in this scoping review were stud-
ies from the United States (n = 9), followed by India (n = 4), Turkey
(n = 5), Italy (n = 3), Jordan (n = 3), Brazil (n = 3), Egypt (n = 1), Poland
(n = 1), United Kingdom (n = 1), Malaysia (n = 1), Scotland (n = 1),
Belgium (n = 1), France (n = 1), Canada (n = 1) and one European
multinational study.
4.2 | Study design
Multiple study designs were used for the articles included in this
scoping review: descriptive studies (n = 22) [cross sectional (n = 19),
prospective quantitative study (n = 1), prospective observational
(n = 1), clinical audit (n = 1)] and experimental studies (n = 10) [ran-
domised controlled trial (n = 1), pretest/post-test (n = 7) and pre-
experimental design (n = 2)], and in several studies, the study design
was not mentioned (n = 4).
4.3 | Study population
In the 36 studies included in our review, nurses’ work settings
varied. The settings/speciality included oncology (n = 8), inten-
sive care (n = 7), emergency (n = 1), surgical specialities (n = 4),
mixed specialties (n = 15) and community nursing (n = 1). There
was an average of 283 respondents per study for a total of 10,191
respondents.
Out of the 36 articles, nurses’ knowledge about CVADs alone
was assessed in twenty-five articles, PIVs alone in seven and both
CVADs and PIVs four articles.
5 | C VA DS —TH E M E S I N TH E LITE R AT U R E
5.1 | Relationship between demographic data and
CVAD knowledge
Our scoping review revealed an inconsistent relationship between
years in nursing practice (seniority) and VAD management knowl-
edge. Although some studies found no relationship between years
in nursing practice and VAD management knowledge (Banks,
et al., 2010; Mason, Ferrall, Boyington, & Reich, 2014; Raynak
et al., 2018),one found a trend towards higher knowledge scores
based on employment seniority (Paolucci, Nutter, & Albert, 2011),
and three studies found that experienced nurses performed sig-
nificantly better than less experienced nurses (Abu Sharour, 2018;
Aloush, 2018; Dedunska & Dyk, 2015). However, one study reported
that older nurses performed more poorly on the knowledge tests
than younger nurses (Esposito, Guillari, & Angelillo, 2017).
RAYNAK et al.
Three studies found no relationship between work setting and
VAD management knowledge scores (Banks, et al., 2010; Mason
et al., 2014), while statistically significant relationships were found
by other authors (Accardi, 2017; Dedunska & Dyk, 2015; Raynak
et al., 2018). Knowledge was higher for nurses working in medicine
units compared to those working in surgical units (Accardi, 2017).
Similarly, Dedunska and Dyk (2015) reported that knowledge scores
were higher for nurses working in intensive care units (ICU) versus
non-ICU settings. For example, working with CVADs more than 50%
of the time was associated with higher scores on a knowledge test
(compared to nurses working with CVAD less than 50% of the time)
(Raynak et al., 2018).
Only one study revealed a statistically significant difference in
the results of a knowledge test on central venous catheter-related
infections when comparing gender. Female nurses scored statisti-
cally higher than their male counterparts, although the absolute dif-
ference was small (Alkubati et al., 2015).
In relation to academic background or advanced certifica-
tion, three studies reported no relationship with VAD manage-
ment knowledge (Al Quadire, 2017; Mason et al., 2014; Raynak
et al., 2018), whereas others found some significant relationship
between VAD management knowledge and nurses holding ei-
ther a Bachelor or Masters degree in nursing (Abu Sharour, 2018;
Aloush, 2018; Barbosa et al., 2017; Kapucu et al., 2016) or hold-
ing an advanced certification (Abu Sharour, 2018; Dedunska &
Dyk, 2015).
Furthermore, some studies also reported whether prior work-
place training in VAD management had any effect on VAD knowl-
edge. Four studies reported that prior training was associated with
higher knowledge (Dedunska & Dyk, 2015; Esposito et al., 2017;
Kapucu et al., 2016). Unfortunately, the time frame between the
training received and the assessment of the nurses’ knowledge was
not provided by the authors except Kapucu et al. (2016), in which
education received more than 2 years ago still positively influenced
VAD knowledge. Aloush (2018) noted in their study that the vast
majority (75%) of nurses participating had not received any for-
mal education about catheter-related infection prevention in their
workplace.
5.2 | State of nurses’ CVAD knowledge
Nevertheless, the majority of nurses did not know the location of
the CVAD catheter (Letournel, 2018; Ozden & Caliskan, 2012), the
indications for a CVAD (Letournel, 2018), the type of material the
CVAD was made of, nor how long the CVAD could remain in situ
(Ozden & Caliskan, 2012). In addition, nurses did not know about the
type of access needles for totally implantable vascular access de-
vices (TIVAD), gauge, nor duration of use (Kapucu et al., 2016; Ozden
& Caliskan, 2012).
With regard to knowledge on infection prevention and control,
60%–100% of nurses knew how to prevent infection, including the
need for disinfection of the needlefree connector (Accardi, 2017;
| 5
Dedunska & Dyk, 2015; Esposito et al., 2017; Lobo et al., 2010;
Paolucci et al., 2011; Raynak et al., 2018). However, in one study,
nurses from varied specialties did not know the rationale for the
disinfection of the needlefree connector (Dedunska & Dyk, 2015).
Knowledge of the moments of hand hygiene varied between 76.4%–
88% (Kapucu et al., 2016; Lobo et al., 2010). A limited number of
nurses (24%) were knowledgeable about the pathophysiology of
CVAD infections (Alkubati et al., 2015).
Regarding the frequency of CVAD replacement, one study re-
ported that only 26% of nurses knew CVADs did not need to be
routinely replaced, but rather only when clinically indicated (Al
Quadire, 2017). Nurses identified the indications for changing a
CVAD dressing (e.g. when loose or soiled) and the appropriate type
of dressing (Dedunska & Dyk, 2015; Esposito et al., 2017; Paolucci,
Nutter, & Albert, 2011), but only 28.9%–65% of nurses were aware of
the recommended frequency for routine dressing changes (Alkubati
et al., 2015; Letournel, 2018; Ozden & Caliskan, 2012; Raynak
et al., 2018). There was much variability found in nurses’ knowledge
of the correct skin disinfection solution, with 20 to 81% of respon-
dents identifying the correct product (Al Quadire, 2017; Dedunska &
Dyk, 2015; Ozden & Caliskan, 2012; Raynak et al., 2018). However,
the nurses were aware not to use hydrogen peroxide as a disinfec-
tant agent (Esposito et al., 2017). Similarly, the majority of nurses
knew to avoid putting antibiotic ointment on the insertion site, al-
though they could not identify the rationale (Alkubati et al., 2015;
Dedunska & Dyk, 2015; Esposito et al., 2017; Labeau, Vereecke,
Vandijck, Claes, & Blot, 2008; Raynak et al., 2018).
A high proportion of nurses knew the type and size of syringe to
use for flushing (Raynak et al., 2018) and that the lumen needed to
be flushed with saline after the administration of a medication or in-
travenous fluids (Esposito et al., 2017). However, 56%-64% of nurses
did not know their institution's CVAD flushing policy (Banks,et al.,
2010; Humphrey, 2015; Letournel, 2018) and 76% were also un-
aware of the requirements to perform pulsatile flushing for CVADs
(Letournel, 2018). Knowledge of the type of needlefree connector
and flushing technique for the connector was reported to be insuffi-
cient (Letournel, 2018).
Replacement of administration sets used for lipid emulsion,
blood and blood products was a known element of CVAD care
and maintenance by 78%–90% of nurses (Dedunska & Dyk, 2015;
Labeau et al., 2009; Raynak et al., 2018). However, only 25%–33%
of nurses were cognisant of the frequency of tubing replacement
for continuous or intermittent infusions (Dedunska & Dyk, 2015;
Raynak et al., 2018).
On the topic of CVAD troubleshooting, variable nursing knowl-
edge about occlusion management was reported. The majority of
nurses were able to recognise an occluded CVAD and could iden-
tify the initial interventions, but if these interventions (e.g. raising
the arm or asking the patient to cough) were unsuccessful, then
knowledge of more advanced troubleshooting was lacking (Mason
et al., 2014; Paolucci, Nutter, & Albert, 2011). For example, 50%–
76% of nurses reported using a troubleshooting technique that was
not supported by evidence (e.g. using saline as an anti-occlusive
6 |
agent, using dexamethasone to confirm placement, instilling heparin
or using warfarin for problematic occlusions; Mason et al., 2014).
Nurses had limited knowledge about complications such as
extravasation, air embolism, and catheter dysfunction (Ozden &
Caliskan, 2012) and tip culture (Banks et al., 2010). In a further study
of oncology nurses, Kapucu et al. (2016) reported that most nurses
did know about extravasation as a complication and the required
interventions.
5.3 | Nurses’ CVAD knowledge scores
This scoping review revealed that ten studies used a single
knowledge score to describe the state of nurses knowledge (Al
Qadire, 2017; Alkubati et al., 2015; Barbosa et al., 2017; Dedunska
& Dyk, 2015; Kelly, Green, & Hainey, 2015; Kurian & John, 2016;
Letournel, 2018; Ozden & Caliskan, 2012; Paolucci, Nutter, &
Albert, 2011; Raynak et al., 2018). Ten additional studies reported
the effect of an educational intervention, using a pretest and post-
test design (Aloush, 2018; Aniyan & Shaiju, 2013; Banks,et al., 2010;
Humphrey, 2015; Mutlu & Senturan, 2017; Ngo & Murphy, 2005;
Page, Tremblay, Nicholas, & James, 2016; Roslien & Alcock, 2009;
Yilmaz, Caylan, Aydin, Topbas, & Koksal, 2007; Xavier, 2013). Two
authors tested nurses’ knowledge using a pre-established mini-
mum satisfactory score. These authors only presented the num-
ber of nurses who obtained a satisfactory knowledge score (Abu
Sharour, 2018; Bijayalaxmi, Urmila, & Prasad, 2010). For the studies
reporting pretest and post-test scores, only the pretest scores are
included in this review as they represent nurses’ knowledge prior to
an intervention. The post-test score results were measured after an
educational intervention.
Therefore, the compiled results included 22 studies totalling
3,930 respondents (median of 64 per study). To calculate the overall
CVAD knowledge score, 20 out of the 22 studies provided a knowl-
edge score. Those 20 individual scores were converted into per-
centages if they were presented differently and then averaged. The
average knowledge score pertaining to CVAD was 55.41% (± 16.99;
n = 20). The number of questions asked in the surveys on knowledge
was presented by 20 authors and varied between 9–50 (mean = 22).
The lowest knowledge score was 26% (n = 2), and three studies re-
ported a knowledge score greater than 75% (76.4% and 81.8%). The
two studies that provided a satisfactory score resulted in an average
of 63% of nurses possessing satisfactory knowledge.
6 | PI V—TH E M E S I N TH E LITE R AT U R E
6.1 | Relationship between demographic data and
PIV knowledge
There were fewer studies focusing on nurses’ knowledge of PIV man-
agement (n = 7) compared to CVAD management (n = 25). Similar
to CVAD knowledge, this scoping review revealed no consistent
RAYNAK et al.
relationship between years in nursing practice (seniority) and PIV
management knowledge. Only one study looked at seniority and
found that staff nurses who had more than 10 years of experience
had higher PIV knowledge scores about the factors associated with
risks of PIV-related infection (Cicolini et al., 2013). Moreover, only
one study looked at the association between age and knowledge
scores and concluded that nurses older than 40 years of age had
greater knowledge regarding protective skin preparation compared
to younger nurses (Bijayalaxmi et al., 2010).
Two studies found statistically significant differences between
work setting and PIV management knowledge scores, where special-
ity units and managerial staff scored higher than nurses from other
areas (Cicolini et al., 2013; Ho, Liw, & Tang, 2016).
In relation to academic background, one study found that
knowledge scores were statistically significant when related to the
nurses’ level of education; more specifically, the median score in-
creased for nurses with a postgraduate degree compared to nurses
with an undergraduate degree (Cicolini et al., 2013). Contrarily, Ho
et al. (2016) did not find statistically significant findings, but re-
ported that nurses with a bachelor's degree scored slightly higher
in knowledge and practice towards the care and maintenance of PIV
catheters. Bijayalaxmi et al. (2010) reported that nurses with bacca-
laureate qualifications had more knowledge about thrombophlebitis
and PIV catheter-related infections than those without a university
education.
6.2 | State of nurses’ PIV knowledge
Between 57.6%–75.8% of nurses questioned were able to answer
correctly questions regarding PIV catheter selection, insertion areas
and steps to be taken in the event an extravasation occurs (Kapucu
et al., 2016). In another study, nurses correctly identified the rec-
ommended dwell time for replacing an uncomplicated PIV (72 hr;
Biswas, 2013).
With regard to knowledge of infection prevention and control,
73.7% of nurses were not familiar with the CDC recommendations
for hand washing before a PIV insertion (Cicolini et al., 2013). In addi-
tion, only 50.4% of nurses could identify the correct antiseptic agent
for skin asepsis prior to insertion (Cicolini et al., 2013).
With respect to PIV dressing changes, there was coherence
between nurses’ knowledge of dressing change frequency and
their observed performance (Boide, Bourigault, des Buttes, &
Lepelletier, 2013). While both sterile transparent film dressing
and sterile gauze can be used to cover the catheter site, 44.6% of
nurses thought that the transparent material was preferred (Cicolini
et al., 2013).
Nurses had a poor understanding of when to change adminis-
tration sets (Cicolini et al., 2013; Kapucu et al., 2016). Furthermore,
two studies indicated that nurses were unaware that an asep-
tic technique needs to be maintained during the management
of infusion lines (Cicolini et al., 2013; Cirelli, de Figueiredo, &
Zem-Mascarenhas, 2007).
RAYNAK et al.
6.3 | Nurses’ PIV knowledge scores
Three studies examined nurses’ PIV management knowledge. One
study presented a single knowledge score (Cicolini et al., 2013), while
the other three studied the effect of an intervention on education
using a pretest and post-test score (Alton, 2012; Fakih et al., 2013;
Woody & Davis, 2013). For the studies reporting pretest and post-
test scores, only the pretest scores are included in this review as
they represent nurses’ knowledge prior to an intervention. The post-
test score results were measured after an educational intervention.
The average knowledge score for the four studies was 65.47%
(±10.96). The average number of questions asked on the surveys
was 15, ranging from 10–18 questions. The total respondents were
1,093 (median 65 per study). The lowest PIV management knowl-
edge score was 45.5% (n = 1), and two studies reported a PIV man-
agement knowledge score greater than 75% (highest score: 81.3%).
When examining knowledge score results for both CVAD (av-
erage 55.14%) and PIV (average 65.48%), the nurses’ management
knowledge on PIVs was higher. The difference between the two
scores (CVAD and PIV) was not statistically significant.
7 | D I S CU S S I O N
This scoping review aimed to understand the current state of nurses’
knowledge regarding the routine care and maintenance of VADs
in adults. Overall, given the sheer quantity of VADs used in health
care, it is surprising that only 36 studies were found, despite rigorous
searching of scientific literature. Even so, these 36 studies were con-
ducted all over the world, suggesting that nurse's knowledge about
management of VADs is a global healthcare concern.
However, the situation described in these assessments of nursing
knowledge can only be described as alarming. For both CVADs and
PIVs, nurses’ knowledge of routine care and maintenance was sub-
par with average scores below 60%. This finding indicates that there
is an important opportunity to improve patient care and outcomes.
We already know that measures of nurses’ knowledge (e.g. pen
and paper or computer tests) do not correlate perfectly with nurses’
performance, as contextual factors play a major role in translating
knowledge into action (Marchionni & Ritchie, 2008). But if nurses’
lack the knowledge of best practices, they are less likely to perform
them even if the context is receptive (Funk, Champagne, Wiese, &
Tornquist, 1991).
Knowledge of CVAD and PIV routine care and management was
compared in this review. Nurses had statistically significant higher
knowledge of PIV management, a finding that is not surprising given
the ubiquity of the PIV in healthcare settings. Since up to 90% of
hospitalised patients will receive some form of intravenous infu-
sion while hospitalised (Weinstein & Hagle, 2014), it is imperative
that PIV care be consistent with the latest evidence-based guide-
lines in order to ensure optimal outcomes. PIV use can be associ-
ated with a plethora of complications, including and not limited to,
infiltration, extravasation, phlebitis, premature catheter failure and
| 7
infection (Helm, Klausner, Klemperer, Flint, & Huang, 2015). PIVs are
now identified as an important source of nosocomial infection, and
cases of death due to PIV infection are now being reported (Ripa
et al., 2018; Sato et al., 2017). Therefore, poor knowledge of routine
maintenance, which has been shown to reduce the prevalence of
complications, has become a major concern.
This scoping review identified the following main themes with
respect to nurses’ knowledge.
7.1 | Nurse demographics and the relationship to
VAD knowledge
With respect to the relationship between demographic variables
and nurses’ knowledge, patterns were apparent irrespective of the
country in which the study was conducted. Unsurprisingly, the age
of the nurses was positively associated with their years of work ex-
perience and seniority in their healthcare organisation. Generally,
older nurses (both in age and in years of experience) had better
knowledge of both CVAD and PIV care and maintenance than their
younger peers (Abu Sharour, 2018; Aloush, 2018; Bijayalaxmi et al.,
2010; Cicolini et al., 2013; Dedunska & Dyk, 2015; Paolucci, Nutter,
& Albert, 2011). However, it was not clear from these studies where
these older nurses had obtained their knowledge (e.g. on-the-job
training, self-study or through the pursuit of advanced nursing de-
grees). It is likely that formal education played a role as it was shown
that nurses who reported university studies at the baccalaureate or
masters level had better VAD knowledge, irrespective of their age
(Abu Sharour, 2018; Aloush, 2018; Barbosa et al., 2017; Bijayalaxmi
et al., 2010; Cicolini et al., 2013; Ho et al., 2016; Kapucu et al.,
2016). Multiple other studies have demonstrated the relationship
between higher nursing education and improved patient outcomes
mediated via nurse knowledge (see Aiken, Clarke, Cheung, Sloane, &
Silber, 2003; Blegen, Goode, Park, Vaughn, & Spetz, 2013; Haskins &
Pierson, 2016). Cicolini et al. (2013) contend that this finding should
represent a starting point for healthcare managers to reflect on the
importance of ongoing nursing education.
7.2 | Nurses’ specific knowledge regarding VADs
In general, nurses were more knowledgeable about PIV catheter se-
lection, insertion sites and dwell times and were found to be lacking
basic knowledge about CVADs, including location within the vascu-
lature, indication and dwell time. This likely reflects the ubiquity of
the PIV compared to the CVAD. For example, in one study, only 26%
of nurses knew that CVADs did not need to be routinely replaced (Al
Quadire, 2017).
These studies also reported great variation in knowledge of
the correct skin disinfection solution for CVADs. Best practice
recommendations still include various products and solutions with
variable percentages of chlorhexidine. Products available on nurs-
ing units vary in concentration of chlorhexidine from 0.5%–2%.
8 |
Nurses do use and assume that products available for use on their
units reflect the latest recommendations when this may not be
the case. The same applies for PIVs, as there were inconsisten-
cies in knowledge regarding recommended skin asepsis (Cicolini
et al., 2013).
Nurses knew the size and type of syringe to use for CVAD flush-
ing and when to flush (Esposito et al., 2017; Raynak et al., 2018), but
knowledge about the pulsatile flushing technique (see Boord, 2019)
was insufficient (Letournel, 2018). This could be related to a deficit
in knowledge about their local institution's flushing policy, as over
50% of nurses were not knowledgeable in this regard (Banks,et al.,
2010; Humphrey, 2015; Letournel, 2018). No studies in this review
examined knowledge regarding PIV flushing.
Furthermore, the frequency of tubing replacement for CVADs
and PIVs for various infusions was known by up to 33% of the study
respondents (Cicolini et al., 2013; Dedunska & Dyk, 2015; Kapucu
et al., 2016; Raynak et al., 2018). Specifically regarding tubing for
lipid and blood product administration, 78% of respondents knew
the correct recommendations (Dedunska & Dyk, 2015; Labeau
et al., 2009; Raynak et al., 2018), likely due to the fact that rec-
ommendations for regular tubing changes are updated more fre-
quently, while the recommendations for lipids and blood products
have not varied in recent years. Indeed, it is likely challenging for
nurses to remain abreast of practices that are rapidly changing.
Even if specialty associations that promote best practices in infu-
sion nursing have created guidelines (e.g. Canadian Vascular Access
Association, 2019ssociation, 2019; Gorski et al., 2016), cost may be
prohibitive to individual nurses and some organisations. Perhaps,
manufacturers could incorporate the current, up-to-date tubing
change frequency on their packaging as a friendly reminder for the
nurses.
With respect to dressing changes, we report that nurses knew
that they should change a dressing that had become soiled or loose,
but they did not know the schedule for routine dressing changes for
CVADs.
Fortunately, our review revealed that a greater percentage of
nurses were knowledgeable about CVAD infection prevention, es-
pecially regarding the disinfection of the ports before accessing
(scrub the hub). More than 75% of nurses could correctly identify
the moments of hand hygiene. However, we deemed knowledge re-
garding the prevention of peripheral line-associated bloodstream in-
fection (PLABSI) unsatisfactory. Knowledge about aseptic technique
for PIV infusion line management was found to be inadequate as well
by two authors (Cicolini et al., 2013; Cirelli et al., 2007).
7.3 | Knowledge about VAD complications
Our study discovered an immediate area for continuing nursing edu-
cation. With respect to VAD complications and their management,
overall knowledge was low except for the small cohort of oncology
nurses who knew how to intervene immediately in the case of ex-
travasation of vesicant solutions (Kapucu et al., 2016).
RAYNAK et al.
7.3.1 | Occlusion management
Nurses were able to recognise and identify initial steps to remedy an
occluded CVAD, but were unaware of more advanced techniques.
Consequently, 50% to 76% of nurses reported using nonevidence-
based techniques to unblock CVADs. This approach to occlusion
management places both the central line and the patient at risk and
suggests a requirement for further knowledge development or the
intervention of a VAD infusion team of expert clinicians (Hadaway,
Dalton, & Mercanti-Erige, 2013).
7.3.2 | Extravasation
Furthermore, nurses were unaware of common complications such
as extravasation, air embolisation, catheter dysfunction (Ozden &
Caliskan, 2012) and tip culturing for CLABSI diagnosis (Banks et al.,
2010). In oncology, a specialty where extravasation can have dev-
astating consequences, nurses were found to be more aware and
knowledgeable of extravasation and its management, for both
CVADs and VADs (Kapucu et al., 2016). While extravasation man-
agement is an important part of cancer chemotherapy nursing prac-
tice (Canadian Association of Nurses in Oncology, 2017), vesicant
solutions are used in many practice areas and it would be essen-
tial that nurses be able to identify and intervene to prevent patient
morbidity.
7.4 | A need for better workplace training
The overall knowledge of nurses with respect to both CVADs and
PIVs was found to be low, and many nurses reported they did not
receive any on-the-job training (Kelly et al., 2015; Letournel, 2018).
This review did find that nurses who were currently working in areas
with more exposure to VADs, such as medical units or ICUs, had
more familiarity with the care and maintenance, suggesting that ex-
posure to these devices allows for the development of better knowl-
edge (Accardi, 2017; Cicolini et al., 2013; Dedunska & Dyk, 2015;
Ho et al., 2016; Raynak et al., 2018), which can be obtained through
training, either provided by employers or by self-directed continu-
ing educational initiatives (Dedunska & Dyke, 2015; Esposito et al.,
2017; Kapucu et al., 2016). However, on-the-job training is not sys-
tematically offered, as noted by Aloush (2018), who reported that
Jordanian nurses had not been provided with any training in the
workplace on catheter-related bloodstream infections (CRBSI) pre-
vention. Nevertheless, workplace learning opportunities are key as
knowledge was found to be greater in nurses who received prior
training, regardless of the time between this training and knowledge
assessment (Dedunska & Dyk, 2015; Esposito et al., 2017; Kapucu
et al., 2016). Ozden and Caliskan (2012) similarly concluded that
planned, continuous and efficient in-service training sessions could
increase nurses’ knowledge about implantable ports. Nurses who
had received these trainings showed improved knowledge scores
RAYNAK et al.
about these VADs. Thus, our study strongly supports the recom-
mendation that all nurses working with VADs have access to routine,
comprehensive on-the-job training.
Moreover, our review underscores that there is room for im-
provement in the educational preparation of nurses with respect
to VAD care. While the education of nurses regarding the care
and maintenance of VADs should be a responsibility shared by
the educational institutions and the healthcare employers (Hunter
et al., 2018; Marchionni, Gauthier, Aube, & Lavoie-Tremblay, 2018;
Vizcarra et al., 2014), there are several mechanisms by which this
can be accomplished. For example, journal clubs have been shown
to improve evidence-based practice skills of allied health profes-
sionals and this is one method to disseminate research findings
(Lizarondo, Grimmer-Somers, Kumar, & Crockett, 2012). Another
avenue to increase interest in VADs and infusion nursing among pre-
licensure nurses, as described by Vioral (2011), is a mentoring pro-
gramme to increase student interest in oncology nursing by pairing
students with members of a local chapter of the Oncology Nursing
Society. Such mentorships could be replicated with nurses who are
members of vascular access and infusion nursing associations (e.g.
Infusion Nurses’ Society, Canadian Vascular Access Association).
To promote nursing student engagement, the Canadian Vascular
Access Association has an undergraduate ambassador to the Board
of Governors. Recently, a student vascular access and infusion nurs-
ing club received official chapter designation from the Canadian
Association of Vascular Access (cvaa.info). These initiatives can only
serve to increase student knowledge and skills related to VADs prior
to licensure.
8 | LI M ITATI O N S
Despite the significance of our findings, we acknowledge several
limitations. First, nursing credentials and certifications vary among
countries. We chose to include only nurses and registered nurses in
the review and to exclude certified nursing assistant (CNA), nursing
aids (NA) and licensed practical nurses (LPNs) when these roles were
identified by the authors as there is tremendous variability in nurs-
ing scope of practice. Variances in nursing education programmes,
as well as credentialing mechanisms, created a challenge since the
professional designation of nurses was not always clear.
Second, given that the purpose of our scoping review was to ex-
plore the current state of nurses’ knowledge regarding the routine
care and maintenance of VAD devices, we focused on the results of
each study rather than conducting a formal appraisal. In the included
studies, the methods were often not described in detail, and the re-
liability and validity of the questionnaires were not always indicated.
Furthermore, many authors did not indicate the content of the ques-
tionnaires used to assess nurse knowledge. This review highlights
the lack of systematic approaches to assess nurses’ knowledge of
the routine care and maintenance of VADs.
Additionally, given the timeframe of the review (2005 to pres-
ent), guidelines for VAD care and maintenance have evolved during
| 9
this period (e.g. regarding re-siting PIVs). This rapid evolution of the
field often creates a challenge for measuring nurses’ knowledge.
Once a study reporting nurses’ knowledge had been published, the
recommended practices had already changed. Indeed, such rapid
changes in practice only serve to underscore the needs for a better
understanding of nurses’ educational needs.
Lastly, due to the nature of a scoping review, there is always a
chance an article could be missed due to human error (i.e. mistakes in
the search and/or indexer), the lack of indexing (i.e. time for indexing
to occur after articles are entered into a database) and the lack of
clarity in the title and abstract (i.e. indexing is absent or incorrect, or
dependent on authors choice of index words).
9 | CO N C LU S I O N
In conclusion, our scoping review revealed 36 studies focusing
on nurses’ knowledge regarding the routine care and mainte-
nance of CVADs (n = 25), PIVs (n = 7) and/or CVADs/PIVs (n = 4).
While there are more studies specific to CVAD management,
the nurses’ management knowledge of PIVs was higher (average
65.47%) compared to CVAD (average 55.14%). The variability in
nurses’ knowledge around both CVAD and PIV led the authors to
conclude that there is much room for improvement in the educa-
tional preparation of nurses and a significant need for workplace
training.
10 | R E LE VA N C E TO C LI N I C A L PR AC TI C E
Our review raises awareness of the poor state of nursing knowl-
edge of VAD routine care and maintenance, while highlighting the
importance of addressing this knowledge gap. Indeed, our findings
derived from the scientific literature in the past 15 years confirm
the need to focus on education, whether through formal university
education, on-the-job training or continuing nursing education.
Additionally, we found variability in knowledge for both CVAD
and PIV care and maintenance in nurses from different countries,
educational backgrounds and specialties, suggesting the need to
encourage educational institutions that prepare entry-to-prac-
tice nurses to provide such teaching. This could help ensure that
new nurses receive some initial education on VAD routine care
and maintenance, which would be further developed with con-
tinuing nursing education provided by the employer. Furthermore,
educating nursing students on VAD care and maintenance could
narrow the knowledge gap noted among nurses with less work
experience. Most importantly, this early education could help
nurses improve the quality and safety of the care that they deliver
to patients and promote their curiosity to further advance their
knowledge of VAD care and maintenance. In hopes of bridging the
concerning knowledge gap of nurses found in this scoping review,
as the next step forward, identifying the most useful educational
strategies is both essential and urgent.
10 | RAYNAK et al.
C O N FL I C T O F I N T E R E S T S TAT E M E N T
The authors have no conflicts of interest or to declare.
AU T H O R C O N T R I B U T I O N S
A.R. designed and directed the scoping review. F.F conducted the
search and V.L. exported the results into the database utilised.
A.R. and V.L reviewed all articles yielded and initially screened
articles based on title and abstract. A.R, V.L., F.P, C.M. and M.G.
reviewed remaining articles full-text and deemed appropriate-
ness based on inclusion/exclusion criteria. All authors contrib-
uted to the data extraction table, synthesis and interpretation of
the results. A.R. created the figure provided and supplementary
file. A.R. took the lead on writing the manuscript. F.P contributed
greatly to the manuscript along with C.M., V.L. and M.G. All au-
thors provided critical feedback which shaped the study, synthesis
and manuscript formation.
ORCID
Andrea Raynak https://orcid.org/0000-0003-0653-3185
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Medline search
1. exp Nursing Staff/
2. exp Nurses/
3. exp Nursing research/
4. exp Nursing care/
5. Nursing records/
6. nursing.fs.
7. (nurse$1 or nursing).tw,kf.
8. 1 or 2 or 3 or 4 or 5 or 6 or 7
9. Health Knowledge, Attitudes, Practice/
10. exp Professional Competence/
11. Guideline Adherence/
12. "Task Performance and Analysis"/
13. exp Clinical audit/
14. Professional practice/
15. Practice guidelines as topic/
16. exp Evidence-based Practice/
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therapy. Philadelphia, PA: Lippincott.
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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section.
How to cite this article: Raynak A, Paquet F, Marchionni C,
Lok V, Gauthier M, Frati F. Nurses' knowledge on routine care
and maintenance of adult vascular access devices: A scoping
review. J Clin Nurs. 2020;00:1–17. https://doi.org/10.1111/
jocn.15419
1. exp Nursing Staff/
17. (know* or aware* or skill* or confidence or confident or
compliance or comply or complied or adhere* or competenc* or
understand* or understood).tw,kf.
18. practice pattern*.tw,kf.
19. ((evidence informed or evidence based) adj2 (care or decision* or
practice)).tw,kf.
20. 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19
21. 8 and 20
22. Practice patterns, nurses'/
23. 21 or 22
24. Vascular access devices/
25. Central venous catheters/
26. Catheterization, central venous/
27. exp Catheterization, peripheral/
28. Catheters, Indwelling/
29. Cannula/
(Continues)
RAYNAK et al. | 13

A P P E N D I X A1 (Continued)

1. exp Nursing Staff/ 1. exp Nursing Staff/

30. Catheter-Related Infections/ 33. (catheter* adj (port or line*)).tw,kf.

31. ((catheter* or device* or placement* or line* or port*) adj2 34. 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33
(vascular or central or venous or vessel* or vein* or intra?venous 35. 23 and 34
or intra-venous or in?dwelling or in-dwelling or peripheral or picc
or artery or arterial or intra?arterial or intra-arterial or implantable 36. limit 35 to yr="2005 -Current"
or midline or femoral or jugular or subclavian or dialysis or 37. limit 36 to (English or French)
intra?osseous or intra-osseous or Swan-Ganz)).tw,kf.
32. (portacath or port-a-cath or hickman* or cannula*).tw,kf.

APPENDIX B2

Author(s); Year Population; Tool utilised

of Publication; Country of Aims/Purpose Related to Nurses’ Study sample size; for knowledge
Journal origin knowledge methodology VAD studied assessment Outcomes and details

Abu Sharour Jordan To assess the oncology nurses’ Descriptive— Oncology; Questionnaire Only 50% of nurses
(2018); Journal knowledge about central Cross 150; CVAD obtained a score
of Vascular line catheters and their care, sectional >60% on the test
Nursing complications, and applications
Accardi Italy To verify whether there are, and Descriptive— Mixed Questionnaire 60% of nurses could
et al. (2012); to which degree, knowledge Cross- Specialty; identify strategies to
Annali di igiene: and adherence to guidelines on sectional 128; PIV & prevent catheter-
medicina the prevention and control of surveys and CVAD related bloodstream
preventiva e di healthcare-associated infections practice infections
comunita by nursing staff observation
Al Qadire (2017); Jordan To evaluate oncology nurses’ Descriptive— Oncology; Questionnaire Knowledge on
American knowledge of guidelines for the Cross- 133; CVAD guidelines for
Journal of prevention of catheter-related sectional prevention of CRBSI
Infection Control bloodstream infections (CRBSI) survey design was very low; mean
score was 2.6/10
Alkubati Egypt To assess knowledge of MDs and Descriptive— Intensive Care Questionnaire Nurses had low
et al. (2015); RNs in ICU about guidelines for Cross- Unit; 60; knowledge about
American prevention of CVAD-related sectional CVAD prevention of
Journal of infection and adherence survey design CVAD-related
Infection Control to these guidelines in their infections
practices
Aloush (2018); Jordan To evaluate the effectiveness Experimental— Intensive Care Questionnaire Overall knowledge
Journal of of an educational course that RCT Unit; 131; scores were low,
Research in aimed to improve nurses’ CVAD mean 8.28/23
Nursing knowledge about CVAD-related
infection prevention guidelines
Alton (2012); Turkey To assess the effect of an Experimental— Mixed Questionnaire The mean pretest
HealthMED educational intervention Quasi- specialty; knowledge score
on nurses' knowledge and experimental, 30; PIV was 8.2/18
management of intravenous pre- and
cannulation poststudy
Aniyan and Shaiju India To evaluate knowledge of staff Experimental— Mixed Questionnaire The mean pretest
(2013); Nursing nurses before and after the Pretest/ Specialty; knowledge score
Journal of India administration of computer- post-test 30; CVAD was 16.53/36
assisted instructions on CVADs

(Continues)
14 | RAYNAK et al.

A P P E N D I X B 2 (Continued)

Author(s); Year Population; Tool utilised

of Publication; Country of Aims/Purpose Related to Nurses’ Study sample size; for knowledge
Journal origin knowledge methodology VAD studied assessment Outcomes and details

Banks et al. United To evaluate the effectiveness of a Experimental— Community; Questionnaire Mean knowledge
(2010); Journal States of focused, multifaceted, evidence- Pretest/ 146; CVAD score on pretest was
for Nurses in America based educational intervention Post-test 69.83%
Professional on registered nurses’ knowledge
Development and perceived competence of
the maintenance and care of
CVADs
To identify relationships between
demographic characteristics
of participants and nursing
knowledge in regard to CVADs
Barbosa Brazil To evaluate the knowledge of Descriptive— Mixed; 106; Questionnaire 75% of nurses
et al. (2017); nurses about good practices in Cross CVAD obtained a score
Journal of the maintenance and dressing of sectional greater than 75%
Nursing UFPE short -term CVAD
on line
Bijayalaxmi India To asses and evaluate the Descriptive— Surgical; 50; Questionnaire Educational level,
et al. (2010); knowledge of staff nurses Cross PIV & CVAD work experience and
Nursing Journal towards management of IV sectional age were associated
of India catheter-related infection to nurse knowledge
on concept,
causes, prevention,
complications and
management of IV
catheter-related
infections
Biswas (2013); United To assess staff's knowledge Descriptive— Surgical; 13; Interviews The majority of
British Journal of Kingdom regarding optimal timing for Clinical audit PIV nurses correctly
Nursing changing PIVs stated the optimal
time for changing
uncomplicated PIV
Cicolini Italy To evaluate nurses’ knowledge Descriptive— Mixed Questionnaire The majority of
et al. (2013); of current recommendations for cross Specialty; nurses had limited
Journal of preventing infections associated sectional 933; PIV knowledge of the
Clinical Nursing with PIV catheters current guidelines
To investigate potential on the prevention of
predictors associated with PIV catheter-related
nurses’ knowledge infection
Cirelli Brazil To evaluate the knowledge of and Descriptive— Mixed Questionnaire 31% of nurses
et al. (2007); adherence to standard practices Prospective, Specialty; identified standard
Revista Latino- in the peripheral venous access quantitative 29; PIV practices in the
Americana de procedures by the nursing team study peripheral venous
Enfermagem access procedure
concept correctly
Dedunska and Poland To evaluate nurses’ knowledge Not mentioned Mixed Questionnaire Among 11 selected
Dyk (2015); about the maintenance of a Specialty; evidence-based
American central venous catheter (CVC) 1868; CVAD recommendations,
Journal of and assessed it with regard to 55% of them were
Infection Control age, work experience, type of known to the nurses;
ward, frequency of trainings, Mean score for the
and postgraduate education questionnaire was
54%

(Continues)
RAYNAK et al. | 15

A P P E N D I X B 2 (Continued)

Author(s); Year Population; Tool utilised

of Publication; Country of Aims/Purpose Related to Nurses’ Study sample size; for knowledge
Journal origin knowledge methodology VAD studied assessment Outcomes and details

Esposito Italy To delineate the knowledge, Descriptive— Oncology; Questionnaire The vast majority of
et al. (2017); attitudes, and behaviour among Cross 335; CVAD nurses answered
PLoS ONE nurses regarding the prevention sectional questions correctly
of CLABSI's and to identify their about the main
predisposing factors. recommendations to
prevent CLABSIs
Fakih et al. (2013); United To evaluate the placement and Experimental— Emergency Questionnaire The mean pretest
American States of care of the PIV catheter in the Quasi- Department; score was 12.2 /15
Journal of America ED experimental, 95; PIV
Infection Control To assess the effect of education pre- and
and feedback on performance poststudy
on practice and outcomes
Ho et al. (2016); Malaysia To determine nurses’ knowledge Descriptive— Mixed Questionnaire Majority of nurses
Medicine & and practice towards care of PIV Cross Specialty; possessed adequate
Health catheters sectional 84; PIV knowledge and
practice towards the
care of PIV catheters
Humphrey (2015); United To determine the knowledge of Experimental— Intensive Care Questionnaire Mean knowledge on
Journal of the States of nurses working in critical care Pretest/ Unit; 64; CLABSI and CLABSI
Association for America areas on factors contributing to Post-test CVAD prevention was
Vascular Access CLABSI 4.6/9
To evaluate the influence of an
educational intervention on
participants’ knowledge of
factors contributing to
CLABSI
Kapucu Turkey To evaluate the knowledge level Descriptive Oncology; Web-based Majority of the
et al. (2016); on chemotherapy administration 165; PIV & and in-print nurses answered
Asia-Pacific through PIV catheters and CVAD questionnaire, correctly questions
Journal of CVADs email and on administration
Oncology face to face of chemotherapy
Nursing interviews using a PIV catheter
and management
of extravasation;
69% of nurses
are not aware of
the replacement
frequency of
infusion sets and
knowledge is lacking
on size of needle to
use with a totally
implantable venous
access device
(TIVAD)
Kelly et al. (2015); Scotland To determine whether the Descriptive— Mixed Questionnaire 55% of nurses have
British Journal of introduction of an innovative Cross- Specialty; with open none or limited
Nursing educational intervention within sectional 69; CVAD ended knowledge
a higher education institution survey design questions
improved the confidence and
knowledge of registered nurses
dealing with CVADs

(Continues)
16 | RAYNAK et al.

A P P E N D I X B 2 (Continued)

Author(s); Year Population; Tool utilised

of Publication; Country of Aims/Purpose Related to Nurses’ Study sample size; for knowledge
Journal origin knowledge methodology VAD studied assessment Outcomes and details

Kurian and India To assess knowledge of staff Descriptive— Mixed Questionnaire 96% of staff
John (2016); nurses regarding CLABSI Cross Specialty; nurses surveyed
International sectional 50; CVAD had inadequate
Journal of knowledge about
Nursing and CLABSIs
Midwifery
Labeau Belgium To determine ICU nurses’ Descriptive— Intensive Care Questionnaire The responses to the
et al. (2008); knowledge of evidence-based Cross- Unit; 762; final questionnaire
American guidelines for preventing sectional CVAD indicated that nurses
Journal of infections and to develop a questionnaire had numerous
Critical Care reliable and valid questionnaire with face misconceptions
that can be used to assess and content about evidence-
critical care nurses’ knowledge validation based interventions
of evidence-based guidelines or application of
for preventing CVAD-related antibiotic ointment
infection. To determine how
an educational programme on
CVAD-related infection affected
nurses’ knowledge.
Labeau 22 To determine European intensive Descriptive— Intensive Care Mailed Knowledge mean
et al. (2009); European care unit nurses’ knowledge Cross- Unit; 3,405; Questionnaire score: 4.4/10
Critical Care countries of guidelines for preventing sectional CVAD
Medicine central venous catheter-related survey
infection from the Centers for
Disease Control and Prevention
Letournel (2018); France To assess the state of practices Descriptive— Mixed Questionnaire Knowledge average
Le pharmacien on peripherally inserted central Cross- Specialty; score: 53%
hospitalier et catheter (PICC) usage sectional auto 33; CVAD
clinicien administered
questionnaire
Lobo et al. (2010); Brazil To evaluate the impact of 2 Descriptive— Intensive Care Questionnaire 88% nurses had
American educational interventions Prospective Unit; 24; adequate knowledge
Journal of on rates of CVAD-related observational CVAD of hand hygiene
Infection Control bloodstream infections study and disinfection for
CVAD dressing
79% nurses were
knowledgeable on
hub disinfection
Mason United To report techniques used by Descriptive— Oncology; Questionnaire Nurses lacked
et al. (2014); States of experienced oncology nurses Cross- 224; CVAD knowledge
Clinical Journal America for CVAD troubleshooting and sectional in occlusion
of Oncology to describe nurses perceived exploratory management
Nursing effectiveness at troubleshooting survey troubleshooting
occlusion techniques
Mutlu and Turkey To assess the effect of Hickman Descriptive— Oncology; 44; Questionnaire Baseline knowledge
Senturan (2017); catheter care training on Cross CVAD prior to a Hickman
International practice and the knowledge sectional educational
Journal of Caring levels of nurses intervention was
Sciences 76%
Ngo and Murphy United To determine whether a Experimental— Mixed Questionnaire Baseline knowledge
(2005); Journal States of proactive intervention for Pre- Specialty; around PICCs prior
of Infusion America PICC care can positively experimental 402; CVAD to educational
Nursing affect nurses’ knowledge and design intervention was
self-efficacy poor (26%)

(Continues)
RAYNAK et al. | 17

A P P E N D I X B 2 (Continued)

Author(s); Year Population; Tool utilised

of Publication; Country of Aims/Purpose Related to Nurses’ Study sample size; for knowledge
Journal origin knowledge methodology VAD studied assessment Outcomes and details

Ozden and Turkey To determine the knowledge Descriptive— Oncology; 45; Questionnaire Knowledge around
Caliskan (2012); level of nurses regarding the Cross- CVAD the understanding
Japan Journal of TIVAD sectional and adherence
Nursing Science survey to policies and
procedures of
TIVAD was poor
(50%)
Page and Nicholas United To assess the effectiveness of a Not stated Oncology; 25; Questionnaire Baseline knowledge
(2016); American States of quality improvement intervention CVAD pre-educational
Society America designed to reduce CLABSI rates CVAD intervention
of Clinical in the oncology in-patient unit was 74.3%
Oncology using simulation-based education
Paolucci United To determine nurses’ knowledge Not stated Surgical; 36; Questionnaire Nurses had a
et al. (2011); States of on VADs PIV & CVAD good/adequate
Journal of the America To examine what predictors of understanding
Association for VAD knowledge are based on of VAD care and
Vascular Access nurses’ characteristics maintenance, 8.1/10
To determine whether nurses’
perception of comfort in
managing VADs match actual
test knowledge
Raynak Canada To determine the current state of Descriptive— Mixed Web-based Knowledge
et al. (2018); nurses’ knowledge on CVADs in Cross Specialty; questionnaire around care and
Journal of two acute care hospitals sectional 374; CVAD maintenance of
the Canadian To gain more information where CVADs was poor
Vascular Access nurses obtained their CVAD (67%)
Association knowledge, facilitators and
barriers to CVAD knowledge
and nurses’ recommendations
for future CVAD care
Roslien and United To evaluate the impact of Not stated Surgical; 11; Questionnaire Baseline knowledge
Alcock (2009); States of PICC education initiative and CVAD pre-educational
Journal for America assess behaviour capability intervention was
Nurses in Staff by a knowledge tests and good/adequate
Development psychomotor skill checklist (82%)
Woody and Davis United To provide education for PIV Experimental— Mixed Questionnaire The mean pretest
(2013); Journal States of therapy, increase awareness, Pretest/ Specialty; score was 12.77/17
of Infusion America and decrease incidence Post-test 35; PIV
Nursing of peripheral vascular
complications.
Xavier (2013); India To assess the knowledge of Experimental— Intensive Care Questionnaire Baseline knowledge
Asian Journal staff nurses regarding CVAD- Quasi- Unit; 50; pre-educational
of Nursing related bloodstream infections experimental, CVAD CVAD intervention
Education and and its prevention before pre- and was poor (22%) and
Research the implementation of video poststudy average (52%)
assisted teaching module
Yilmaz Turkey To determine the effect of Experimental— Mixed Questionnaire Baseline knowledge
et al. (2007); education on intravascular Pretest/ Specialty; pre-educational
Infection control catheter–related infection rates Post-test 52; CVAD CVAD intervention
and Hospital and on how well healthcare was 60.7%
Epidemiology workers understand the risk
factors associated