Abstract

Objective

The aim of this study was to determine the attitudes and awareness of nursing students regarding evidence-based practices for the prevention of peripheral catheter-associated infections.

Method

This descriptive and cross-sectional study was conducted with 2^nd, 3^rd and 4^th year nursing students (n=327) who were studying in the nursing department of a state university’s health college and practicing clinical practice. Data were collected using student introduction form, evidence-based practices in the prevention of peripheral catheter-associated infections information form, and attitude scale toward the importance and use of evidence-based nursing for students.

Results

The mean total score of the attitude scale toward the importance and use of evidence-based nursing for students. was 69.94±16.26, and the mean knowledge score of evidence-based practices in the prevention of peripheral catheter-related infections was 12.37±2.64. Nursing students had the highest knowledge (97.2%) about the practice of “Aseptic technique should be followed during insertion and care of peripheral intravenous catheters", and the lowest knowledge (74.9%) about the practice of “Infusion sets used continuously in patients who are not given blood, blood products or lipid emulsions do not need to be changed more frequently than 96 hours, but should be changed at least every seven days".

Conclusion

Nursing students’ attitudes toward the importance and use of evidence-based nursing are above the medium level, and their awareness of evidence-based practices in the prevention of peripheral catheter-related infections is high. To increase the attitudes and awareness of nursing students toward evidence-based practice, evidence-based nursing courses should be added to the nursing education curriculum and students should be encouraged to conduct scientific research and participate in scientific activities.

Introduction

The peripheral venous catheter (PVC) is frequently used for administration of drug therapy, peripheral parenteral nutrition, hemodynamic monitoring, prevention of fluid and electrolyte loss, transfusion of blood and blood products, and diagnostic procedures (1-3). The PVC is used in 58-87% of hospitalized patients during their treatment (3, 4). Although PVCs are a vital tool when applied correctly and effectively, they can also cause many complications, such as infiltration, tissue damage, pain, and phlebitis, due to patient-related factors and malpractise. These complications may occur during PVC application or 24-96 hours after catheter removal (1). PVC complications lead to an increased risk of repeated failed PVC procedures and catheter-related bloodstream infections. PVC-associated infections constitute a significant proportion of bloodstream infections (5). The development of PVC-associated infections leads to increased exposure to diagnostic and therapeutic interventions, prolonged hospitalization, and stress for patients and their relatives. It also increases the workload of healthcare professionals and the cost of healthcare expenditures (4, 6, 7). Catheter-acquired infections account for 12-35% of the mortality rate in hospitals (8).

PVC-associated infections can be prevented when the causative agents are considered and necessary precautions are taken (4, 5). Increasing nurses’ compliance with evidence-based practice guidelines and the use of checklists are recommended to prevent PVC-related complications (2-4,9). Nurses are responsible for the insertion, care, and evaluation of PVC in line with evidence-based information (3, 8, 9). Nurses’ knowledge and awareness of international evidence-based guidelines for the prevention of PVC-associated infections is extremely important in terms of guiding the nursing care process and supporting clinical decisions. However, it is reported in the literature that there are deficiencies and obstacles in nurses’ and nursing students’ knowledge of evidence-based guidelines and reflection on research results in clinical practice (4, 10-12). The use of research results and evidence-based practice in clinical settings is strongly emphasized in nursing education, although there are various challenges and barriers for nurses and nursing students related to the translation of theoretical knowledge into practice (6, 11, 13, 14).

There is limited evidence in the literature regarding nursing students’ knowledge of PVC management. Assessing students’ adequate knowledge of this procedure at different levels of nursing education is important in terms of documenting learning outcomes, preventing complications, and supporting patient safety (15, 16). Therefore, this study aimed to determine the attitudes and awareness of nursing students toward evidence-based practice in the prevention of peripheral catheter-associated infections.

Material and Method

Aim and Description

This descriptive cross-sectional study was conducted to determine the attitudes and awareness of nursing students toward evidence-based practices for the prevention of peripheral catheter-related infections.

Research Questions

What are the attitudes of nursing students toward evidence-based nursing?

What is the level of nursing students’ awareness of evidence-based practices in the prevention of peripheral catheter-related infections?

Participant

The study population consisted of 2^nd, 3^rd and 4^th year nursing students who were studying at a state university’s school of health in January-February 2024 and engaged in clinical practice (n=381). No sampling calculation was performed in the study; the aim was to reach the entire population. The sample consisted of 327 students (participation rate 85.8%) who voluntarily agreed to participate in the study and completed the questionnaire forms.

Data Collection Tool

Student introduction form and information form on evidence-based practices in the prevention of peripheral catheter-associated infections and attitude scale toward the importance and use of evidence-based nursing for students were used for data collection. Research data were collected face-to-face from the students.

Student introduction form: This is a form prepared by the researchers to determine the socio-demographic and academic characteristics of nursing students, including age, gender, grade, taking research and biostatistics courses, taking evidence-based nursing courses, wanting to take postgraduate education, following scientific publications related to nursing, wanting to take part in scientific research, attending scientific meetings, and knowing how to search the literature, and consisting of a total of 10 questions (4, 9, 17, 18).

Evidence-based practices in the prevention of peripheral catheter-associated infections information form: This form was prepared by the researchers in accordance with the Center for Disease Control and Prevention Guidelines for the Prevention of Intravenous Catheter Infections published in 2011 and the Turkish Society of Hospital Infections and Control National Vascular Access Management Guidelines published in 2019 (17, 18). The questionnaire comprises 14 questions to assess students’ knowledge of evidence-based practices in the prevention of peripheral catheter-associated infections. Four of the items that make-up the form are related to the procedure of PVC insertion (1-4), three are related to the evaluation of PVC (5-7), four are related to PVC care (8-11) , and three are related to the frequency of PVC change (12-14). In the evaluation of the form, each application was considered as “I have knowledge (1 point),” “I have no knowledge (0 points),” and the evaluation was performed over the total number of known applications. The total score that can be obtained from the form varies between 0 and 14. The high number of items that the students evaluated as having knowledge indicated that their awareness of evidence-based practices in the prevention of peripheral catheter-associated infections was high. To ensure the content validity of the form, expert opinions were obtained from five faculty members specialized in the field of nursing principles and surgical diseases nursing, and a pilot study was conducted with 10 students outside the research group.

Attitude Scale on the Importance and Use of Evidence-Based Nursing for Students

The scale developed by Yanıkkerem et al. (20) in 2023 comprises 18 statements. The scale statements are in a 5-point Likert-type structure scored as “strongly agree”, “agree”, “undecided”, “disagree” and “strongly disagree”. The scale has two sub-dimensions: the importance of evidence-based nursing and the use of evidence-based nursing. The total score that can be obtained from the scale varies between 18 and 90, with higher scores indicating higher levels of attitude toward the importance and use of evidence-based nursing. In the study of Yanıkkerem et al. (20) the Cronbach's alpha value of the scale was found to be 0.94. In this study, 0.97 was found.

Data Collection Process

The data used in this study were collected from nursing students by the researchers. Students who voluntarily agreed to participate in the study were asked to read the questions carefully and answer them completely. It took approximately 5 minutes to answer the questionnaires.

Statistical Analysis

The IBM Statistical Package for the Social Sciences (version 21.0) software was used for data evaluation. The numbers and percentages were used to evaluate categorical variables, and the mean and standard deviation were used for continuous variables. Independent samples t-test and One-Way Analysis of Variance tests were used to compare quantitative continuous data between independent groups. The threshold value of statistical significance was set as p<0.05.

Ethical Consideration

Ethics committee approval was obtained from the Trakya University Non-Interventional Clinical Research Ethics Committee (no: 2023/518, date: 25.12.2023). The purpose of the study, the protection of personal information, confidentiality, and voluntary participation were explained to the participants in writing, and their informed consent was obtained. The Declaration of Helsinki was followed throughout the study. The principles of research and publication ethics were followed.

Results

The mean age of the nursing students who participated in the study was 21.21±1.84 years, 35.2% were studying in the second year, and 68.2% were female. 34.6% of the students took research and biostatistics in nursing and 28.1% took evidence-based nursing courses. 54.4% of the students followed scientific publications related to nursing, 69.1% wanted to take part in scientific research related to nursing, and 30.6% attended scientific meetings related to nursing. 37.9% of the students stated that they knew how to search scientific literature and 60.9% of them wanted to receive postgraduate education (Table 1).

The mean total score of the nursing students on the attitude scale toward the importance and use of evidence-based nursing for students was 69.94±16.26, the mean score of the sub-dimension of the importance of evidence-based nursing was 30.73±7.11, and the mean score of the sub-dimension of the use of evidence-based nursing was 39.21±9.29. The mean score of the students’ knowledge of evidence-based practices in the prevention of peripheral catheter-related infections was 12.37±2.64, the mean score of PVC insertion was 3.44±0.96, the mean score of PVC evaluation was 2.70±0.69, the mean score of PVC care was 2.84±0.56 and
the mean score of PVC change frequency was 3.37±1.01 (Table 2).

In this study, the mean scores of second-year nursing students on the total and sub-dimensions of the attitude scale toward the importance and use of evidence-based nursing for students were significantly lower than those of third- and fourth-year students (p<0.05). The mean scores of the students who had taken evidence-based nursing courses were significantly higher than those of the students who had not taken this course (p<0.05). There was no significant difference (p>0.05) between the mean scores of the students’ gender, the status of taking research and biostatistics courses in nursing, the status of following scientific publications, the status of wanting to take part in scientific research, attending scientific meetings, even searching the scientific literature, and the status of wanting to receive postgraduate education and the mean scores of the total and sub-dimensions of the attitude scale toward the importance and use of evidence-based nursing for students (Table 3).

In this study, the mean knowledge score of evidence-based practices in the prevention of peripheral catheter-associated infections was significantly higher among second-year students than third-year students, female students than male students, students who followed scientific publications related to nursing than those who did not, students who wanted to take part in scientific research related to nursing than those who did not, students who attended scientific meetings related to nursing than those who did not, students who knew how to search scientific literature than those who did not, and students who wanted to take postgraduate education than those who did not (p<0.05). There was no significant difference between the mean scores of the students’ knowledge of evidence-based practices in the prevention of peripheral catheter-associated infections and their status of taking research and biostatistics in nursing and evidence-based nursing courses (p>0.05) (Table 3).

Nursing students had the highest knowledge (97.2%) about the practice of “Aseptic technique should be followed during insertion and care of peripheral intravenous catheters” and the lowest knowledge (74.9%) about the practice of “It is not necessary to change the infusion sets used continuously in patients who are not given blood, blood products or lipid emulsions at intervals more than 96 hours, but they should be changed at least every seven days” (Table 4).

Discussion

Nursing Students’ Attitudes Toward the Importance and Use of Evidence-based Nursing

Evidence-based nursing practices are an indispensable element for nurses, patients, and healthcare systems to improve the quality of healthcare (20). Evidence-based nursing is a problem-solving approach that evaluates the most current and best evidence with clinical expertise and considers the patient’s preferences and needs (19, 20). Evidence-based practices have been shown to reduce length of stay and cost of care, eliminate unnecessary practices, improve quality of care, and improve patient outcomes (9, 20). Therefore, it is important to inform students about evidence-based nursing practices in undergraduate nursing education and to develop a positive attitude toward this issue (11, 15, 19). In this study, nursing students’ attitudes toward the importance and use of evidence-based nursing were found to be above the middle level. Studies examining nursing students’ attitudes toward evidence-based nursing have shown that students’ attitudes are above the middle level (16, 21-23). It is important to comply with evidence-based practices to prevent peripheral catheter-related infections. However, nursing students who participated in our study exhibited deficiencies regarding the importance and use of evidence-based practices.

The attitudes of 2^nd grade nursing students toward the importance and use of evidence-based nursing were lower than those of 3^rd and 4^th grade students. It is believed that the knowledge and experience of 2^nd grade students are lower than those of other grades, which led to this finding. In this study, we determined that students who took evidence-based nursing courses had higher attitudes toward the importance and use of evidence-based nursing. In our country, evidence-based nursing courses are conducted either as elective courses or as a subject integrated into another course. Integrating evidence-based nursing courses into nursing education curricula will increase students’ attitudes toward the importance and use of evidence-based nursing (24). In the institution where the study was conducted, an evidence-based nursing course is an elective course. Considering that students who take this course will have higher levels of knowledge about evidence-based nursing, their attitudes are positively affected in parallel.

Nursing Students’ Awareness of Evidence-based Practices for Preventing Peripheral Catheter-associated Infections

PVC, a basic intervention in healthcare services, is the process of entering the patient’s peripheral vein using a short catheter (4). It is the responsibility of nurses to ensure appropriate care of PVC application using evidence-based information and to provide the necessary follow-up information to prevent complications that may arise (4, 6, 8, 18). In the present study, nursing students had a high awareness of evidence-based practices for the prevention of peripheral catheter-related infections. Nurses should improve their knowledge and skills to provide the necessary care for their patients. Knowledge and implementation of evidence-based practice guideline recommendations for the prevention of PVC-associated infections play an important role in the prevention of infection development (4, 8). In our study, students had the highest awareness of PVC insertion and the lowest awareness of PVC replacement. In a study conducted by Dayan et al. (8) with nurses, it was reported that nurses had more knowledge about PVC insertion and less knowledge about PVC replacement.

The students had the highest awareness of evidence-based practices in the prevention of peripheral catheter-related infections based on compliance with the aseptic technique during peripheral intravenous catheter insertion and care. In the literature, it has been reported that nurses and nursing students have high levels of knowledge about ensuring hand hygiene before peripheral catheter insertion and compliance with aseptic technique (6-8). The main determinants of PVC-associated infections are hand hygiene, compliance with the aseptic technique, preparation of intravenous solutions, and duration of catheter stay (6, 17, 18). The necessity to comply with the aseptic technique in both PVC and all other nursing applications is one of the most emphasized aspects of education. Therefore, it is expected that students will have the highest rate of awareness for this item.

It was determined that the lowest awareness of the students regarding evidence-based practices in the prevention of peripheral catheter-associated infections was that it was not necessary to change the infusion sets used continuously in patients who were not given blood, blood products, or lipid emulsions more frequently than 96 hours, but at least every seven days. In the literature, it has been stated that the knowledge level of nurses and nursing students regarding the prevention of PVC-associated infections is not sufficient with the replacement of infusion sets more frequently than every 96 hours when neither lipid nor blood products are administered (3, 8). The lack of sufficient evidence regarding the known optimum usage time can be considered as an important factor affecting the low level of knowledge on this subject. It is thought that determining and implementing a protocol regarding the frequency of change of infusion sets by utilizing evidence-based practices in clinical areas and informing students about this protocol will increase the awareness of students (6, 15).

Among the nursing students who participated in the study, it was determined that students who followed scientific publications related to nursing, wanted to take part in scientific research related to nursing, attended scientific meetings related to nursing, knew how to scan scientific literature, and had a higher awareness of evidence-based practices in the prevention of peripheral catheter-related infections. It has also been reported in the literature that students who follow scientific publications and attend scientific meetings have higher attitude scores toward evidence-based nursing (22, 23). To use evidence-based nursing practices, the ability to access and use scientific knowledge is essential. Participation in congresses and symposiums contributes to the foundation of nursing care practices and the development of professional developments. It is inevitable that students who follow scientific publications, participate in scientific meetings, and know how to access information will base their professional knowledge and practices on a more professional basis and use new information to perform their profession in the best way in line with evidence-based practices (22, 24).

Study Limitations

The research data were based on the self-reports of the students, and no observation was made on whether the students applied evidence-based practices. The research was conducted in an institution; thus, the results of this study cannot be generalized to all nursing students.

Conclusion

Nursing students’ attitudes toward the importance and use of evidence-based nursing are above the medium level, and their awareness of evidence-based practices in the prevention of peripheral catheter-related infections is high. The students had the highest awareness of PVC insertion and the lowest awareness of PVC replacement. Following scientific publications related to nursing, wanting to take part in scientific research related to nursing, attending scientific meetings related to nursing, and knowing how to scan scientific literature increase students’ awareness of evidence-based practices in the prevention of peripheral catheter-related infections. Taking evidence-based nursing courses increases students’ attitudes toward the importance and use of evidence-based nursing. To increase nursing students’ attitudes and awareness toward evidence-based practice in the prevention of PVC-associated infections, evidence-based nursing courses should be added to the nursing education curriculum as a compulsory course, and students should be encouraged to conduct scientific research and participate in scientific activities.