Knowledge and practice towards care and maintenance of peripheral intravenous cannula among nurses in Chitwan Medical College Teaching Hospital, Nepal

Abstract Aim The study is mainly concerned about the care and maintenance of peripheral intravenous cannulation: to determine the knowledge and practice of nurses towards care and maintenance of IV cannula and to find out the obstacles encountered in caring and maintaining IV cannula. Intravenous cannulation is a common procedure performed by nurses in every hospital and closely associated with the risk of nosocomial infections if standard care is not provided. Design A descriptive cross‐sectional study design was carried out. Methods Nurses' knowledge and practice towards care and maintenance of peripheral intravenous cannula were assessed using a validated semi‐structured self‐administered questionnaire through the census method. Data were analysed through SPSS program. The comparison was done between knowledge and practice. Results The findings revealed that 84.72% respondents were doing correct practices despite the fact that only 82.47% respondents had proper knowledge. Most nurses have good knowledge of caring and maintaining peripheral intravenous cannulation but there were some without proper knowledge and practice. This could be a potential risk factor for patient safety.

It is an integral part of professional nursing practice in all the healthcare institutions (Arbaee, 2016), which is done for different purposes like IV infusion and medications (Ray-Barruel, Polit, Murfield, & Rickard, 2014) and is kept for the different duration of time depending on patient's condition with a potential risk of microbial growth (Urbanetto Jde et al., 2016). Such infections are also the part of nosocomial infections and relatedly associated

| Aim
Reflecting on the facts mentioned above, the current study is carried out to determine the knowledge and practice of nurses towards the care and maintenance of IV cannula and obstacles encountered during the procedure. Intravenous cannulation is common procedures performed by nurses in every hospital and closely associated with the risk of nosocomial infections if standard care is not provided. The results from the study can help in formulating a better programme, which reduces the incidence of PIC-related infections and uplifts the standard of care. Following the discussion above, the questions of interest include the following: • What are the contributing factors leading to the complication of peripheral intravenous cannulation?
• What are the implementations needed for correct nursing practices to care and maintain peripheral intravenous cannulation? Therefore, the significance of the study will be to analyse the nurse's knowledge towards the care and maintenance of peripheral intravenous cannulation at Chitwan Medical College Teaching Hospital (CMCTH).

| Design
A descriptive cross-sectional study with a quantitative approach design was used in the research. The research design incorporated both quantitative and qualitative methodologies to find out in-depth descriptive information about care and maintenance of peripheral intravenous cannulation. Nurses' knowledge and practice towards care and maintenance of peripheral intravenous cannula and its association with experience, education, position and the department were assessed using a validated semi-structured self-administered questionnaire.

| Sample and setting
Census method of sampling technique was used among the nurses of CMCTH. Only the inpatient department nurses, both the junior and the senior who were interested to participate in the study, were included, whereas those on long leave, uninterested or from outpatient department were excluded. Ultimately, two hundred nurses participated in the study from different inpatient wards.

| Data collection
The valid and reliable standard structured tool was used for data collection, developed by Author Ahmad Nizal Mohd Ghazali and colleagues (Arbaee, 2016). The adapted validated semi-structured selfadministered questionnaire was distributed to the selected nurses and collected after they finished on the same day.
Each questionnaire comprised four sections. The first section was about respondents' demographic characteristics, years of work experiences, education level, position and working department.
Followed by the second section about knowledge on care and maintenance of peripheral intravenous catheter, which was measured through 19 premises with a normal scale ("yes," "no" and "I don't know"). Similarly, the third section was about nurses' practice towards care and maintenance of peripheral intravenous cannulation and was measured through total 17 premises, where 16 premises with a normal scale (yes, no and I don't know) and remaining 1 with three different options. And finally, the fourth section was barriers encountered for caring and maintaining peripheral intravenous cannulation, which was analysed following the similarity of the answers.

| Data analysis
The collected data were checked, reviewed and organized daily for its completeness and consistency. The data were entered into the statistical package for social science (SPSS) version 20 and then analysed and interpreted in terms of descriptive statistics like frequency and percentage.

| Ethics
For ethical consideration, official permission letter was taken from CMCTH. Informed consent was taken from respondents after clarification of the objectives of the study. Respondents were assured that the information they provide would be confidential and were allowed to participate in a free and unbiased environment.

| RE SULTS
Demographic data like work experience, educational level, position and the working department would influence their understanding and knowledge towards care and maintenance of PIC. Findings of demographic data revealed that among 200 nurses, most respondents (57%) had work experiences below 1 year; they were still new without enough experiences. Most (76%) of their educational levels were PCL Nursing. Regarding their position, 86% were staff nurse and only 14% was a senior staff nurse. More than half of the respondents (53.5%) were in the critical unit (Table 1).
Nurses' knowledge towards the care and maintenance of peripheral IV cannula was assessed through nineteen questions as shown in  Table 3 shows the respondent's practice on care and maintenance of IV cannula. Here, sixteen statements were given to assess their practice. Most (84.72%) of the respondents followed the proper practice, 14.22% respondent did not follow the proper practices, and minority (1.06%) were not confident on their practice whether they were doing correct or incorrect.
In Table 4, nurses' intervention if no signs and symptoms of complication or infection after 72 hr of IV cannula insertion was assessed, where most respondents changed the new cannula.
In Table 5, barrier encountered in caring and maintaining of peripheral IV cannulation was asked with respondents. Most respondents agreed on the incooperated patient and small vein prone to blockage and damage. The minorities agreed on giving too strong medication make the vein easily block. surgery, anaesthesiology, interventional radiology, pulmonary medicine, paediatric medicine and nursing (Miller & O'Grady, 2012).

| D ISCUSS I ON
Choosing the IV route and selecting an appropriate size of vascular access device are the most important factors in preventing IV site infection (Scales, 2008). In this study, 100% of respondents have knowledge of the appropriate size of the cannula. For site selection, the PIC is usually inserted into a metacarpal vein on the back of the hand or a vein in the lower arm, either the cephalic or basilic vein. However, femoral veins should be avoided because of the higher density of skin flora in this area, which would put the patient at increased risk of infection (Arbaee, 2016;Scales, 2008). In this study, most respondent (82.5%) knew about the site selection for IV cannulation, whereas remaining 17.5% respondent did not know. Qin, 2016; Webster et al., 2008Webster et al., , 2015Dougherty, 2000). The CDC guidelines also recommend that peripheral intravenous catheter should be removed or replaced every 12-72 hr to avoid complication such as thrombophlebitis (Arbaee, 2016;Miller & O'Grady, 2012;O'Grady et al., 2011). Most hospitals in China also follow this CDC recommendation (Li, Liu, & Qin, 2016;Dougherty, 2000). The two major sources of bloodstream infection associated with IV device are colonization of the device itself and contamination of the fluid administered through the device (Bijayalaxmi et al., 2010). About 87% of the respondents in this study also knew as well as followed the practice of removing the IV cannula in every 12-72 hr from insertion. Also, most respondents (98%) immediately changed the IV cannula to the non-infected part when they saw the sign of phlebitis.
Nurses' knowledge and early recognition of risk factors for the development of phlebitis can reduce complications, which improves the quality of care, patient safety, patient satisfaction ratings and at the same time reduces the length of hospital stay and the overall cost of health care (Milutinovic, Simin, & Zec, 2015). In this study,  An inadequately secured PIC also increases the risk of CRBSIs, as the pistoning action (moving back and forth in the vein) of the catheter can allow migration of organisms along the catheter and into the bloodstream (Marsh, Webster, Mihala, & Rickard, 2015). This information was known to only 67% who also failed to use transparent dressing in practice. Additionally, 95% of respondents changed the dressing when it was wet or dislodged.
Removing IV cannula immediately when not in use helps in reducing the risk of infection occurrence, which was agreed by 85% of the respondents. Accurate documentation like the date and time of cannula insertion, labelling IV equipment and fluid containers with date and time they are opened to ensure they have changed appropriately demonstrate better cannula care, encourage research-based standardized practice and provide guidance as well as evidence of competence (Scales, 2008;Trim, 2005

| Limitation and recommendation
This study is undertaken in a single hospital and is only analysed quantitatively. The scope of the study can be increased to several hospitals without limiting only to quantitative design but also including qualitative study design for assessing the factors affecting the nurses' knowledge and practices. This may help in better generalizations of the findings, which can be used to reduce hospital-acquired infections related to the PIC and to enhance the quality of care in the hospital.

| CON CLUS ION
The risk and complications of PIC could endanger the patient's life.
So, in the clinical area, nurses must be knowledgeable and competent in every aspect of IV cannulization. In this study, most nurses were having a good knowledge of caring and maintaining of peripheral IV cannulation but there were still some nurses who did not have proper knowledge and experience for using IV cannulation which could be a potential risk factor for patient safety. This may be attributed to the fact that most respondents were junior nurses with <1 year experience in the clinical area. Their knowledge towards care and maintenance of IV cannula was very limited which might result in practicing incorrect method. The results should sensitize healthcare managers to improve nursing training and education, according to clinical risk management perspectives.

ACK N OWLED G EM ENTS
The authors would like to acknowledge the Chitwan Medical Collage Teaching Hospital (CMCTH) and the nurses of CMCTH who were participated in this study.

CO N FLI C T O F I NTE R E S T
None.

AUTH O R CO NTR I B UTI O N S
CO: study conception and design, data collection, literature reviews, analysis and drafting of the manuscript. GG: data collection.
MK, DW and QZ: data analysis, literature review and drafting of the manuscript.