Exploring Australian emergency department clinicians' knowledge, attitudes and adherence to the national peripheral intravenous catheter clinical care standard: A cross‐sectional national survey

This study aimed to (i) capture clinicians' knowledge, attitude and adherence to the first Australian national peripheral intravenous catheter (PIVC) Clinical Care Standard, (ii) examine the instrument performance of the knowledge related questions and (iii) explore the educational needs for, and barriers to, Standard adherence among Australian ED clinicians.

• Nearly half of respondents claimed that they were unfamiliar with the Standard.• Self-reported practices regarding routine insertion of idle catheters, using antecubital fossa as the first insertion site, insertion without confidence and lack of routine reviewing the ongoing needs of peripheral intravenous catheter were not aligned with the Standard.
• Unawareness of the Standard and non-practical recommendations were rated as the top barriers to Standard adherence.

Introduction
][6] Despite a large amount of evidence available, varied practice is still commonly observed worldwide with an average guideline adherence rate of only 34%. 7Numerous studies have suggested a wide range of concerns regarding PIVC insertion and management in EDs, where nearly onethird of PIVCs (26-32%) are inserted. 8For example, up to 50% of PIVCs inserted in ED are never used. 9espite more than one-third of adults 10,11 and up to half of children having difficult access, 12 PIVC insertion is often considered a basic clinical skill and performed by junior clinicians because of underestimation of required skills.A common use of antecubital fossa for non-trauma patients disregards a large amount of evidence suggesting it is associated with a high failure rate, 13,14 risk of infection, 15 and patient discomfort (area of flexion). 1In general, suboptimal adherence to PIVC guidelines and perceived low PIVC risk in patient safety are common. 16The application of PIVC insertion management principles requires improvement.
Theories and models have been developed to optimise the understanding of guideline adherence. 17,18The Awareness to Adherence Model is a well-structured and validated model to explore four key steps (awareness, agreement, adoption and adherence) in impacting guideline uptake and compliance. 19However, clinicians' knowledge, attitude and practice regarding guideline-recommended PIVC insertion and maintenance practice are patchy so far, especially since no study has been conducted in an ED environment previously.Therefore, it is timely to explore clinicians' adherence to the Standard by identifying the knowledge-practice gap against the benchmark, which in turn would inform the strategies to close the gap and achieve a better practice for this most common invasive procedure in the ED environment.The study aims to assess the knowledge, attitudes and self-reported adherence to the Standard as well as the educational needs and barriers to preventing adherence among Australian ED clinicians.

Methods
This cross-sectional national online survey was designed to explore if ED clinicians were adhering to the recommendations in the Standard.The study was designed to (i) capture Australian ED clinicians' knowledge, attitude and self-reported adherence to the PIVC Standard; (ii) examine the instrument performance of the knowledge related questions and (iii) identify educational needs and barriers that impact adherence.The study was structured and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. 20The study has received ethical approval from the Griffith University Ethics Committee (2022/025).

Sample and setting
There were 20 273 nurses working in Australian EDs in 2019 21 and 1761 ED doctors employed in 2016. 22The online survey was distributed to ED doctors and nurses across various ED contexts in Australia via the ED network (e.g.College of Emergency Nursing Australasia), non-ED network (e.g.Queensland Nurses and Midwives Union), vascular-related research network (e.g.Alliance for Vascular Access Teaching and Research ® ) or word of mouth by ED clinicians or researchers via emails or social media (e.g.Facebook) from March to June 2022.All ED doctors and nurses in Australia were eligible to participate in the survey.Participants who worked outside EDs were excluded from the study.The snowball sampling method was utilised although the representative of the sample is not guaranteed, which may create bias.As this is an exploratory study and the recruitment methods were utilised, it was not considered necessary to undertake a power calculation.

Data collection and content validity
The anonymous survey was hosted via an online survey website (LimeSurvey @ ).The validated Awareness to Adherence Model 19 was chosen as it matches our study aims.It was used to design the survey in order to measure clinicians' knowledge (awareness), attitudes (agreement) and practice (adoption and adherence) that potentially impact adherence.The survey included (i) non-identifiable professional characteristics and individuals' PIVC related experience; (ii) knowledge of the Standard on either a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) or multiple-choice questions; (iii) attitude towards the Standard on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree); (iv) adherence to the Standard on a 5-point Likert scale (1 = always, 5 = never); and (v) educational needs and barriers to prevent adherence via multiple-choice question/answers.
The survey was based on standard vascular access for the inpatient population.
The questions were optimised by ensuring all questions were designed to be relevant to the ED context as well as aligning with the 10 key recommendations of the Standard by ED and/or PIVC clinical and research experts.Several variables were measured in the survey.For example, knowledge refers to the answers provided in the survey either correct or incorrect based on the recommendations of the Standard.Content validation was achieved by external ED and/or PIVC clinical and research expert (n = 5, with a total of 72 years of ED experience) review via an established process which was used in other study 23 to ensure a cross-match of survey questions and the Standard.Face validity and piloting (feasibility and readability) was achieved via established processes including 10 ED clinicians testing the questionnaire, which led to a minor revision of questions before distribution. 24

Data analysis
Based on a ED clinician population size of 22 034, 21,22  Participants' demographic and responses were reported descriptively using percentages for categorical data and median and interquartile range (IQR) or mean and standard deviation (SD) for continuous variables after checking the distribution.Survey performance was described via standard item analysis, and processed using Microsoft Excel. 25he difficulty level of an item was defined as the proportion of respondents who answered the question correctly. 26If the difficulty level is more than 0.9, the question is considered as too easy.If the score is less than 0.1, the question is considered too hard.Item discrimination index (DI) was analysed by examining how each item is related to overall test performance by using the formula (upper 27% scoreslower 27% scores)/number of respondents. 27Based on Ebel's guidelines 28 on classical test theory item analysis items were categorised in their discriminating indices: DI ≥ 0.40item is functioning satisfactorily; 0.30 ≤ DI ≤ 0.39little or no revision is required; 0.20 ≤ DI ≤ 0.29item is marginal and needs revision; DI ≤ 0.19item should be eliminated or completely revised.The quality of a response alternative was defined by calculating the proportion of respondents who chose an alternative value. 26

Instrument performance
Overall, the item difficulty levels of most of the questions (8 out of 11) were considered appropriate when the score is less than 0.9.Three questions were too easy with item difficulty scores either equal to or more than 0.9, including choosing right PIVC size (0.96), reviewing ongoing need (0.9) and site inspection (0.93).The item discrimination scores of the majority of questions were considered either satisfactory or good, apart from two questions, choosing right PIVC size (0.07) and reviewing ongoing need (0.14), having a value less than 0.15.

Attitude
A total of 389 participants completed this section.Although most of the responses are positive, participants' attitudes regarding multiple attempts and ongoing competency monitoring conflict with the Standard (Fig. 1).About a quarter (n = 91, 23%; 95% CI 20-28) of participants either disagreed or strongly disagreed (median 3.2) that multiple attempts to achieve PIVC insertion are a common problem in ED.One-third of participants

Practice and adherence
A total of 384 respondents completed this section.Some self-reported practices do not align with the Standard.More than half of the participants claimed that they routinely insert a PIVC despite believing that only blood tests are needed, including 18% of participants (n = 70; 95% CI 15.7-22) who reported it as always and frequently, and 37% (n = 141; 95% CI 32-42) reported it as sometimes (median 2.7) (Fig. 2).The majority of participants routinely chose (sometimes to always) the cubital fossa as the first-choice site (n = 321, √All above 319 (88%; 86-92) †Seventy-six respondents did not answer any of the questions in this section.‡Item difficulty is defined as the proportion of respondents who answered the question correctly.If the score is more than 0.9, the question is considered as too easy.If the score is less than 0.1, the question is considered as too hard.§Item discrimination is used to examine how each item is related to overall test performance by using item-to-total correlations by analysing the relationship between each item and the total test score.CI, confidence interval; i.v., intravenous; PIVC, peripheral intravenous catheter.84%; 95% CI 80-87; median 3.3).Nearly half of the participants (n = 177, 46%; 95% CI 41-51; median 2.7) disclosed that they sometimes attempted to insert PIVCs even when not confident about the likelihood of success.Participants estimated that only 50% of ED doctors (median 50, IQR 30-85) are competent in US-guided PIVC insertion in their ED and almost no nurses (median 0, IQR 0-5) are competent with this skill.About 40% of participants (n = 154; 95% CI 35-45; median 3.0) either never or rarely reviewed the ongoing need for PIVCs before patients were transferred to the ward.

Education needs and barriers to adherence
Two-thirds of participants (n = 254, 75%; 95% CI 70-79) reported that they were aware that their hospital or organisation provide formal PIVC related competency training or ongoing education resources (Table 3).More than half of the participants (n = 174, 51%; 95% CI 46-57) believe that they need more education about the Standard.They rated the unawareness of the Standard (n = 206, 61%; 95% CI 56-66) and that the Standard is not practical for all ED presentations (n = 248, 73%; 95% CI 68-78) as the top two barriers to Standard adherence.

Discussion
This national survey is the first to evaluate Australian ED clinicians' knowledge, attitude and selfreported adherence to the Standard.As the Standard is the first Australian purpose-built PIVC Standard released in mid-2021, it is critical to conduct a timely review and evaluation of the new Standard among the ED clinicians who insert most PIVCs in hospital settings.The results of our survey captured considerable variations between clinicians' knowledge, attitude and practice, which reflect a diverse acceptance and uptake of the recommendations, underpinning the quality of care and patient safety issues.It is important to highlight that the survey received a large number of responses from experienced ED clinicians (e.g.nurse respondents had a median of 8 years of ED experience and 64.7% have done more than 800 PIVC insertions) despite the survey being conducted during the COVID pandemic.Their responses to the survey reflect the potential limitations of the Standard in how it applies to ED clinicians' daily practice, as well as the need for hospitals and speciality organisations to provide more education to ED clinicians about the Standard.The findings of the survey represent a unique perspective of frontline ED clinicians and provide some insightful evidence for policymakers to consider and address the possible limitations of the Standard in future.It also highlights the need to develop an EDspecific Standard.In the following paragraphs, we used the four key steps (awareness, agreement, adoption and adherence) in the Awareness to Adherence Model to guide our discussion on what impacts guideline uptake and compliance. 19hese key steps are well aligned with knowledge (awareness), attitudes (agreement) and practice (adoption and adherence) that were measured in the survey.
Given the increased demands of measuring the existing PIVC related knowledge, an appropriate instrument suitable for measuring PIVC related knowledge is needed.Several vascular access related instruments that have been developed internationally have limited transferability in providing a comprehensive assessment of broad PIVC related topics. 29,30Therefore, this instrument was developed to assess all aspects of PIVC related knowledge and can be used in similar studies in other settings of English-speaking countries where similar guidelines exist.
Nearly half of the respondents were unfamiliar with the Standard.They also rated the lack of awareness as one of the biggest barriers to adherence.It is expected that all healthcare services in Australia demonstrate that they meet the new national Standard and the accreditors will assess the healthcare services' performance against the Standard.As there are always competing interests in education and priorities for individual organisations or departments, the Standard may not yet have been adequately promoted to their ED clinicians.Thus, it is possible that some ED clinicians are unaware of the new Standard despite it being released more than 6 months before the survey was conducted.Lack of awareness and lack of familiarity with the guideline contents are frequently reported barriers to adherence in many studies. 31,32Being unaware of the guideline recommendations can lead to patient harm when management is based on evidence that is outdated or no longer relevant. 33he survey results indicate the need for timely education to increase clinicians' knowledge and awareness of the guideline contents.However, the contents of the Standard are not completely foreign to clinicians, as the Standard is based on years of well accepted research findings.Furthermore, in the past 5 years, many Australian initiatives proactively addressed some common PIVC issues such as idle catheters. 34,35et, a high rate of awareness and agreement does not guarantee a high level of guideline adherence and good practice.The inconsistency is widely observed in a few areas including idle catheters and PIVC site choice.
Although there was a high rate of awareness and agreement among participants about avoiding idle catheters, more than half of the participants routinely inserted a PIVC just to obtain blood samples.PIVCs were placed 'just in case' and are considered as a 'routine' and low risk ED procedure to avoid potential 'inconvenient' insertions during potential patient deterioration. 36ikewise, contrary to the recommendations on PIVC site choice, although participants are aware of and agreed on the importance of avoiding flexion areas, the majority of participants revealed that they routinely chose antecubital fossa as the first site choice in their daily practice, which is similar to other literature. 37ometimes, awareness does not necessarily align with the agreement.More than half of the participants reported that the Standard is not practical for all ED presentations, with a belief that these recommendations do not meet the needs of diverse ED presentations and complex environmental challenges (e.g.time constraints, heavy workload and patient deterioration).It is worth pointing out that this result may not be reliable as most of the participants who rated this barrier also stated that they were unaware of the Standard.However, disconnection between awareness and agreement in guideline recommendations is a common issue in medical guidelines 7 because of poor applicability to patient care, non-practical recommendations and disbelief that recommendations will lead to desirable outcomes. 31,38In addition, the survey findings indicate that sometimes clinicians adopt recommendations that they may not necessarily agree with.This phenomenon is thought to be related to peer pressure, patient demand, practice organisation policies, fear of malpractice and financial penalties. 7It signals the necessity to commence the discussions and investigation between the recommended practice versus feasible practice in ED settings in future studies.It is also important to acknowledge the recommended practice in the Standard may not be the best practice for ED clinicians in their unique clinical environment, although the representative from the ACEM and College of Emergency Nursing Australasia participated in the roundtable and the Standard was endorsed by the colleges.
As an exception, participants' inadequate knowledge, negative attitude and self-reported varied practices in managing patients with difficult venous access (DIVA) raise alarm.The Standard recommends the first insertion for DIVA patients should be performed by an experienced clinician who is competent in technology-assisted devices to maximise the first insertion success rate and preserve DIVA patients' limited vein integrity. 2 Unfortunately, our survey results suggest that only half of the physician respondents are competent with US-guided insertion skills.Although ED nurses and junior medical staff are the main PIVC inserters for this 'basic' 'entry level' procedure, 8,39 almost none of the nurse respondents are competent with this skill.
Clinicians reported struggling to practice and adhere to the Standard, although they acknowledged and accepted its key recommendations.Although there are many strengths of the Standard underpinning by the most recent and gold standard research evidence, our survey results suggest that its applicability and suitability to be utilised by ED frontline clinicians in their daily practice is questionable.As this broad-based Standard is developed for a generalised clinician population, it is unsurprising to observe it is difficult to maintain the high relevance to all ED practices.In fact, the Standard has acknowledged this limitation by clearly stating that 'It does not replace the need for specialised decision-making for PIVC insertion appropriate to the individual clinical circumstances of the patient and the context in which care is provided (such as during anaesthesia, light sedation, short-term cannulation for diagnostic imaging purposes, acute resuscitation and acute trauma management)'. 2eanwhile, we also want to acknowledge that although not all recommendations are highly relevant to ED settings, some suboptimal PIVC practices in ED can and should be improved to optimise patient safety.The gap between guideline adherence, knowledge and attitude, suggests a failure to implement the key recommendations, which poses a risk to threaten patient safety and quality care for this most common invasive procedure.Shifting clinicians' awareness to an agreement to reach guideline adoption and adherence in practice is a complex process. 7Therefore, it is vital to acknowledge that the dissemination of guideline recommendations is a challenging task and the availability of guidelines alone is insufficient to change practice. 7To better understand what factors influence ED clinicians' decision making in their practice, more implementation science focused research needs to be conducted.Therefore, appropriate strategies could be implemented to overcome potential barriers to close the evidence-practice gap to ensure guideline compliance and adoption in challenging and complex ED environments.

Limitations
Several limitations need to be acknowledged.The generalisability of the study findings outside of Australian ED settings is unclear; however, this valid and reliable survey instrument could be utilised in other settings, with similar guidelines in place.The examination of eligibility for entering the survey relied on participants' self-reporting alone as it was impossible to verify it in an online survey.We were unable to calculate the response rate because of the survey dissemination strategy being utilised.Furthermore, we did not analyse the effect of confounders on the outcomes as they do not match our study objectives and aims.Although we did not discuss the control for confounding, readers can draw some conclusions about whether the demographic or clinical factors may have influenced the results as we described the participant cohort.In addition, selection bias and response bias are associated with the sampling method used in the study, which might lead to inaccurate findings.Response bias was minimised by drafting neutrally worded questions and conducting the survey anonymously.Selection bias was managed by distributing the survey via multiple methods (e.g.emails, social media, college and word of mouth).However, our study findings are well aligned with previously published literature 30,40 with additional value providing a unique overview of clinicians' responses to the new Standard.

Conclusion
Australian ED clinicians report that PIVC clinical knowledge, practices and attitudes are disconnected from the 2021 PIVC SCC.The findings of the survey highlight that it may not be feasible to follow some recommendations of the Standard in daily ED practice.Thus, an EDspecific Standard is needed to promote guideline uptake and compliance by ED clinicians.Hospitals and organisations also need to provide more education about the Standard to promote clinician awareness.Future studies need to explore the applicability and relevancy of some recommendations in depth in the ED settings as they may cause low adherence to the Standard.
the initial survey with feedback and review by AJU, CMR, MT, MB and EP.HX coordinated the distribution of the survey and collection of responses.
MT analysed the responses.HX drafted the manuscript with input from all other authors.

TABLE 2 .
Participant's knowledge with survey performance © 2023 The Authors.Emergency Medicine Australasia published by John Wiley & Sons Australia, Ltd on behalf of Australasian College for Emergency Medicine.AUSTRALIAN ED CLINICIANS' KNOWLEDGE, ATTITUDES AND ADHERENCE

TABLE 3 .
Education needs and barriers to adherence No233 (69; 64-73) †Ninety-four respondents did not answer any of the questions in this section.CI, confidence interval; PIVC, peripheral intravenous catheter.