Assessment of ability to initiate Peripheral Intravenous (IV) Access

Assessment of ability to initiate Peripheral Intravenous (IV) Access

Many students in the nursing program plan to pursue a career in acute care nursing – which is essentially hospital-based nursing. One of the most vital skills to have in this setting is the ability to initiate a peripheral IV access, as patients receive a good number of medications through the intravenous route. As such, I decided to issue a formative assessment to evaluate the students’ ability to initiate a peripheral IV access in the laboratory portion of my Introductory to Medical Surgery class during their midterm week.

 

Prior to coming to lab, students must complete assigned modules which includes videos demonstrating the assigned skills for the week on our nursing skills platform (ATI learning). They must complete a pre-test (no minimum score required) that assesses their knowledge of the topic prior to completing the module and a posttest (after completion of the module scoring at least 80%) to demonstrate assimilation of the knowledge learned. Assessment of ability to initiate Peripheral Intravenous (IV) Access

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Given the aforementioned, I enter into the lab environment expecting my students to have gained an understanding of the knowledge behind the skill and have familiarized themselves with the steps involved to demonstrate this skill in the lab environment.  During week 2, I review this skill and demonstrate it to the students. After ensuring that they have a good understanding on the demonstration of the skill, and they have asked questions as needed, I then ask them to practice on their own to ensure proficiency. I observe each of them as they re-demonstrate the skill to me, correcting any wrong techniques.

 

I inform them during week 2, that on their 8^th lab week, an assessment wherein they would demonstrate their competency in initiating a peripheral IV access, would occur. My hope was that the combination of learning about the skills through completion of the module (with a posttest score of 80%), watching my demonstration of the skill in lab during week 2, and re-demonstrating the skill to me during week 2, they would obtain competency in the skill (demonstrated by the formative assessment during week 8).

 

Overall, the goals of the assessments are:

 

1. To ensure that my students can insert a peripheral IV in a competent and safe manner. Thus, any changes in techniques, or unsafe practices can be noted and corrected to achieve competency of the skill.
2. To increase the comfortability of the student and to reduce the anxiety that the student may feel when their competency of a skill is being assessed in future lab or clinical settings. Throughout their student nursing clinicals and future skills labs, they will be incessantly observed; hence, this would serve as additional preparation for the future.
3. To ascertain competency of this skill for future clinical practice. Assessment of ability to initiate Peripheral Intravenous (IV) Access

 

 

Scoring guide for the above assessments follow:

 

 

 

Student’s Name ____________________________________________________

Date: _____________________________________________________________

Faculty’s Name: _____________________________________________________

Pass/Fail/Remediate: ________________________________________________

 

 

 

Skill: Peripheral Intravenous (IV) insertion	Satisfactory	Unsatisfactory	Evaluator’s comments
*Verify prescription for peripheral vascular access, including the purpose of access
Gather necessary supplies
*Verify client identification
Introduce yourself to the client, provide privacy as needed
Determine whether the client has allergies
Provide client education
*Perform hand hygiene
Adjust the client’s bed to a comfortable working level
Assess the client for an appropriate site for peripheral access based on client condition and reason for access
Select the appropriate catheter size for location and purpose of IV
Position the client in low-Fowler’s and place a towel or protective pad under the client’s arm
*Apply clean gloves
Prepare supplies, including IV catheter, extension tubing, and dressing
*Select and palpate the appropriate vein
*Cleanse the area with 0.5% chlorhexidine or per facility policy, using a gentle, but from back and forth motion. Allow to dry completely
Apply tourniquet
*Do not touch insertion site after cleaning the skin Assessment of ability to initiate Peripheral Intravenous (IV) Access
Using nondominant hand, hold the skin taut about 1 to 2 inches below the venipuncture site and anchor the vein
*Align the IV catheter with the vein, with bevel side up. At a 10- to 30-degree angle, puncture the skin. Advance the needle into the vein.
Once blood is visible in the flashback chamber, continue to advance the catheter about 0.25 inches into the vein
*Advance the catheter off of the needle and into the vein, When needle is completely out, activate safety device.
*Release the tourniquet
Apply pressure to vein above insertion site to prevent bleeding
Quickly attach extension tubing to IV catheter hub
Stabilizing the catheter, pull back on the syringe to assess for blood return. Then flush the IV site with the saline, observing for signs of infiltration or leaking. Remove syringe and close the tubing clamp
If necessary, apply skin protectant prior to stabilization device
*Place a transparent  dressing over the IV insertion site and stabilization device (if used)

 

*If starred item is missed student requires automatic remediation.

 

Assessment Explanation

 

Starred items were pre-selected by myself by considering the actions that if missed would impose a patient safety risk, or pose an infection risk to the patient.

 

The following learning objectives were addressed by this assessment:

 

• Select the appropriate equipment for initiating intravenous therapy.
• Describe the steps for initiating intravenous therapy.
• Use the correct techniques for inserting and securing an intravenous line.

 

The following student learning outcomes were addressed by this assessment:

 

• Describe a management plan for various physiological alterations
• Evaluate the use of evidence-based practice in the delivery of client care.

 

Reasoning: IV insertion is a necessary component in the acute care setting to managing certain physiological alterations. An Intravenous line is utilized to administer intravenous medications that can correct many of the physiological alterations discussed throughout the course. In addition, the theoretical and practical portion of this skill is evidence-based practice.

 

Initially, the students get a brief overview of IV insertion and get to watch a video demonstration of the skill during the lecture portion of this course (which I also teach). During Week 2 in lab, I review the theoretical aspects of the skill in discussion format during which I ask my students to regurgitate the knowledge they have learned on most aspects of the skill while highlighting vital aspects of the skill (see the starred items). The reasoning behind highlighting the starred items during discussion is that these items ensure patient safety. After the discussion, I then demonstrate the skill as I reiterate those items that ensure patient safety. After my demonstration, I then encourage students to practice as I observe each student re-demonstrate the skill. Some of the students emphasized that the skill was more difficult to execute than it looked during my demonstration.

 

Of note, I have two lab sections with 7 students in one section and 8 students in the other section.

During the practice time, the students worked in pairs, and I would observe students completing the skills. I would also correct their techniques during the session. I found that most students struggled with applying the tourniquet. This part of the skill is not a starred item (see scoring guide) but in clinical environment, learning how to tie a tourniquet is a critical action needed to find a viable vein for peripheral IV insertion. Given this, I spent some extra time re-demonstrating the skill to the students. In general, most students were proficient in redemonstrating the skill to me during practice time although there were some noted struggles and they were as follows:

 

1. About 3/4^th of all the students could not tie the tourniquet correctly (not a starred item). Though this action is not a starred item, this action is paramount critically to locating a viable vein. I corrected their error by redemonstrating to them how to appropriately tie the tourniquet.
2. About half of the students advanced the entire needle into the vein, whereas they were supposed to advance the catheter into the vein (this action is a starred item). I corrected their error by letting them know that the reason for this was to prevent puncturing of the vessel wall leading to infiltration of the vein which leads to inability to use the vein to administer medications intravenously. I then redemonstrated the skill showing them that the catheter not the needle needed to be advanced.
3. Over half of the students struggled with inserting the needle at the correct angle (10-30 degrees) (this action is a starred item). This was corrected by re-demonstrating the correct angle for insertion. The reasoning behind the necessity of IV insertion at the correct angle is that if the angle is not low enough, this could also lead to infiltration of the vein. Assessment of ability to initiate Peripheral Intravenous (IV) Access

 

On the day I officially assessed their competency on the skill of inserting an Intravenous line only 2 students required remediation of the skill due to missing a starred item. The first student missed only one starred item – “do not touch insertion site after cleaning the skin”. The second student missed – “verify client identification” and “perform hand hygiene”.

I reemphasized the need to not miss the aforementioned critical item and set a remediation date with both of those students for 2 weeks after the official assessment date.

 

Of the students who performed the procedure correctly, the most missed items (non-starred items) were as follows:

 

1. Tied the tourniquet too loose.
2. Assess for blood return

 

As this is my first time administering an official lab assessment at Malcolm X College, I have no established trends in this assessment for which I can make historical comparisons. Therefore, I will highlight trends in my previous experience administering assessments in the lab setting. In my previous experience in administration of assessments in the lab, students typically do make some minor mistakes on their initial practice sessions after they have witnessed a demonstration of the skill. They usually do not typically miss actions which pose a safety risk or infection control risk (during official assessment after they have had practice sessions) – especially if it is highlighted by their instructor and they have previously completed assigned modules and watched assigned demos prior to attending class.

Students who typically miss critical actions (starred items) during official assessments tend to miss those actions due to unpreparedness, inadequate use of practice opportunities, or nervousness and overthinking during their assessment. Students who miss critical actions due to Assessment of ability to initiate Peripheral Intravenous (IV) Access

 

nervousness are usually able to identify exactly what they did wrong even before instructors tell them. Students who are unprepared usually cannot identify what they did wrong. Even when the skill steps are reviewed with them and context clues are given, they are still not able to identify what they did wrong.

With the two students who missed starred items, I could see that one of the students was very nervous, thus missing those critical actions, but the other one was unprepared. These conclusions were made due to my previous experience and trends I have noted in administration of assessments in the lab setting.

After reviewing the skill verbally with both students and reassessing their understanding by asking for teach back in verbal form, they were required to repeat this assessment 2 weeks later so that I could assess their competency.

Both students successfully completed the assessment without missing any starred items.

 

Improvement of Assessment

 

Please note my recommendations for improvement of this assessment for the future below:

 

1. To ensure that the students’ have a more robust learning experience and have more practice time to master the skill, I would allow for review of this skill again during a review week prior to an official assessment.
2. I would also highlight the trends from this assessment (as a new baseline) specifically pitfalls and commonly missed actions by previous students.

 

Summary

 

This assessment gave me the following invaluable feedback regarding my students:

 

1. Their level of preparedness prior to seeing a live demonstration of the skill based on the modules they completed and pre-watched demos of the skill
2. Their learning styles – a large majority of my students are visual learners. Therefore, demonstration of a skill for their learning was more valuable to them than hearing or reading about the skill. This feedback enables me to tailor my lessons to
3. Their ability to insert a peripheral intravenous line correctly and safely. Assessment of ability to initiate Peripheral Intravenous (IV) Access

 

Though this assessment was designed to evaluate my students, I also had some learning points I gleaned through this process and they are as follows:

 

1. I assumed that most of my students would not miss this (non-starred) action – “Cleanse the area with 0.5% chlorhexidine or per facility policy, using a gentle, but back and forth motion. Allow to dry completely”. I made this assumption because this action was emphasized on numerous occasions – specifically in the modules they cover, the demo videos, and my demonstrations. In addition, no one missed this action during their practice sessions. Thus, I did not make this a starred item. Forgetting to perform the aforementioned item poses a huge infection risk to the patient – therefore, this should have been a starred item. I realized this during the official assessment when vone student (one of the ones who required remediation) missed this action.  Moving forward, I will make this a starred item and ensure that in future assessments, this action is mentioned as a potential pitfall.

 

2. Having an extra practice session (two total) at the midterm point could reduce the anxiety surrounding being observed by the instructor, instead of only having the one at the beginning of the semester.

 

3. Demonstration of a skill further solidifies the theoretical knowledge regarding the skill – I found that students in this lab section readily and eagerly answered questions posed in the lecture portion of this class regarding the skill especially surrounding maintaining patient safety and infection prevention. Assessment of ability to initiate Peripheral Intravenous (IV) Access

 

To conclude, assessments not only give information on students’ theoretical and practical knowledge, it also delineates their learning styles and creates an opportunity to establish baseline metrics for refining the assessment in the future.

I was also able to realize assumptions that I make that could potentially not accommodate comprehensive learning. All in all, assessment and learning are a two-way street; it can foster learning that targets students’ learning styles and it can refine delivery of course content. Assessment of ability to initiate Peripheral Intravenous (IV) Access