Assignment Task
Background & Justification
Complication rates for Peripherally Inserted Central Catheter’s (PICC) differ from hospital to hospital and can be as high as 70% (Krein et al., 2019). Research indicates that majority of these complications can be avoided by targeting barriers and enabling factors that affect nursing management of PICC care (Morrison, 2012; Vincelette, 2018). PICC’s are placed in acutely ill patients and are preferred over other central catheters due to their ease of access for drug administration and lower infection rates (Vincelette, 2018). Advantages of PICC’s include venous access for up to 6 months, blood sampling without skin pricks, and simultaneous and rapid administration of fluids and drugs (Püschel, 2018). However, various studies note that current education to ensure PICC line competency have not been adequate at ensuring evidence-based practice (Püschel, 2018; Vincelette, 2018). Maintaining PICC line competency, as outlined within Central Venous Access Devices (CVAD), is a challenge in our healthcare environment with increasing time pressure to improve workflow, increasing patient-to-nurse ratio, rising patient acuity levels and tightening budgets (Cortés, 2022). Inconsistent use of PICC’s can result in serious complications (e.g. blood stream infections, occlusions, thromboembolism, PICC migration) in an already unstable patient (Cortés, 2022). The integrative literature review aims to access and analyse existing research to identify ‘barriers’ and ‘enabling’ factors that affects nurse’s adherence to evidence based PICC management in tertiary healthcare setting.
Identifying ‘barriers’ and ‘enabling’ factors to help facilitate nurse’s adherence to evidence based PICC line management can inform current policy and allow hospitals to allocate required resources towards decreasing PICC related complications (Podrazilova & Hudackova, 2015). Patients and their families can suffer significant distress from PICC complications (Krein et al. 2017). Examples include missed dosses due to occlusions, risk of haematoma and thrombotic events, psychological trauma associated with multiple PICC procedures, and further decline in patients’ health status due to blood stream infections (Krein et al. 2017; Püschel, 2018). Advocacy and action towards evidence-based practice decreases PICC line complications (Püschel, 2018). This improves patient healthcare outcomes, patient experience, while also decreasing financial costs associated with extended admissions and prolonged therapy (Morrison, 2012; Vincelette, 2018). It can also improve nurses overall experience with PICC use (Cortés, 2022).
The review will discuss the significance of evidence based PICC care. P.I.O model will be used to outline the topic for investigation, inclusion and exclusion criteria will also be identified, along with search strategy. Mixed Method Appraisal Tool (MMAT) will be used to evaluate the quality of literature search. Braun and Clarke’s thematic analysis identified 5 themes affecting competent PICC line care: (1) Individual knowledge, skill and attitude towards PICC management; (2) Impact of leadership on staff education and policy; (3) time pressures and lack of accountability as barriers to appropriate PICC care; (4) patient factors affecting provision of nursing care; and (5) appropriate communication and teamwork as facilitators for evidence-based practice. The implication of these findings will be further discussed in relation to healthcare practice, education, policy, and future research.
Aim & Purpose of Review
The integrative literature review aims to access and analyse existing research to identify ‘barriers’ and ‘enabling’ factors that affects nurse’s adherence to evidence based PICC care in tertiary healthcare setting. The importance of appropriate PICC management (i.e. Central Venous Access Device) is well recognised within the paediatric population, however, there has been limited focus on the seriousness of PICC complication in the adult population and nurses frontline role in its prevention (Zheng et al., 2020; Di Fine et al., 2018). Exploring nursing perspectives to identify ‘barriers’ and ‘enabling’ factors for appropriate PICC care, allows for targeted and effective interventions in the healthcare practice (Purran et al., 2016).
Type of Review
Integrated literature review is used to answer the following research question: “What are the ‘barriers’ and ‘enabling’ factors that affect nurses’ adherence to evidence based PICC line care in tertiary healthcare setting?” With the complexity of information available on PICC’s, it is imperative to have a method for synthesising knowledge from previous studies to better inform healthcare practice (Torraco, 2005). An integrated literature review allows one author to analyse and synthesise primary research findings, to assess the scope of literature, and summarise available knowledge to attain a more holistic understanding of current (Souza et al., 2010). Integrated literature review is a tool that facilitates healthcare policy based on evidence-based practice within nursing (Souza et al., 2010).
Search & Retrieval (inclusion/exclusion table, PRISMA chart)
The databases used for the integrative literature review are CINHAL and Medline (via Ovid). These databases contain high quality, peer-reviewed evidence that’s specific to nursing research and healthcare practice. Boolean operators and truncations were used with the key words: ‘Peripheral inserted central catheter’, ‘catheter care, peripheral inserted central,’ ‘nursing attitudes, perceptions, opinion, experience, view, reflection and belief,’ and ‘adverse, complication, factors.’ Due to the limited number or peer-reviewed journal articles exploring ‘barriers’ and ‘enabling’ factors effecting PICC care, broader search terms such as ‘Peripheral inserted central catheter’ and ‘nursing clinical competence’ were used to yield larger search results in Medline (n=457) and CINHAL (n=375). Articles were searched from the period of 2012 till 2023 and were filtered to be English only. Each article was then reviewed to ensure that they were primary research, directly relevant to the research topic and were either qualitative or mixed methods. The search yielded 15 articles (See Figure 1). The P.I.O model has been chosen to define the research question.
The variables to be investigated are ‘barrier’ and ‘facilitating’ factors affecting evidence-based nursing practice of PICCs. The study seeks to identify these variables. Three types of research designs have been identified to add valuable insight into the adherence of evidence based PICC care and management. These are: (1) qualitative studies that have descriptive and/or phenomenology framework (n=5); (2) Mixed-method observational studies that evaluated nurse’s adherence and deviation from evidence-based PICC care (n=6); and (3) the implementation of educational and skill-based intervention to assess individual knowledge and skill outcomes (n=3). These studies report proportion of change in PICC complications post educational and skill-based interventions, while also utilising qualitative methods such as open-ended surveys, to explore factors that affect evidence-based PICC care. It is important to note that the primary goal of the research is to identify all ‘barriers’ and ‘facilitators’ that effect nurses’ adherence to evidence based PICC line management, the focus is not to investigate if education and skill-based training alone is sufficient in improving evidence-based nursing management of PICC. Qualitative and mixed research methods are chosen to answer ‘how’ nursing adherence to evidence-based PICC care can be promoted, and ‘why’ we may still have high PICC complication rates.
The inclusion and exclusion criteria are outlined above ( see Table 2). Primary research studies that examined the research question with qualitative or mixed methods research design were included in the integrated review. To increase the yield of research, all countries exploring the research question and all departments of the tertiary healthcare setting were included. Research articles that explored nurse confidence, PICC complications and/or adherence to evidence based CVAD/PICC management were included in the study.
Exclusion criteria were all the research articles that didn’t address the research question. That were not in English, research conducted before 2012, or with patients aged below 18 years. Any articles that did not discuss CVAD/PICC management was also excluded from the integrated review.
Critical Appraisal
Mixed Method Appraisal Tool (MMAT) will be used to evaluate the quality of literature used within the integrated literature review. A major challenge encountered in the appraisal of individual studies, is the use of multiple methodologies (Hong et al., 2018). For example, this review includes both qualitative and mixed method studies. MMAT overcomes this challenge by allowing for appraisal of multiple study designs: qualitative, mixed method research, appraisal of randomised control trials, non-randomised studies and quantitative descriptive studies (Hong et al., 2018). MMAT is commonly used for health-related research. Inclusion of different study methods allows for a richer understanding of contextual factors and its impact on patient outcomes. However, there is still room for improvement for MMAT (Hong et al., 2018). MMAT tool focuses on quantification of quality over content, however, it has been criticised for the risk of overly positive answers, with the use of “cannot tell” option for inadequately reported papers (Hong et al., 2018). It has been recommended that MMAT appraisal tool be limited to published studies that match the quality of reporting required for literature review (Hong et al., 2018). See Appendix 1 for MMAT tool outline and the critical appraisal of 15 peer-revied journal articles.
Thematic Analysis