Nurse Education Today 107 (2021) 105157 Available online 27 September 2021 0260-6917/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Evidence of learning on the insertion and care of peripheral venous catheters in nursing students: A mixed study Judith García-Exposito a, Mercedes Reguant b, Olga Canet-Velez c,d, Francisca Ruiz Mata e, Teresa Botigue a,f, Judith Roca a,f,* a Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, 2 Montserrat Roig, St., 25198 Lleida, Spain b Department of Research Methods and Diagnosis in Education, University of Barcelona, 171 Passeig de la Vall d'Hebron, St., 08035 Barcelona, Spain c Faculty of Health Sciences Blanquerna, University Ramon Llull, Spain d Global Health, Gender and Society Research Group (GHenderS), 326-332 Padilla, St, 08025 Barcelona, Spain e School of Nursing Gimbernat, University Autonoma de Barcelona, Av. De la Generalitat, 202-206, 08174 Barcelona, Spain f Health Care Research Group (GRECS), Biomedical Research Institute of Lleida, 80 Alcalde Rovira Roure, St., 25198 Lleida, Spain A R T I C L E I N F O Keywords: Education Evidence-based guidelines Nursing Students Peripheral venous catheter A B S T R A C T Objectives: 1) To assess nursing students' evidence-based knowledge on the use of PVCs, and 2) to examine the perception of learning and teaching strategies aimed at this skill. Background: Insertion and care of Peripheral Venous Catheters (PVCs) are essential skills in undergraduate nursing education. Appropriate knowledge of this skill is crucial to improve clinical practice and patient safety. Therefore, training becomes an enabler for safe practice. Design: A multi-centre convergent parallel mixed-methods. Setting and participants: A total of 675 second-, third- and fourth-year nursing students from 3 nursing schools took part in the study. Methods: Quantitative data collection used a validated 15-question survey on knowledge of PVC management, and a descriptive and inferential analysis was carried out. Qualitative data were collected via a questionnaire consisting of 4 open-ended questions assessing knowledge, teaching methodologies and scenarios, and points for improvement. Results: Most participants were female (74.04%), with a mean age of 22.45 (SD ˆ 4.65), who had no experience in the health field (61.8%). They obtained a mean knowledge score of 7.27 (SD ˆ 2.64) out of 15. The students who obtained higher scores had a mean professional experience of 7.96, SD ˆ 2.66 (p 0.000) and were in their final year, with a mean of 8.59, SD ˆ 2.56, (p 0.000). On the other hand, the students assessed their knowledge as basic but improving year by year. They also identified a need to apply more active and experiential method- ologies that would allow for reflection. Conclusion: Level of educational level and experience is associated with increased knowledge. In order to improve knowledge, changes must be made in the training process to incorporate methodologies such as simulation and online training. There is a need to develop programmes that favour the alignment of theory with clinical practice. 1. Background Insertion and care of Peripheral Venous Catheters (PVCs) are basic skills taught in undergraduate nursing education. These widely used procedures in hospitalised patients provide quick and safe access to the bloodstream (Parreira et al., 2020; Souza et al., 2015). Nursing students must undergo training and supervised practice to develop the skill of delivering intravenous cannulation (Morgaonkar et al., 2017). It is important to note that the knowledge and skills to be developed should be based on: assessment, insertion, care, and management of vascular access devices (Carr et al., 2018). However, inadequate or unsound knowledge of PVCs can lead to a high likelihood of malpractice. Thus, * Corresponding author at: Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, 2 Montserrat Roig, St., 25198 Lleida, Spain. E-mail addresses: mreguant@ub.edu (M. Reguant), olgacv@blanquerna.url.edu (O. Canet-Velez), francisca.ruiz@eug.es (F. Ruiz Mata), teresa.botigue@udl.cat (T. Botigue), Judith.roca@udl.cat (J. Roca). Contents lists available at ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/locate/nedt https://doi.org/10.1016/j.nedt.2021.105157 Received 7 May 2021; Received in revised form 18 July 2021; Accepted 22 September 2021 Nurse Education Today 107 (2021) 105157 2 the level of knowledge and skills acquired is directly associated with adherence to patient safety principles (Vaismoradi et al., 2020). It has been shown that managed correctly, PVCs are safe devices with little risk to patients (Høvik et al., 2019). However, it is crucial to dispel the perception that PVCs are innocuous and associated with minimal risk of infection (Vendramim et al., 2020). The most common compli- cations are phlebitis (44%), infiltration (16,3%) and, subsequently, a lower incidence of occlusion and catheter dislodgement (7.6% and 5.6%, respectively) (Simin et al., 2019). Although these complications may develop into more severe consequences such as bloodstream in- fections, they are less frequent (Mermel, 2017). This all seems to confirm that the level of knowledge acquired by students is essential in two respects: to perform clinical practice place- ments that genuinely improve clinical experience and nursing compe- tence (Cicolini et al., 2014; Woody and Davis, 2013; Simonetti et al., 2015); and to avoid complications and strengthen the quality of care and patient safety (Ahlin et al., 2017; Osti et al., 2019). Undoubtedly, to improve the management of PVCs and reduce failure rates, this knowl- edge needs to be grounded in evidence-based interventions (Alexandrou et al., 2018). Previous studies (Dogu Kokcu and Cevik, 2020; Etafa et al., 2020; Simonetti et al., 2019) have identified nursing students' knowledge of this subject but have not explored the teaching-learning process entailed in its development. Identifying knowledge makes it possible to detect educational needs and establish priorities in educational programmes (Simonetti et al., 2019), but it is necessary to explore how and where. According to Zabalza (2011), it is not only important what information is provided but how it is supplied and how students process it. Therefore, it is indispensable to explore how students assess the learning process. In line with the points detailed above, our study has a twofold objective: 1) to analyse nursing students' evidence-based knowledge of PVC management; and 2) to examine the perception of the learning and teaching strategies used in nursing education. 2. Methods 2.1. Study design We proposed a multi-centre convergent parallel mixed-methods design study (Creswell, 2014). 2.2. Context and participants A convenience sample of three university nursing schools took part in the study. These educational institutions, state, private and mixed (a private nursing school affiliated to a state university), represent all possible management models in Spain. The nursing Degree in Spain is a four-year full-time programme. The population were nursing students in the second, third or fourth year of their course. First-year students were excluded due to their lack of knowledge of the subject matter and possible low level of competence, as well as students who did not consent to participate. The total population who were invited to participate was 934 par- ticipants, from which 675 responses were received, which represents 72.26% of the total. Based on the literature (Cicolini et al., 2014; Labeau et al., 2008a, 2008b) the sample was sufficient and representative, being greater than 71%. 2.3. Instruments Quantitative data on knowledge of PVC care were collected using an extended version of the questionnaire by Cicolini et al. (2014) on pre- venting peripheral venous catheter-related infections, based on a study by Labeau et al. (2008b) on central venous catheters. This version, which was translated, expanded and validated to the Spanish context by the research team within the same research project, became the instrument we termed Evidence-based knowledge on PVC management. The results of the validation process according to psychometric data of the questionnaire in Spanish showed a good concordance assessment according to the intraclass correlation coefficient values of 0.91. Like- wise, the instrument showed adequate reliability, understood here as internal consistency, with a total Cronbach's alpha of 0.703. The in- strument consisted of two parts: general data of the participants and 15 questions on their knowledge of PVCs. The question-answer model comprised one question and 4 answer options, with only one correct answer (score 1 point), 2 options for incorrect or distractor answers (score 0 points) and a final “I do not know” (score 0 points). The maximum obtainable score was 15 points, and the minimum score was zero. The random control formula was not applied, i.e. the possibility of answering a question incorrectly did not penalise the final score obtained. Qualitative data were collected using a questionnaire consisting of 4 open-ended questions on: 1) perception of acquired knowledge, 2) teaching methodologies that had favoured knowledge development, 3) teaching scenarios that have allowed learning, and 4) aspects to improve the teaching-learning process. 2.4. Data collection Quantitative and qualitative data were collected concurrently. The self-administered questionnaires were answered in an average time of 20–25 min between November 2019 and January 2020. Data facilitators collected each completed questionnaires in an envelope to guarantee confidentiality and anonymity. 2.5. Data analysis Inferential analysis was performed for quantitative data, descriptive (frequencies, percentages, mean and standard deviation). We checked the conformity of the variables for normal distribution using the Kolmogorov-Smirnov test (p 0.06 > 0.05). Subsequently, parametric tests were performed using: student's t-test for the comparison of means of independent populations and ANOVA to simultaneously compare the means of more than two populations. The data were analysed using IBM SPSS Statistics 22, and the level of significance applied for all assess- ments was p < 0.05. The qualitative data were analysed using the classical content anal- ysis method (Leech and Onwuegbuzie, 2007), supported by Atlas-Ti version 8 software. This analysis allowed us to identify relevant con- cepts, patterns of ideas, and frequency of key ideas. 2.6. Rigour and quality criteria The criteria of scientific rigour proposed by Onwuegbuzie and Burke (2006) of legitimation, design quality and interpretive rigour were ensured throughout the study. This multi-method strategy enabled complementarity and triangulation of the data. The researchers constantly reviewed the study to guarantee the consistency of the data and the inferences made. 2.7. Ethical approval This study was approved by the CAERFIF research committee of the Faculty of Nursing and Physiotherapy, University of Lleida. Author- isation was obtained from the three participating nursing schools. The students signed a written consent form to take part in the study. All data were treated confidentially and anonymously. J. García-Exposito et al. Nurse Education Today 107 (2021) 105157 3 3. Results 3.1. Characteristics of the participants The participants were 675 nursing students aged between 18 and 50 years, with an average age of 22.45 years (SD ˆ 4.65), of whom 74.04% were female. The university access route was mostly secondary school level at 63.80%, and 61.8% had no work experience in the healthcare field. Table 1 shows the characteristics of the sample. 3.2. Level of evidenced-based knowledge The participants obtained an overall mean score of 7.27 out of 15 points (SD ˆ 2.64) in their level of knowledge. Their knowledge of PVCs showed no significant differences in score between genders (t ˆ 0.32 and bilateral significance p 0.749 > 0.05). The female students scored a mean of 6.96 (SD ˆ 2.50), and males a mean of 6.89 (SD ˆ 2.37). No significant differences were found between the different access routes to the university either (Snedecor's ANOVA test F ˆ 2624 p associated value p ˆ 0.05 and multiple comparisons p > 0.05). The students with a secondary school access route obtained a mean score of 7.08 (SD ˆ 2.7); the undergraduates scored a mean of 7.59 (SD ˆ 2.39); and those stu- dents with other university Degrees obtained a mean score of 7.88 (SD ˆ 1.99). The students who entered the university through the path of ac- cess for over 25 to 45 year olds, obtained the lowest score, with a mean of 6.7 (SD ˆ 3.41). In contrast and positively, professional healthcare experience influ- enced students' test scores (t ˆ 5.558 and bilateral significance 0.00 < 0.05). Professional experience was related to students who are techni- cians or nursing assistants. The students with professional experience obtained a higher knowledge score, with a mean of 7.96 (SD ˆ 2.66), than those with no experience, who obtained a mean of 6.63 (SD ˆ 2.48). The score by academic year rose steadily in all the participants, ac- cording to the contrast of the Snedecor F statistic, which scored 98.620 and its associated p value p ˆ 0.000 < 0.50; favouring the higher year group. The second-year students obtained the lowest scores, with a mean of 5.58 (SD ˆ 2.4), followed by the third-year students, with a mean of 7.76 (SD ˆ 2.02). The fourth-year students received the highest scores, with a mean of 8.59 (SD ˆ 2.56). Table 2 shows the complete instrument (questions and answers) and the results by responses and academic year. The analysis by academic year showed that the percentage of correct answers per question was also broadly maintained gradually. The exception was question 6, which received an incorrect response across all three academic years, in contrast to the higher score of 2nd-year students. Following the previous data, the difficulty index was higher in the second year than in the last years (Table 3). This table shows significant differences (p < 0.05) in all the items included, implying that the students' academic year affected the response. Fig. 1 shows all the students' overall results and each one of the questions according to whether they responded incorrectly, correctly or did not know. 3.3. Assessment of learning and training strategies A total of 2910 units of meaning were retrieved from the results of the qualitative data analysis on the students' perception of learning and the teaching strategies linked to the teaching of this subject. The units were then coded and classified according to similarity into 3 themes: the perception of acquired knowledge (589 units of meaning), training scenarios for assimilating and consolidating knowledge (885 units of meaning) and the detection of possible factors for improving the learning process (1376 units of meaning). Table 4 shows the three themes, along with their corresponding main categories and example data. 4. Discussion The dual purpose of this mixed-methods study was to assess nursing students' knowledge of PVC management to prevent infection and to explore elements of learning that can improve teaching. 4.1. Knowledge acquisition of PVCs We found that the students' level of knowledge of PVCs was sufficient to low, which is consistent with the results of other studies (Dogu Kokcu and Cevik, 2020; Etafa et al., 2020; Simonetti et al., 2019). Similarly, those who had a higher knowledge were the senior students (Dogu Kokcu and Cevik, 2020; Simonetti et al., 2019) and the students with prior work experience (Etafa et al., 2020). This difference could be explained by their proximity to the clinical environment (Dogu Kokcu and Cevik, 2020). The incremental structure of the first-year curriculum includes basic subjects, which are more theoretical and include less clinical practice. This gradually progresses to nursing science subjects and more clinical practice. As in other studies, no gender differences were observed (Etafa et al., 2020; Simonetti et al., 2019, 2015). The score analysis shows that the participants achieved a mean overall score of 7.27 out of 15 points (SD ˆ 2.64). The average score did not reach the 7.5 pass grade. However, there was a definite trend to- wards a rise in the percentage of students passing (>7.5 points in the test): 21% in the second year, 55.6% in the third year and 63.5% in the fourth year. This confirms that the level of studies and the greater exposure to clinical practice contribute to higher knowledge uptake. In what follows, the results per item and overall accuracy are dis- cussed in a stepwise manner from highest to lowest. The questions obtaining the most correct scores were: site of PVC placement (83.4%), recognition of the upper extremities (EESS), the first action for phlebitis (76.1%), removing the catheter (Webster et al., 2019), and use of aseptic technique during connection/disconnection of infusion lines (75.1%). The last recommendation shows even higher results than those by Etafa et al. (2020). It is relevant to note that the same score was obtained for the question on the correct concentration of chlorhexidine before insertion of PVCs (70.7%) as in the study by Simonetti et al. (2019). Compared with the study by Osti et al. (2019) conducted on nurses, the students did not recognise the type of gloves to use when inserting the different types of catheter (55.3%), choosing sterile ones for all peripheral and central catheters. Students often have difficulties assimilating the concepts of asepsis and sterility, and when in doubt, they choose the most protective one. In contrast, the nurses identified non-sterile catheters for peripheral lines. This is relevant because risk assessment and the adoption of preventive or aseptic measures is a nursing competence (Denton and Hallam, 2020). Therefore, acquired knowledge of protective and aseptic equipment should be assured dur- ing training. Our results showed low scores regarding the infusion/administration set replacement after blood transfusion (53.5%), lipid emulsions Table 1 Characteristics of the sample: number (n) and frequencies (%). Variables n % Agea 22.45 4.65 Sex Men 175 25.93 Women 500 74.07 Path to university Secondary school 430 63.80 Training courses 189 27.90 Other university degrees 36 5.34 Over 25–45 years old 20 2.96 Nursing degree year 2nd 229 34 3rd 243 36 4th 203 30 Health worker No 417 61.8 Yes 258 38.2 a Mean and standard deviation (SD). J. García-Exposito et al. Nurse Education Today 107 (2021) 105157 4 Table 2 Questionnaire results by academic year. Global 2nd 3rd 4th n % n % n % n % 1. Sterile gloves must be used when placing catheters:: a. Peripherals 13 1.9 11 4.8 1 0.4 1 0.5 b. Centrals* 373 55.3 77 33.6 131 53.9 165 81.3 c. In all types of catheters 276 40.9 129 56.4 110 45.3 37 18.2 d. I do not know 13 1.9 12 5.2 1 0.4 0 0 2. It is recommended to perform an antiseptic hand wash before insertion of Peripheral Venous Catheters (PVCs)… a. No, it's sufficient to wash hands with a non-antimicrobial soap o with alcohol-based hand rubs * 159 23.6 27 11.8 61 25.1 71 35.0 b. No, you do this only for invasive procedure 25 3.7 9 3.9 6 2.5 10 4.9 c. Yes, always 471 69.8 177 77.3 173 71.2 121 59.6 d. I do not know 20 3.0 16 7.0 3 1.2 1 0.5 3. It is recommended to use an aseptic technique during connecting/disconnecting the infusive lines (i.e. no touch technique)… a. Yes, always * 507 75.1 142 62.0 204 84.0 161 79.3 b. No, it's sufficient to wash hands with an antimicrobial soap 115 17.0 42 18.4 34 14.0 39 19.2 c. No, because it increases the risk of infection 8 1.2 6 2.6 2 0.8 0 0 d. I do not know 45 3 39 17.0 3 1.2 3 1.5 4. It is recommended to use steel needles (butterfly type) for the administration of drugs… a. No, because they might cause tissue necrosis if extravasation occurs * 268 39.7 57 24.9 98 40.3 113 55.7 b. Yes, if I have to inject drugs for a short time 129 29.1 39 17.0 41 16.9 49 24.1 c. Yes, always 32 4.7 13 5.6 16 6.6 3 1.5 d. I do not know 246 36.4 120 52.5 88 36.2 38 18.7 5. It is recommended to change the dressing on the catheter insertion site… a. On a daily basis 44 6.5 19 8.3 16 6.6 9 4.4 b. Every 3 days 158 23.4 59 25.8 49 20.2 50 24.6 c. When indicated (soiled, loosened, …) and at least every five, six or seven days** 445 65.9 129 56.3 174 71.6 142 70.0 d. I do not know 28 4.1 22 9.6 4 1.6 2 o 6. It is recommended to cover up the catheter insertion site with… a. Polyurethane dressing (transparent, semipermeable) 523 77.5 145 63.3 205 84.4 173 85.2 b. Gauze dressing 33 4.9 17 7.4 13 5.3 3 1.5 c. Both are recommended because the type of dressing does not affect the risk for catheter related infections* 73 10.8 35 15.3 16 6.6 22 10.8 d. I do not know 46 6.7 32 14.0 9 3.7 5 2.5 7. It is recommended to disinfect the catheter insertion site with… a. 0.5% Chlorhexidine gluconate solution * 477 70.7 141 61.6 191 78.6 145 71.4 b. 0,2% tinture of iodine 70 10.4 19 8.3 20 8.2 31 15.3 c. 10% alcohol 63 9.3 22 9.6 23 9.5 18 8.9 d. I do not know 65 9.6 47 20.5 9 3.7 9 4.4 8. It is recommended to apply an antibiotic ointment at the insertion site of a PVC… a. Yes, because it decreases the risk for 49 7.3 21 9.2 20 8.3 8 3.9 b. No, because it causes antibiotic resistance * 229 33.9 55 24.0 79 32.5 65 32.0 c. No, because it does not decrease the risk for catheter related infections 221 32.7 68 29.7 88 36.2 65 32.0 d. I do not know 176 26.1 85 37.1 56 23.0 35 17.1 9. When lipid emulsions are administered through a PVC (peripheral parenteral nutrition), it is recommended to replace the administration set… a. Within 24 h * 279 41.3 64 27.9 123 50.6 92 45.3 b. Every 72 h 210 31.1 70 30.6 77 31.7 63 31.0 c. Every 96 h 8 1.2 4 1.8 1 0.4 3 1.5 d. I do not know 178 26.4 91 39.7 42 17.3 45 22.2 10. A Medium Venous Catheter (MVC) or Peripherally Inserted Central Catheter (PICC) should be substituted for the use of a PVC if intravenous (IV) therapies have a duration of more than: a. 3 days 64 9.5 27 11.8 31 12.8 6 3.0 b. 6 days* 160 23.7 54 23.6 34 14.0 72 35.5 c. 10 days 240 35.6 44 19.2 95 39.0 101 49.8 d. I do not know 211 31.3 104 45.4 83 34.2 24 11.7 11. It is recommended to use a system for manipulation and IV access through PVCs: a. With needle 172 25.5 76 33.2 50 20.6 46 22.7 b. Without needle* 260 38.5 52 22.7 121 49.8 87 42.9 c. Either way, both systems are valid. 42 6.2 13 5.7 17 7.0 12 5.9 d. I do not know 201 29.8 88 38.4 55 22.6 58 28.5 12. The site of choice for the placement of the PVC is... a. Upper or lower extremity 64 9.5 29 12.7 22 9.1 13 6.4 b. Upper extremity * 563 83.4 161 70.3 214 88.1 188 92.6 c. Lower extremity 14 2.1 9 3.9 4 1.6 1 0.5 d. I do not know 34 5.0 30 13.1 3 1.2 1 0.5 13. In the event of administering blood or blood products, the PVC set must be changed.... a. Within 24 h of the start of the infusion* 361 53.5 80 24.9 144 59.3 137 67.5 b. Every 96 h 23 3.4 5 2.2 8 3.3 10 4.9 c. Upon removal of the PVC 90 13.3 32 14.0 42 17.3 16 7.9 d. I do not know 201 29.8 112 48.9 49 20.1 40 19.7 14. When signs of phlebitis (tenderness, warmth, erythema or palpable venous cord) or infection from the PVCs occur... a. The infusion must be halted and the equipment changed. 102 15.1 35 15.2 46 18.9 21 10.3 b. Antibiotics must be administered through the catheter itself. 15 2.2 13 5.7 1 0.4 1 0.5 c. The catheter must be removed* 514 76.1 141 61.6 193 79.4 180 88.7 (continued on next page) J. García-Exposito et al. Nurse Education Today 107 (2021) 105157 5 (41.3%), needle-system use (38.5%) and steel needle use (39.7%). The scores obtained were lower than those in other studies conducted in very different contexts, such as Italy (Simonetti et al., 2019) and Ethiopia (Etafa et al., 2020). Thus, given the students' uncertainty surrounding the basic guidelines for administration set replacement, training needs to be reinforced. The study by Cicolini et al. (2014), also conducted on novice nurses, reported that although the students recognised the need to replace administration sets after administration of lipid emulsions and blood, as well as the correct use of needle-free systems, they scored low results on the use of steel needles for administering drugs. Failure to be aware of this guideline increases the risk of extravasation. Continuing on the theme of catheter selection and site, the students struggled to understand when to replace the catheter with a medium (MVC) or central catheter (CVC) (23.7%) and the correct size of the catheter to be placed (36%). These results could be explained by the fact that this is specialised information, typically covered in the higher years of nursing education. MVCs, especially CVCs, allow for prolonged therapy, infusion of vesicants and irritants, and reduce repeat phlebot- omy (Mattox, 2017). Studies evaluating the association of a PVC over long periods are scarce; however, its use is not recommended when managing an infusion therapy pattern of more than 6 days (Wei et al., 2019). Several studies have linked the larger catheter size to more local complications such as phlebitis (Wei et al., 2019). Deficient knowledge was observed on handwashing (23.6%) and the application of antibiotic ointment (33.9%). Students recognised the importance of handwashing but were confused about the correct type of hygiene. Few studies associate hand disinfection with PVC complica- tions and do not offer specific guidelines on the type of soap or hydro- alcoholic gel, dosage and duration (Lee et al., 2019). The misconception that antibiotics aid healing could explain the use of antibiotic ointment (Etafa et al., 2020). The students correctly identified situations requiring dressing changes (65.9%), but they mistook the choice of dressing. This question received the lowest number of correct answers (10.8%). The students chose the transparent dressing as the best option, explained by its widespread use in clinical hospital practice. In contrast, evidence-based recommendations (Gorski et al., 2016; O'Grady, 2017) and other studies (Alexandrou et al., 2018) identify transparent and sterile gauze dress- ings as equally valid. However, it is essential to include in the protocols the type of dressing to secure the PVC to the patient's skin according to the viable options for each hospital (De Sousa Salgueiro-Oliveira et al., 2019). The qualitative and quantitative results on the students' level of knowledge complement each other and are coherent. Students recog- nised that their knowledge is basic and insufficient in the qualitative phase, and they still have a great deal to learn. Table 2 (continued ) Global 2nd 3rd 4th n % n % n % n % d. I do not know 44 6.5 40 17.5 3 1.3 1 0.5 15. It is recommended that the following PCV should be placed: a. Larger size 294 43.6 78 34.2 98 40.3 118 58.2 b. Smaller size* 243 36.0 63 27.6 104 42.8 75 36.9 c. Larger external diameter 15 2.2 7 3.3 7 2.9 1 0.5 d. I do not know 123 18.2 80 34.9 34 14.0 9 0.4 The asterisk* indicates the correct response. Table 3 Percentage of correct responses and difficulty index per question and academic year. No. question Global 2nd 3rd 4th Fa p Qn_01 55.3% (0.45) 33.6% (0.66) 53.9% (0.46) 81.3% (0.19) 57.839 0.000 Qn_02 23.6% (0.76) 11.8% (0.88) 25.1% (0.75) 35.0% (0.65) 17.067 0.000 Qn_03 75.1% (0.25) 62.0% (0.38) 84.0% (0.16) 79.3% (0.21) 17.327 0.000 Qn_04 39.7% (0.60) 24.9% (0.75) 40.3% (0.60) 55.7% (0.44) 22.652 0.000 Qn_05 65.9% (0.34) 56.3% (0.44) 71.6% (0.28) 70.0% (0.30) 7.291 0.001 Qn_06 10.8% (0.89) 15.3% (0.85) 6.6% (0.93) 10.8% (0.89) 4.669 0.010 Qn_07 70.7% (0.29) 61.6% (0.38) 78.6% (0.21) 71.4% (0.29) 8.458 0.000 Qn_08 33.9% (0.66) 24.0% (0.76) 32.5% (0.67) 46.8% (0.53) 13.058 0.000 Qn_09 41.3% (0.59) 27.9% (0.72) 50.6% (0.49) 45.3% (0.55) 13.940 0.000 Qn_10 23.7% (0.76) 23.6% (0.76) 14.0% (0.86) 35.5% (0.65) 14.655 0.000 Qn_11 38.5% (0.61) 22.7% (0.77) 49.8% (0.50) 42.9% (0.57) 20.510 0.000 Qn_12 83.4% (0.17) 70.3% (0.30) 88.1% (0.12) 92.6% (0.7) 23.794 0.000 Qn_13 53.5% (0.47) 34.9% (0.65) 59.3% (0.41) 67.5 (0.33) 27.421 0.000 Qn_14 76.1% (0.24) 61.6% (0.38) 79.4% (0.21) 88.7% (0.11) 24.428 0.000 Qn_15 36% (0.64) 27.9% (0.72) 42.8% (0.57) 36.9% (0.63) 5.771 0.003 a Snedecor F statistic. Qn_0 1 Qn_0 2 Qn_0 3 Qn_0 4 Qn_0 5 Qn_0 6 Qn_0 7 Qn_0 8 Qn_0 9 Qn_1 0 Qn_1 1 Qn_1 2 Qn_1 3 Qn_1 4 Qn_1 5 CORRECT 373 159 507 268 445 73 477 229 279 160 260 563 361 514 243 INCORRECT 289 496 123 161 202 556 133 270 218 304 214 78 113 117 309 DON'T KNOW 13 20 45 246 28 46 65 176 178 211 201 34 201 44 123 0 100 200 300 400 500 600 Fig. 1. Overall results by questions and answers: frequencies. J. García-Exposito et al. Nurse Education Today 107 (2021) 105157 6 4.2. Learning process: contexts and teaching methodologies for improvement Knowledge of nursing practice and patient safety, linked explicitly to PVCs, stems from formal education and nurse-patient interactions in the clinic (Muniz Braga et al., 2019). Therefore, nursing educators should emphasize evidence-based knowledge that can be correctly transferred to clinical practice (Simonetti et al., 2019). To do this, it is essential to improve information literacy and the ability to interpret research with interactive and clinically integrated teaching strategies (Fiset et al., 2017; Horntvedt et al., 2018). The integration of evidence-based prac- tice in training allows us to graduate nurses who provide multidimen- sional, safe, profitable and high-quality care (Wakibi et al., 2021). Student training on the use of PVCs is still based on technical skills, particularly needle insertion; this knowledge needs to be more comprehensive to include patient safety (Ravik et al., 2017). The stu- dents demand practical-theoretical knowledge that can be transformed into direct or experiential knowledge through workshops, skills classes, seminars or problem-based learning. Along these lines, the study by Brannan et al. (2016) details that students are more likely to have active, visual, sensing, and sequential learning styles, and that these styles have a greater impact on knowledge and ultimately improve clinical reasoning in practice. Among the findings of our study, simulation emerges as a powerful learning tool. While low-fidelity simulation is limited, it helps skills performance and familiarity with the subject matter. However, it does not allow for safe practice because it does not simulate a real-world environment or a critical event (Ravik, 2015). Indeed the respondents who did most of their aseptic technique training in simulation or the clinical setting appeared more likely to feel confident in their ability to insert and maintain devices than those who received the majority of education in lecture (Carter et al., 2017). In the teaching process, stu- dents reported the enhancement of simulation and its combination with virtual resources as a point of improvement. Simulation coupled with technology enhances learning (De Souza-Junior et al., 2020). In conso- nance with other authors (Hinkin and Cutter, 2014), our results show a clear divergence between theory and practice. Furthermore, when stu- dents do not adequately integrate the knowledge acquired in the uni- versity, they may attach more importance to their knowledge of clinical practice, even if this is incorrect. Therefore, training should be extended to generic competencies such as critical thinking (Rahiman et al., 2018), enabling them to query their behaviour or actions without risk of con- flict or embarrassment (Hinkin and Cutter, 2014). There are different ways to carry out nursing procedures correctly; students must be able to distinguish between these different interventions without jeopardising patient safety (Ewertsson et al., 2017). Other variables determining the level of knowledge on catheter care include self-efficacy, problem- solving, liking the profession and year of study (Dogu Kokcu and Cevik, Table 4 Matrix of findings. Themes Categories Example data (unit of meaning) Perception of acquired knowledge Knowledge is fundamental, hence, they still have much to learn “I admit that my knowledge is limited and that I had many doubts when answering the questionnaire.” P55 “My knowledge is good but insufficient to offer optimal care to patients”P241 The higher their academic year, the higher their perception of having attained a higher level of knowledge “I still have a lot to learn, but I see that year by year, I’m acquiring more knowledge and don’t have as many doubts.” P32 “Little by Little I internalize the theoretical knowledge but I lack professional experience to reinforce it, but in each practice I find myself more sure”P192 The dichotomy between theory and practice is viewed as a barrier to learning “My knowledge can be improved, but I see that the techniques are not always performed correctly in clinical practice…” P118 “There should be a better link between the classroom and the hospital, if not for us, it is a mess… We do not know how to act”P443 Training scenarios for integrating and consolidating knowledge Scenarios that practise and develop skills that help to prepare them better for clinical practice better (workshops, skills classrooms, case solving and problem-based learning seminars) “It's important to be able to practice in the classrooms with the manikins and simulators; it helps you recognise the subject and gain a bit more confidence.” P520 “The skills classrooms make you feel sure about how to act in the clinic” P91 The importance of clinical practice placements as a genuinely relevant learning space “Theory helps us to do better in clinical practice placement, but in my opinion, the hospital is where you really learn.” P19 “Doing practice is in my opinion very important, you learn by doing with the patient, and this really helps you to integrate”P599 Factors for improving the learning process Reinforcement of simulations, self-learning strategies and virtual resources “Simulation is a near-real environment where you can allow yourself to make mistakes and learn as well.” P246“ …the images, the videos allow you to interact more realistically, then it's easier, you don’t have to imagine because you experience it…” P657 More active, participatory, individualised and evidence-based methodologies “They should give classes that are more dynamic, with less theory and fewer explanations from teachers”. P343 “The knowledge we learn should be based on the best evidence, which is sometimes not the case… there are different criteria among teachers.” P125 Strategies to promote inquiry and reflection “Methodologies should arouse our interest as students to query and reflect, and thus to investigate and Table 4 (continued ) Themes Categories Example data (unit of meaning) study more.” P324 “We must be more critical of the information, not all the information available on the internet is valid”P63 Continuum between theory and practice, and unify criteria “Teaching the same protocols as those used in hospitals would be immensely helpful, so you don’t get confused or don’t recall how to act.” P394 “I like it when subjects propose joint sessions with clinical experts, they help us understand better”P637 J. García-Exposito et al. Nurse Education Today 107 (2021) 105157 7 2020). Students demand inquiry, questioning and reflection as elements that favour learning. Thus, there is a need to create a conscious and grounded practical knowledge through inquiry (Domingo and Gomez, 2014), given that students' knowledge and/or skills improve when reflecting on critical events or daily practice (Andersen, 2016). Clinical practice is where higher levels of reflection are achieved (Roca et al., 2020), that is, higher order cognitive skills. As students spend more time in the clinic they can become more aware of gaps in their knowledge and increase their confidence better with clinical practice in comparison to the classroom (Huang et al., 2020). Thus, students' perception of the learning context (clinical or academic) can change their learning approach, going from a more superficial to a deeper one (Takase and Yoshida, 2021). It is crucial to harness the students' potential as future professionals, as noted in the study of Forberg et al. (2014), which reported that recently graduated nurses showed greater adherence to the principles of PVC care due to their having acquired more up-to-date knowledge and higher technological skills. Moreover, there is a need for constant knowledge reinforcement during the post-graduate period in the clinical context (Keleekai et al., 2016). 4.3. Limitations This study allowed us to establish associations between variables but not causal relationships between possible predictors of knowledge among students. Similar studies should be conducted with nursing ed- ucators and clinical practice tutors to address this knowledge deficit comprehensively. 5. Conclusions The students' level of knowledge of PVC insertion and care was generally low. Those who obtained the highest scores were senior-year students and those with previous clinical experience. Thus, the level of education and experience could explain these higher scores. Basic knowledge of hand hygiene and aseptic techniques, selection of catheters and sites, site dressing regimens, skin preparation, replace- ment of administration sets and needleless intravascular catheter sys- tems should be reinforced. This strengthening directly improves clinical practice and adherence to the principles of quality of care and patient safety. Changes in nursing education must be structured on the following four levels: emphasis of scientific and experiential knowledge over theoretical and procedural knowledge; application of new teaching methodologies such as clinical simulation and online and technological or interactive resources; need to align theory with clinical practice by developing shared evidence-based programmes which emphasize continuous collaboration between students, professionals and educators to create a more positive attitude in all participants; and promotion of transversal competencies such as critical thinking, reflective thinking or problem-solving that promote student inquiry and the application of evidence-based nursing knowledge. Finally, for the development of evidence-based practice, it is essential that educators plan its develop- ment in a transversal and integrated way throughout the curriculum, using theoretical reference models and seriously planning the develop- ment context and the strategies to be used. CRediT authorship contribution statement Judith García-Exposito: Formal Analysis, Investigation, Resources, Writing – Review & Editing. Mercedes Reguant: Formal Analysis, Investigation, Resources, Data Curation, Writing – Original Draft, Writing – Review & Editing. Olga Canet-Velez: Investigation, Re- sources, Data Curation. Francisca Ruiz: Investigation, Resources, Data Curation. Teresa Botigue: Investigation, Resources - Review & Editing. Judith Roca: Conceptualization, Methodology, Formal Analysis, Investigation, Resources, Data Curation, Writing – Original Draft, Writing – Review & Editing, Supervision. Declaration of competing interest All the authors have no conflict of interest. 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