Improving vascular access knowledge and assessment skill of hemodialysis staff

Methods

The study was a quasi-experimental, pretest and posttest group design with the nonequivalent control group, conducted in a convenience sampling of dialysis RNs and certified PCTs in seven urban metropolitan dialysis facilities from November 2022 to April 2023. None of the participants in the study were dialysis facility access champions. After the study protocol was reviewed, Institutional Review Board (IRB) exempt approval was granted from A.T. Still University (IRB approval number KS20221130-001.is.) and approval obtained from Fresenius, N.A. Holdings, Inc. The intervention consisted of a knowledge test and an advanced education module grounded in a cognitive apprenticeship theoretical framework and developed in accordance with vascular-access best-practice recommendation guidelines set forth by the National Kidney Foundation’s Vascular Access Workgroup of the Dialysis Quality Outcomes Initiative best-practice guidelines addressing access location (Guideline 3), access types and materials (Guideline 4), vascular access use (Guideline 11), and access flow dysfunction, monitoring, and surveillance (Guideline 13) [26].

After knowledge test review by two interventional nephrologists and two interventional radiologists, the test items were assessed by content validity index (CVI) [27], 28]. The content validity ratio (CVR) was calculated to determine the testing items considered essential utilizing the formula CVR=(N_e (−) N/2)/(N/2), where N_e is the number of interventionists who considered the item essential and N is the total number of interventionists [28]. Items with a CVR on the Lawshe scale of greater than 0.78 were included. The number of test items judged relevant and clear was divided by the total number of items to obtain a CVI. The CVI was calculated utilizing the formula CVI(R=N_r/N, where N_r is the number of experts giving a rating of very relevant and N is the total number of experts [27], 28]. Values for the CVI are from 0 to 1; an item rated>0.79 indicates that the item is relevant and clear, 0.7–0.79 indicates that the item needs revision, and an item rated below 0.7 causes the item to be discarded [27]. The interventionists scored the tests and returned them by email within 2 weeks of distribution. Items judged relevant and clear with a CVI greater than 0.79 were included in the testing instrument. 10 questions were eliminated, and 10 questions were revised. The reliability of the test instrument was assessed utilizing the test-retest method. The instrument was then administered in a test-retest format to a pilot group of 10 dialysis nurses 2 weeks apart and assessed by Pearson’s correlation analysis. A linear relationship existed with both variables normally distributed, as assessed by the Shapiro-Wilks test. There was a moderate correlation with a Pearson’s coefficient, r₈=0.52. However, this was not statistically significant, (p=0.12). This was attributed to the small sample size. The revised test item to determine vascular access knowledge had a moderate level of internal consistency, as determined by a Cronbach’s alpha of 0.613. The revised final 10-question true/false testing instrument is seen in Supplementary Material.

The educational module was developed and designed to supplement initial staff training, but it was focused more on hemodialysis access physiology, pathology, and physical examination correlates. Observation of predialysis assessment skill to determine the presence or absence of sentinel signs of malfunction was completed after delivery of the educational module to the intervention group over the following 3 months. The total number of participants to achieve statistical power was calculated in G*Power. Utilizing an eight-group mixed analysis of variance (ANOVA), at an alpha level of 0.05, a power level of 0.80, and with a medium effect size of 0.25, the calculated sample size was 56.

The chairside skills observed during predialysis vascular access monitoring closely adhered to the traditional “look, listen, and feel” assessment standard and were categorized into four critical areas. These included identifying sentinel signs of access failure such as enlarging pseudoaneurysms, nonhealing cannulation sites, changes in bruits, hyper-pulsatility, prolonged bleeding, or requiring a tourniquet to facilitate dialysis. Additionally, difficulties reported during cannulation or treatment completion were noted. Each skill was evaluated utilizing a scoring system ranging from 0 to 3 in which 0=not performed, 1=partially performed, 2=performed but incorrectly assessed, and 3=correctly completed and accurately assessed. Composite scores, reflecting the overall quality of the assessment, ranged from 0 to 12.

Data were analyzed utilizing IBM SPSS Statistics Version 28.0.0.0 [29]. After assumption testing, a three-way multifactorial ANOVA with two between-subjects independent variables and one within-subjects independent variable (MF- ANOVA BBW) was utilized to study the effect of an advanced vascular access module on vascular access knowledge. The assumption of normality for the pretest PCT comparison group and the posttest PCT comparison group was accepted by the Shapiro-Wilk test (p>0.05). However, the following groups failed to pass normality and required further testing: (a) pretest RN comparison; (b) pretest RN intervention; (c) pretest PCT intervention; (d) posttest RN comparison; (e) posttest RN intervention; and (f) posttest PCT intervention. The skewness statistic for each group was divided by the standard error of the skew. Each was found to have a skewness value of less than 1.79; therefore, normality was accepted. Variances were homogeneous in all eight group combinations between the clinical role and study group for knowledge pretest scores (RN comparison: W_{3, 55}=0.768, CI 76.10, 85.15, p=0.013, PCT comparison: W_{1, 57}=0.210, CI 73.45, 83.48, p=0.649) and posttest scores (RN intervention: W_{3, 55}, CI 76.17, 86.05, p=0.273, PCT intervention: W_1,57=1.258, CI 75.62, 87.71, p=0.267). The sphericity assumptions were not applicable to this design.

A two-way MF-ANOVA was applied to study the effect of an advanced vascular access module on skill in vascular access assessment to determine the presence or absence of abnormal examination findings. Statistical assumptions were tested prior to conducting the analysis. Each group failed normality testing as assessed by the Shapiro-Wilk test; however, each was found to have a skewness statistic divided by the standard-error skew of less than 1.75 and, therefore, normality was accepted. The homogeneity of variance of examination skill between the clinical role and the study group passed the assumption as determined by Levene’s test (W_{3, 55}=1.29, CI 2.39, 3.59, p=0.942).

Results

Seven urban metropolitan dialysis facilities were approved for the study from November 2022 to April 2023. Five of the seven approved dialysis facilities participated in the study, and the personnel included 75 hemodialysis RNs and PCTs, with 59 completing all components of the study. Among the staff who agreed to participate, 13 did not complete all aspects of the study due to schedule changes, time away, fear of potential job jeopardy, or job turnover. Three withdrew prior to any testing. The total and distribution of the participants by group and clinical role is shown in Table 1.

For knowledge testing, RNs in both the comparison and intervention groups scored higher than PCTs, except for the pretest score in the intervention group. Overall comparison group means for pretest and posttest for the RN and PCT clinical role groups showed little change; however, the intervention group posttest means were markedly higher for both the RN and PCT groups. These data are presented in Table 2.

There was not a statistically significant three-way interaction between time, study group, and clinical role, F (1, 55) = 1.04, p\p=0.312, partial η2=0.02. There was a statistically significant two-way interaction between the time and the study group, F (1, 55)=30.393, p<0.001 (Figure 1).

Figure 1:

Mean test knowledge scores by study group.

There was no significant three-way interaction between time, study group, and clinical role, F (1, 55)=1.04, p=0.312, partial η ²=0.02. However, a significant two-way interaction was found between the time and the study group, F (1, 55)=30.39, p<0.001 (Figure 1). Other two-way interactions were not statistically significant.

Utilizing a Bonferroni-adjusted alpha level of 0.025, the study group had a significant effect on posttest scores, F (1, 55)=29.48, p<0.001, but not on pretest scores, F (1, 55)=0.45, p=0.51. Posttest scores were higher in the intervention group than the comparison group, with a mean difference of 13.1 (95 % CI [83.51, 92.04]), t(57)=59.50, p<0.001, d=10.96.

For clinical skill in identifying sentinel signs of malfunction, there was no significant difference between groups. The mean skills score difference was 0.41 (95 % CI [-0.43, 1.24]), t(57)=1.13, p=0.731, d=1.56.

There was also no significant interaction between clinical role and study group, F (1, 55)=0.79, p=0.379, partial η ²=0.01. Additionally, neither the clinical role (F (1, 55)=0.049, p=0.826, partial η ²=0.01) nor the study group (F (1, 55)=0.96, p=0.332, partial η ²=0.02) significantly influenced the identification of abnormal vascular access.

Discussion

The primary purpose of this research study was to determine the effect of an advanced vascular access educational module presented to hemodialysis RNs and PCTs to improve vascular access knowledge and its application to physical assessment to identify a dialysis access at risk for malfunction. Vascular access knowledge was assessed prior to synchronous instructional intervention. A repeat knowledge test and access assessment skill test in recognizing the presence or absence of abnormal findings consistent with access malfunction were administered.

In this study, it was discovered knowledge mean posttest scores were statistically significantly higher in the intervention group for both hemodialysis RNs and PCTs. The data support previous research that showed there were improvements in vascular access knowledge in hemodialysis nurses after an educational intervention [30], [31], [32]. However, findings of this study are unique in that increases in vascular access knowledge after an advanced vascular access educational module have not been tested or reported previously in PCTs. The mean pretest scores were similar in both RNs and PCTs, suggesting that fundamental vascular access training in access knowledge is retained and is similar for both dialysis RNs and PCTs despite their differences in typical predialysis training educational requirements. However, PCTs increased their vascular access knowledge less than dialysis RNs after the intervention. Thus, PCTs should also be a focus group for vascular access training because they also perform access assessment prior to cannulation.

There were no statistically significant differences between the intervention and comparison groups in skill level to determine the presence of sentinel physical findings indicative of access malfunction. Further, there was no statistically significant difference in physical examination skill level between dialysis RNs and PCTs. This aspect of the study is unique in that it exposes a false assumption that didactic and cursory or observational education alone improves technical skill in dialysis access assessment. The lack of skill improvement highlights the need for not only advanced vascular access didactic education, but also improved practical hands-on training or experiential training in determining normal and abnormal physical assessment findings in dialysis vascular access. Combining didactic education and practical vascular access hands-on training can lead to improved accuracy in detecting access malfunction [33].

One of the major problems in training physicians, RNs, and PCTs is the gap between theory and practice. Bridging this gap should be at the heart of any program to train medical professionals [34]. An active learning approach provides the basis for future research in vascular access care at the most basic clinical level to determine the effectiveness of a problem-based, hands-on, mentored educational program geared specifically toward real patient problems in hemodialysis vascular access.

This research exposes a gap in the translation of hemodialysis vascular access didactic knowledge for dialysis RNs and PCTs to practical application in access physical assessment to determine the presence of access pathology specifically related to the dialysis treatment or its measured dialysis adequacy. Competency in physical assessment skills is considered a mainstay of nursing practice; however, it has been noted there are disparities in the skills that are taught compared with skills that are most frequently utilized [35], 36]. The age-old Halsted model approach of “see one, do one, teach one” has been a mainstay in medical procedural and physical examination skills education for well over a century and remains an effective way to mentor these skills [36], 37]. One cannot substitute hands-on education to promote experiential learning in the context of real clinical problems. It should be no different in the education of dialysis RNs and PCTs who are entrusted with the daily care of this most vulnerable patient population.

Conclusions

A well-functioning vascular access is of paramount importance to ensure delivery of the dialysis prescription. Dialysis RNs and PCTs are on the front lines of providing quality dialysis care to patients who are dialysis-dependent and are charged with the assessment of the vascular access prior to each dialysis treatment. These critical caregivers are often the first ones who would be able to detect and report abnormal assessment findings necessary to prevent access thrombosis and subsequent access failure. Proper knowledge of the physiology and function of the access is the first step to developing assessment skills necessary to recognize abnormal findings. This study has shown that vascular access knowledge can be improved in both dialysis RNs and PCTs with a targeted intervention grounded in education theory; however, the increase in access knowledge does not necessarily translate to significant improvement in access assessment skills in either RNs or PCTs.

Despite the limitations, the results of this research are important findings and exposed a critical gap in the transition of vascular access knowledge to the practical skill of access assessment. The findings also suggest the need for restructuring the clinical training of dialysis RNs and PCTs in vascular access management and care. Utilizing a constructivist approach, building upon the fundamental knowledge of vascular access physiology and mechanisms of failure, an active learning strategy in solid experiential learning should be employed to transfer knowledge to practical access assessment skill. Newer active learning technologies targeted to the dialysis patient’s vascular access can be useful in teaching proper assessment skills and identifying problems in recognition of pathologic signs associated with access failure. On this basis, it is recommended that these newer educational strategies in physical assessment of hemodialysis vascular access should be explored to further support dialysis RNs and PCTs in providing optimal care to end-stage renal disease patients.