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American Journal of Critical Care. 2008;17: 65-71
Copyright © 2008 by the American Association of Critical-Care Nurses.
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CE Article

Critical Care Nurses’ Knowledge of Evidence-Based Guidelines for Preventing Infections Associated With Central Venous Catheters: An Evaluation Questionnaire

By S. Labeau, RN, MSc, A. Vereecke, RN, D.M. Vandijck, RN, MSc, MA, B. Claes, RN, MSc, S.I. Blot, RN, MSc, PhD on behalf of the executive board of the Flemish Society for Critical Care Nurses. S. Labeau is a PhD student in the Faculty of Healthcare, Ghent University College, Ghent, Belgium. A. Vereecke is a master’s student in the Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium. D.M. Vandijck is a PhD student in the Department of Intensive Care, Ghent University Hospital and the Faculty of Medicine and Health Sciences, Ghent University. B. Claes is head of the Department of Intensive Care, University Hospital of Antwerp, Antwerp, Belgium. S.I. Blot is a researcher at Ghent University Hospital and a professor in the Faculty of Medicine and Health Sciences of Ghent University and at Ghent University College.

Corresponding author: Stijn Blot, PhD, Ghent University Hospital, Infectious Diseases Dept, De Pintelaan 185, 9000 Ghent, Belgium (e-mail: stijn.blot{at}UGent.be).


   Abstract
Top
 Abstract
Methods
 Results
 Discussion and Limitations
 Conclusion
 References
 
Background Lack of adherence to recommended evidence-based guidelines for preventing infections associated with use of central venous catheters may be due to nurses’ lack of knowledge of the guidelines.

Objective To develop a reliable and valid questionnaire for evaluating critical care nurses’ knowledge of evidence-based guidelines for preventing infections associated with central venous catheters.

Methods A total of 10 nursing-related strategies were identified from current evidence-based guidelines for preventing infections associated with use of central venous catheters. Face and content validation were determined for selected interventions and multiple-choice questions (1 question per intervention). The test results of 762 critical care nurses were evaluated for item difficulty, item discrimination, and quality of the response alternatives or options for answers (possible responses).

Results All 10 items had face and content validity. Values for item difficulty ranged from 0.1 to 0.9. Values for item discrimination ranged from 0.05 to 0.41. The quality of the response alternatives (0.0–0.8) indicated widespread misconceptions among the critical care nurses in the sample.

Conclusion The questionnaire is reliable and has face and content validity. Findings from surveys in which this questionnaire is used can lead to better educational programs for critical care nurses on infections associated with use of central venous catheters.

Notice to CE enrollees:
A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
  1. Describe how lack of adherence to evidence-based guidelines affects the prevention of central line infections.
  2. Recognize 10 recommended guidelines from the US Centers for Disease Control and Prevention for preventing intravascular catheter-related infections.
  3. Understand the importance of educating healthcare workers as part of a quality improvement program to reduce central venous catheter–related infection.
To read this article and take the CE test online, visit www.ajcconline.org and click "CE Articles in This Issue." No CE test fee for AACN members.

Central venous catheters (CVCs) are life-sustaining devices but are associated with a risk for infections that can increase morbidity and mortality and the cost of care.1–5 Infections associated with intravascular catheters account for 10% to 20% of all nosocomial infections.6 The mean rate of CVC-related bloodstream infection in the intensive care unit (ICU) is 5.3 per 1000 catheter days.7 From 10% to 70% of all CVC-related infections are preventable.8 Therefore, evidence-based guidelines have been published.5,9,10

The guidelines for the prevention of intravascular catheter-related infections,7 published by the US Centers for Disease Control and Prevention, provide recommendations for catheter care whose preventive value is supported by scientific research.

Although the recommendations are evidence based, nonadherence to them has been reported.11–13 This lack of adherence may be due to a lack of knowledge of the guidelines. Research12,14–18 has indicated that education of healthcare workers, preferably as part of a multifaceted quality improvement program, can reduce the rate of CVC-related infection.

The study reported here is part of a project of our research group to determine ICU nurses’ knowledge of evidence-based guidelines for preventing infections.19,20 Our objective was to develop a reliable and valid questionnaire that can be used to assess critical care nurses’ knowledge of evidence-based guidelines for preventing CVC-related infection and to determine how an educational program on CVC-related infection affected nurses’ knowledge.


Intravascular catheter-related infections cause 10% to 20% of all nosocomial infections.

 


   Methods
Top
 Abstract
 Methods
Results
 Discussion and Limitations
 Conclusion
 References
 
The study was approved by the ethics committee of Ghent University Hospital, Ghent, Belgium.

Selection of Interventions and Design of the Questionnaire
The interventions to prevent CVC-related infection were selected on the basis of the current guidelines7 of the US Centers for Disease Control and Prevention for the prevention of intravascular catheter-related infections. These guidelines are supported by the results of rigorously selected clinical trials or systematic reviews and were prepared by a multidisciplinary working group of professionals in different fields of medicine and nursing.

On the basis of the guidelines, 10 interventions or strategies related to central venous catheters and with relevance for nursing practice were selected:

  1. Frequency of CVC changes
  2. Frequency of changes in CVCs over a guidewire
  3. Frequency of changes in pressure transducers and tubing
  4. Use of coated CVCs
  5. Frequency of changes of catheter dressings
  6. Use of gauze and polyurethane catheter dressings
  7. Use of 2% aqueous chlorhexidine for disinfecting the insertion site
  8. Use of antibiotic ointment
  9. Frequency of changes in administration sets when lipid emulsions were administered
  10. Frequency of changes in administration sets when neither lipid emulsions nor blood products were administered

As in previous studies,19,20 a multiple-choice question with 4 response alternatives or options (the correct answer/response and 3 distractors or alternatives that are not the answer) was developed for each item on the list (Table 1Go). For each test item, the response alternatives included the phrase "I do not know" to avoid gambling by the respondents. The 2 remaining response alternatives consisted of strategies whose preventive value has not been established in evidence-based studies.


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  		Table 1 Questionnairea

 
Expert Validation
A panel of 7 experts examined the 10 preventive interventions and the questionnaire for face and content validation.21 Of the experts, 6 had at least 10 years of experience in an ICU; 1, who had worked as a nursing hospital hygienist for several years, had 3 years of ICU experience. All 7 had at least a master’s degree in nursing sciences (or medical-social sciences) and were involved, at least locally, in research on ICU-acquired infections.


Nurses had numerous misconceptions about the care of central venous catheters.

 

For face validity, experts were asked if all questions were clearly worded and would not be misinterpreted. For content validity, the experts evaluated the nursing relevance of the 10 selected interventions by using a scale of 1 to 3, where 1 = not relevant, 2 = relevant but not necessary, and 3 = absolutely necessary. The experts were also asked if questions about any other preventive interventions should be added to the questionnaire.

The remarks of the panel were collected and discussed and were used to revise the questionnaire. The experts examined the revised questionnaire and unanimously declared agreement with its content and clarity.

Assessment of the Questionnaire
One way to improve education is to revise tests on the basis of test scores.22 Therefore, the level of difficulty and the discrimination of each item on the questionnaire were determined, and each of the 4 response alternatives or options for each question was evaluated for quality.22–24

  Difficulty Level.   The difficulty level of an item or question is defined as the proportion of respondents who answer the question correctly.22–24 Possible values range from 0.0 to 1.0. Items are considered too easy if they are answered correctly by more than 90% of the respondents (value >0.9) and too difficult if they are answered correctly by less than 10% of the respondents (value <0.1).

  Item Discrimination.   The extent to which items on a questionnaire discriminate between high scorers and low scorers is termed the discrimination index.22–24 In order to calculate the discriminative value of each item, the respondents were divided into high scorers and low scorers; each group accounted for 27% of the total number of respondents. Then, the following formula was used: (number of correct answers in the high-scorer group – number of correct answers in the low-scorer group)/total number of correct answers in both groups. Values of 0.35 and higher are good values, values from 0.25 to 0.35 are satisfying/good, values from 0.15 to 0.25 are mediocre/satisfying, and values less than 0.15 are bad/mediocre.25,26

  Quality of the Response Alternatives.   The quality of a response alternative is defined by calculating the proportion of respondents who choose the alternative. Values range from 0.0 to 1.0.22–24 Response alternatives with a value of 0.0 are not attractive, and those with a value of 1.0 might be too attractive.

Population Surveyed
The questionnaire was distributed and collected during the annual congress of the Flemish Society of Critical Care Nurses (Ghent, Belgium, November 24, 2006). Of the 855 registered participants, 762 completed the questionnaire (89.1% response rate). The responses were collected anonymously. The questionnaire also included questions on general characteristics of the respondents: sex, years of ICU experience, number of ICU beds in the hospital where the respondent worked, and whether the respondent had a special degree in emergency and intensive care. Such a degree can be achieved after the basic 3-year nursing education (bachelor’s degree) and is acknowledged as a bachelor-after-bachelor degree.


   Results
Top
 Abstract
 Methods
 Results
Discussion and Limitations
 Conclusion
 References
 
Expert Validation
For clarity, some items needed to be slightly reworded. The experts considered all 10 items of the questionnaire relevant for nursing practice. The final questionnaire is shown in Table 1Go.

Characteristics of the Sample
The majority of the 762 respondents were women (n = 581, 76%; Table 2Go). A total of 353 respondents (46%) had more than 10 years of ICU experience, and 349 (46%) worked in units with more than 15 beds. Most of the respondents (n=557, 73%) had a special degree in intensive care and emergency nursing.


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  		Table 2 General characteristics of the population surveyed (n = 762)

 
Item Analysis
Values ranged from 0.1 to 0.9 for item difficulty and from 0.05 to 0.41 for item discrimination (Table 1Go). Values were good to satisfying for 9 of the 10 questions. For question 9 (frequency of changes in administration sets when lipid emulsions were administered), however, the values were too low, indicating that respondents had a good knowledge of this intervention. Nevertheless, question 9 was kept in the questionnaire because of the relevance of the question for ICU nurses. Also, in a criterion-referenced test such as this questionnaire, items valuable for content are not necessarily excluded because they are too easy.27,28

The quality of the response alternatives was 0.0 for 9 of the 10 questions, suggesting a possible need for reformulation. However, another interpretation of this finding is that respondents refrained from gambling because of the response alternative "I do not know." Additionally, possible formulations were limited because the response alternatives were restricted to interventions with an investigated preventive value.

The responses to the final questionnaire indicated that nurses had numerous misconceptions about the care of CVCs. First, that they often responded that the use of coated CVCs does not result in a significant decrease in catheter-related infections (value 0.4); however, the guidelines7 recommend these catheters in settings with a high rate of catheter-related infections for patients whose CVC is expected to remain in place for more than 5 days. Second, the respondents chose the use of polyurethane dressings at the catheter site (value 0.7), whereas both gauze and polyurethane dressings are recommended7 (value 0.2). Finally, the nurses selected 0.5% alcoholic chlorhexidine solution (value 0.8) over the recommended 2% aqueous chlorhexidine solution7 (value 0.1).

All respondents thought correctly that the use of an antibiotic ointment at the catheter insertion site is not recommended. Remarkably, most nurses thought use of such an ointment is not recommended because antibiotic ointments do not decrease the risk for catheter-related infections (value 0.6), whereas the correct reason is that the use of these ointments causes antibiotic resistance (value 0.3).


All respondents thought correctly that use of antibiotic ointment at the insertion site is not recommended, but they did not understand the rationale.

 

For the first 3 items on the questionnaire (use of coated CVCs, type of catheter dressing, and type of disinfection solution), respondents are convinced that an intervention without evidence-based preventive value is preferred over the evidence-based intervention. Nurses seem to have a misconception about the reason antibiotic ointments are not used at the catheter site. Discovering this kind of widely spread misconception is important for focusing education of critical care nurses.


   Discussion and Limitations
Top
 Abstract
 Methods
 Results
 Discussion and Limitations
Conclusion
 References
 
The questionnaire had both face and content validity. We did not determine construct validity, which indicates what construct a test actually measures and can be established by using the known-groups technique. In this procedure, groups that are expected to differ on the critical attribute take the test, and group scores are compared.28 In order to establish construct validity for our questionnaire, the test should be presented to a group other than critical care nurses. The scores of the non–critical nurses should differ from those of a group of critical care nurses. Nevertheless, CVCs are not used exclusively in the ICU; they have become frequently used devices in many units. In Flanders, CVC care is included in the curriculum of the 3 basic years of nursing education. Thus, knowledge of CVC care should have become common knowledge among nurses. Establishing construct validity could support or contradict this assumption.

Use of the convenience sample of nurses attending the annual congress of the Flemish Society of Critical Care Nurses could lead to selection bias and create a barrier to extrapolating our results. Nevertheless, the 762 nurses in our sample account for 21% of all Flemish critical care nurses. Moreover, this bias can be limited because the federal government in Belgium obliges all critical care nurses who have a special degree in intensive care and emergency to attend at least 16 hours a year of continuing education to maintain this degree.

Finally, guidelines are revised according to the latest research and adaptation, and reevaluation of the questionnaire will be necessary for the prevention of CVC-related infection.


   Conclusion
Top
 Abstract
 Methods
 Results
 Discussion and Limitations
 Conclusion
References
 
The questionnaire developed to assess critical care nurses’ knowledge of evidence-based strategies for preventing CVC-related infection is reliable and has face and content validity. The questionnaire can be used before and after an educational program on prevention of such infections to determine the effectiveness of the program.

Results of surveys in which the questionnaire is used can lead to better educational programs for critical care nurses on infections associated with use of CVCs.

FINANCIAL DISCLOSURES
None reported.

eLetters
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SEE ALSO
To learn more about treating central catheter infections, visit http://ccn.aacnjournals.org and read the article by Racco and Horn, "Central Catheter Infections: Use of a Multidisciplinary Team to Find Simple Solutions" (Critical Care Nurse, February 2007).

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809–2273 or (949) 362–2050 (ext 532); fax, (949) 362–2049; e-mail, reprints{at}aacn.org.


   REFERENCES
Top
 Abstract
 Methods
 Results
 Discussion and Limitations
 Conclusion
 References
 

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