A Simulation-Based Blended Curriculum for Short Peripheral Intravenous Catheter Insertion: An Industry Practice Collaboration

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1 A Simulation-Based Blended Curriculum for Short Peripheral Intravenous Catheter Insertion: An Industry Practice Collaboration Kevin R. Glover, MS, MEd; Brian R. Stahl, BSN, RN, CRNI, PLNC; Connie Murray, MEd; Matthew LeClair, MA; Susan Gallucci, BSN, RN-C; Mary Anne King, MAS, BSN, RN-BC; Laura J. Labrozzi, BSN, RN, CMSRN; Catherine Schuster, PhD, RN; and Nowai L. Keleekai, PhD, RN-BC abstract Despite peripheral intravenous catheter (PIVC) insertion being a commonly performed skill, practicing nurses may receive little substantive education, training, or opportunities to practice this skill at a competent level. This article describes a collaboration between private industry and a hospital to modify, implement, and evaluate a simulation-based blended PIVC insertion continuing education program for staff nurses. Included is an overview of the practical and theoretical rationale for the initial development of the curriculum to address an identified PIVC insertion education gap, the collaborative modification and implementation of the program, and an evaluation of the program. The curriculum combined self-paced e-learning and classroom-based deliberate practice with simulation tools of varying fidelity in a peer-to-peer learning environment. Given the mutual challenges of resource allocation in industry training and clinical nursing education departments, interprofessional partnerships may be an effective option for sharing instructional knowledge and resources to promote innovation and improve patient care. J Contin Educ Nurs. 27;48(9): Since the publication of The Future of Nursing (Institute of Medicine, 2), experts in nursing education have been advocating the redevelopment of nursing curricula guided by instructional design best practices. These best practices for 2st century multigenerational, multimodal learners require a robust curriculum that includes (a) self-paced knowledge acquisition through multimedia e-learning curricular components; (b) integration of simulation-based technologies to deliberately practice invasive procedural skills while receiving immediate feedback for error correction until competent; (c) collaborative experiential learning environments so students can construct new knowledge together; and (d) meaningful and comprehensive learner testing to validate that the curriculum Mr. Glover is Corporate Vice President, Medical Affairs, Clinical Education Program Development, Research, and Innovation, Mr. Stahl is Manager, IV Therapy Training and Clinical Education, Ms. Murray is Director, Clinical Education and Training, Mr. LeClair is Director, Curriculum Development, Electronic, and Mobile Learning, and Dr. Schuster is Manager, Nursing Research, B. Braun Medical Inc., Bethlehem, Pennsylvania; Dr. Keleekai is Nurse Researcher, and Ms. Gallucci, Ms. King, and Ms. Labrozzi are Nurse Educators, Overlook Medical Center, Summit, New Jersey. 27 Glover, Stahl, Murray, et al.; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4. International ( org/licenses/by-nc/4.). This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial. The authors thank Robert B. Dawson, DNP, MSA, APRN, ACNP-BC, CPUI, VA-BC, CEO and Consultant, Vascular Access Consultants, LLC, and Russell Nassof, JD, Executive Vice-President, RiskNomics, LLC, who served as subject matter experts for the content development of the elearning curricular component. The authors also thank Colleen Eagle, who provided editorial review of the manuscript, and all of the skills evaluators and nurse participants. K.R.G., B.R.S., C.M., M.L., and C.S. are employees of B. Braun Medical, Inc. Registered copyrights for the educational programs described in this article include the Peripheral IV Catheter Insertion Skills Checklist, B. Braun Medical, Inc., 24, the Peripheral IV Catheter Insertion Skills Checklist Observer Training Program, and the Fundamentals of Peripheral IV Access elearning Program, B. Braun Medical, Inc., 24. The authors have disclosed no other potential conflicts of interest, financial or otherwise. Address correspondence to Nowai L. Keleekai, PhD, RN-BC, Nurse Researcher, Overlook Medical Center, 99 Beauvoir Ave., Box 26, Summit, NJ 79; Nowai.keleekai@atlantichealth.org. Received: December 9, 26; Accepted: May 3, 27 doi:.3928/ The Journal of Continuing Education in Nursing Vol 48, No 9,

2 has resulted in the transfer of new knowledge and skills (Decker, Sportsman, Puetz, & Billings, 28; Jeffries, 27). Reinventing nursing education to meet these instructional design best practices is an expensive and time-consuming endeavor for which nurses must cultivate new allies (Institute of Medicine, 2, p. 33). Given the increasingly limited resources of many organizations, it will be difficult to make meaningful progress alone. Short peripheral intravenous catheter (PIVC) insertion is one of the most common invasive procedures performed in a hospital, with at least 9% of patients receiving some form of IV therapy (Institute for Safe Medication Practices, 25). Yet, most nurses acquire this invasive procedural skill with little formal training and few opportunities for deliberate practice (Alexandrou et al., 22; Wilfong, Falsetti, McKinnon, Daniel, & Wan, 2). The results of a 23 Infusion Nurses Society IV Safety Practice survey (N = 345) reported that 57% of nursing students or less receive any form of PIVC insertion instruction and that after nursing school, only 7% received some form of on-the-job-training (Vizcarra et al., 24, p. 22). Lyons and Kasker (22) reported that many practicing nurses also lack PIVC procedural confidence due to limited education during orientation, which results in increased nursing stress and poor patient care. High overall premature PIVC failure rates ranging from 35% to 5% have been reported due to phlebitis, infiltration, dislodgement, occlusion, leakage, or bloodstream infection. These unacceptable failures are associated with many factors, including the bundle of procedural products used, the expertise of the nurse inserting and maintaining the PIVC, the patient s response to both the bundle of products combined with how the insertion procedure was performed, and the subsequent care and maintenance of the catheter (Helm, Klausner, Klemperer, Flint, & Huang, 25). Because nursing expertise clearly plays a central role in achieving PIVC patient outcomes, research that leads to evidence-based PIVC education has been advocated (Alexandrou et al., 22; Helm et al., 25; Parker, Benzies, Hayden, & Lang, 26; Wallis et al., 24). Regarding specific practice issues, several authors have suggested that greater focus on staff PIVC education could advance nursing knowledge, skills, and confidence, resulting in improved patient assessment, site selection, aseptic technique, skin preparation, maintaining dressing integrity, recognition and documentation of patient PIVC-associated complications, and compliance with best practice guidelines (Cicolini et al., 24; DeVries, Valentine, & Mancos, 26; Woody & Davis, 23). In a multicenter prospective study of,498 patients by Cicolini et al. (24), the authors cited that anatomical site selection and a lack of adherence to in situ PIVC placement recommended guidelines resulted in increased rates of phlebitis. They concluded that additional staff education was needed. DeVries et al. (26) reported a 9% reduction in PIVC-associated bloodstream infections after implementing a fundamental PIVC insertion and education bundle for bedside nurses that increased staff awareness of proper skin preparation, aseptic technique, and the importance of the care and maintenance of dressings. Nursing education leaders in another tertiary health care setting developed an educational intervention to improve the recognition and reporting of infiltration and phlebitis on medical surgical units, which was identified by the risk management database as a concern. Although the differences between pre- and postknowledge scores were not significant (p =.2), the unexpected results of the research served as a catalyst to develop annual PIVC procedural education to validate competency related to PIVC-related complications (Woody & Davis, 23). Finally, in addition to the patient care aspects, financial implications are also associated with less than optimal PIVC insertion and maintenance, which advance the argument by nursing education leaders to research and redevelop PIVC nursing curricula. When one considers the reported cost of uncomplicated PIVC procedures, ranging from $28 to $35 per procedure, the global financial burden associated with premature removal of PIVCs is estimated to range from $9.8 to $7.5 billion annually (Helm et al., 25; Schuster, Stahl, Murray, Keleekai, & Glover, 26). When nurse educators and leadership at a 54-bed, nonuniversity-affiliated teaching hospital evaluated the 2 monthly rescue calls that the IV therapy department was receiving to place PIVCs on two postsurgical units and one medical surgical orthopedic unit, they recognized the opportunity to improve the PIVC insertion knowledge, confidence, and skill in their staff nurses. The hospital nursing education department lacked the necessary resources required to create a comprehensive, evidence-based, technology-rich PIVC insertion curriculum. Industry educators had sufficient resources for such a rich curriculum development but lacked the necessary resources to implement and evaluate the influence of the curriculum in a practical hospital environment. This mutual resource challenge led to a unique industry practice partnership to collaboratively modify an existing curriculum to meet the needs of practicing nurses. A plan for piloting the program on three hospital units, implementing the program, and evaluating the program s outcomes was developed. 398

3 This article describes the three major elements of a reinvention of PIVC insertion education, including: l The learning science rationale behind the initial development of a comprehensive, simulation-based blended curriculum to improve PIVC insertion knowledge, confidence, and skills of practicing nurses as identified in the literature. l The collaboration between industry and a teaching hospital to modify and implement the curriculum for practical use as continuing education for staff nurses. l The evaluation of the curriculum and the collaborative interprofessional industry practice process by nurses and members of both organizations involved. LEARNING SCIENCE RATIONALE FOR CURRICULUM DEVELOPMENT Continuing education for practicing nurses should require significant cognitive effort and be focused on creating curricula that help them construct new knowledge and skills by either reinforcing appropriate prior knowledge and experience or replacing conflicting knowledge and skills with new insights and understandings (Glover, 24; Glover & Murray, 2; Moore, Green, & Gallis, 29). Automaticity refers to any learned task that becomes habitual through experience to the extent that performing the task requires minimal attention or conscious thought. In health care, automaticity is often described as an illness script a learned task repeated so frequently it becomes encoded in long-term memory as a recognized schematic pattern, which can result in intuitive clinical practice without deliberative analysis (Stiegler & Gaba, 25). Automaticity can be positive if the unconsciously competent clinical application of knowledge and skills is grounded in expertise. However, the negative consequence of automaticity is that, over time, the repetitive incorrect clinical application of knowledge and skills can become ingrained in the experienced nurse, making reeducation particularly difficult (Ericsson, 24). Driscoll (25) compared humans to computers in the way knowledge is acquired, processed, stored, retrieved, and applied. Due to the brain s limited capacity to process high volumes of sensory input, human beings selectively choose to attend to certain incoming information while simultaneously choosing to ignore other information, thus allocating cognitive resources to manage limited capacity. Selective attention is the only way that sensory input reaches conscious thought. Many nurses are overextended, work in high-stress environments, and are often highly distracted. Consequently, the current authors posited that the PIVC insertion curriculum would need to overcome automaticity and the selective attention of busy nurses who might not be aware of their PIVC insertion learning needs. The authors predicted that maintaining the selective attention of these nurses, who were not conscious of their knowledge and skill deficits, would pose a significant challenge when they were presented with continuing education in PIVC insertion. To address these issues, the authors modified a simulation-based blended curriculum established on a multimodal Learner-Centric Instructional Design Model (Glover, 24; Glover & Murray, 2), which incorporates elements of cognitive information processing, deliberate practice, constructivism, and multiple intelligence theories of learning and instruction (Driscoll, 25; Ericsson, 24; Gardner, 24; Kolb, 984). The current authors believed that a blended instructional approach best addressed the complexity of knowledge acquisition by practicing nurses. The PIVC insertion curriculum was designed to capture and maintain the selective attention of nurses while also overcoming the negative consequence of automaticity. The knowledge and skill components demanded consistent cognitive effort by using selfpaced interactive multimedia instruction followed by increasingly difficult, deliberate, simulated PIVC insertion practice in a peer-to-peer collaborative learning environment. Coursework also catered to multiple intelligences and learning styles (Gardner, 24; Kolb, 984) through: l Experiential, hands-on simulated practice (body/kinesthetic learners). l Text-based and narrated online instruction (verbal/linguistic learners). l Animations and videos (visual learners). l Classroom facilitation that emphasized individual learning through exploration (intrapersonal learners). l Peer-to-peer collaboration (interpersonal learners). The implementation of this curriculum, combined with intermittent reflection and a return to patient care between the instructional components, was expected to result in improved confidence and retention of PIVC insertion knowledge and skills. A COLLABORATIVE PROJECT TO IMPLEMENT AND EVALUATE THE CURRICULUM The PIVC insertion curriculum, initially developed by industry for internal procedural training of customer-facing employees (Glover, 24; Glover & Murray, 2), was modified for the continuing education of nurses in the participating hospital. The interprofessional team included employees from both the The Journal of Continuing Education in Nursing Vol 48, No 9,

4 TABLE PIVC INSERTION CONTINUING EDUCATION RESEARCH TEAM ROLES AND RESPONSIBILITIES Industry Partner Hospital Partner Primary Responsibilities Vice president clinical education Nurse researcher Research project oversight Research protocol development CE program modification CE implementation planning Research outcomes identification Research results dissemination Director clinical education Manager clinical education Director e-learning Nurse researcher 2 CE unit educators CE educator CE program development CE program modification Research protocol development CE implementation planning CE implementation execution Research outcomes identification CE assessment tools creation Research results dissemination Research protocol development CE assessment tools creation Assessment tools validation and reliability testing Research outcomes identification Research results analysis Research results dissemination CE program modification Research protocol development CE implementation planning CE implementation communication and logistics Research outcomes identification Research results dissemination 8 PACT nurses PIVC skills assessment tool observers and evaluators Biostatistician Research results analysis Note. PIVC = peripheral intravenous catheter; CE = continuing education; PACT = Professional Advancement Clinical Tracks. hospital and industry, with representatives from nursing research, nursing education, instructional technology, curriculum development, biostatistics, and project management (Table ). Collectively, the team modified the curriculum and created a methodology to implement and evaluate it. Representatives of the staff nurse learners were deliberately not included in the development of the modified curriculum, as their inclusion would have biased the results of the research study designed to evaluate the program. The curriculum included a 2-hour didactic Fundamentals of Peripheral IV Access e-learning course and an 8-hour live simulation-based PIVC insertion training course. The protocol to assess the learning influence of the modified curriculum was approved by the hospital s institutional review board. Sixty-three nurses (Table 2) participated in a randomized crossover study to evaluate the effects of the curriculum by completing pre- and postassessments for PIVC insertion knowledge, confidence, and skills in a simulated clinical environment. The study design requires participants to be randomly assigned to either an intervention or wait-list control group. The intervention group receives the intervention first, followed by a predefined interim period, after which time (crossover) the wait-list control group then also receives the intervention. Outcome measures are evaluated for all participants at baseline and after each group receives the intervention (Shadish, Cook, & Campbell, 22). The pre- and postintervention PIVC insertion knowledge, confidence, and skill assessment results reinforced the learning need as generally described in the literature. As reported by Keleekai et al. (26), the 63 study participants, randomized into two groups, were similar for knowledge, confidence, and skills at baseline. Compared with the wait-list group, the intervention group had significantly higher scores for knowledge (p =.), confidence (p =.5), and skills (p =.9) on completing the PIVC insertion training program. After crossover, the wait-list group had similarly higher scores for knowledge, confidence, and skills as the intervention group. Between the immediate preintervention 4

5 and postintervention periods, the intervention group improved scores for knowledge by 3%, improved scores for skills by 24%, and decreased scores for confidence by.5%, whereas the wait-list group improved scores for knowledge by 28%, confidence by 6%, and skills by 5%. The average number of rescue calls to the IV therapy department from the study units to insert PIVCs decreased during the study period compared with the same months of the previous year (3 versus 2), but this difference was not statistically significant (p =.54). The remainder of this article focuses on describing the modified curriculum for practical use as a continuing education program for staff nurses, planning for and implementing the program, evaluating nurse learner satisfaction with the curriculum, and a project review by nurses and members of both organizations involved in the partnership. Fundamentals of Peripheral IV Access e-learning Course The original PIVC insertion curriculum was a live 2-day program with the first day dedicated to didactic instruction and the second day dedicated to simulationbased PIVC insertion practice. During the initial protocol development, it was determined that 6 hours of off-unit live learning would not be practical for the targeted nurses. The industry partner evaluated the content and developed an interactive e-learning course component to deliver the didactic instruction. The e-learning course was then further reviewed by the clinical partners for content, congruence with hospital policy, and ease of use. This modified curriculum consisted of a total of hours of instruction: 2 hours online and 8 hours of live simulation-based practice. The e-learning course was developed specifically for nurses to reinforce, further develop, or reconstruct their knowledge and understanding of important topics related to PIVC insertion and how to systematically apply best practices to improve patient care and promote patient safety. The course was segmented into seven subject modules, each expected to take approximately 5 to 2 minutes to complete. The modules included Introduction, Anatomy, Assessment, Catheter Selection, Procedure, Complications, and Risk Management. An engaging learning experience was promoted through clinical notes, case studies, simulated practice exercises, and knowledge checks with built-in feedback. At the conclusion of each module, participants completed a short knowledge assessment. Consistent with hospital policy and conducive to self-study while maintaining patient care responsibilities, nurses were allowed 4 weeks to complete the e-learning course at their own pace. A cumulative knowledge assessment score of 8% TABLE 2 DEMOGRAPHIC CHARACTERISTICS OF NURSE PARTICIPANTS (N = 62) a Variable Gender Value Female 54 (87%) Male 8 (3%) Age (years) Mean 6 SD Range 22 to 65 Years as RN Mean 6 SD. 6.4 Range to 42 Nursing degree b Diploma 2 (2%) Associate (7%) Baccalaureate or higher 38 (63%) Nursing specialty certification Yes 2 (32%) No 42 (68%) a No demographic information obtained for one participant. b Two participants had missing data (3%). or better and completion of an end-of-course evaluation were required for nurses to advance to the live simulation course. Live Simulation-Based PIVC Insertion Training Course During the live course, nurses practiced PIVC insertions in three progressively difficult simulation workshops using tools of increasing fidelity, as recommended in the literature (Brydges, Carnahan, Rose, Rose, & Dubrowski, 2). The aim of incorporating a variety of simulation technologies throughout the course was to maintain learner attention by capturing and training all elements of the PIVC insertion procedure, thereby making this training more meaningful to practicing nurses. Relevant content coupled with effort through increasingly difficult simulated procedural practice enhances encoding of new knowledge and skills into long-term memory. In addition, this combination promotes the retrieval of this knowledge for later application during patient care (Dickerson, 22; Driscoll, 25; Glover, 24; Glover & Murray, 2; Moore et al., 29). Facilitators reinforced key points from the e-learning throughout the live course and shared best practices for The Journal of Continuing Education in Nursing Vol 48, No 9, 27 4

6 PIVC insertion while also providing feedback to correct errors. To encourage learning through doing, observing, and coaching, participants were randomly paired prior to each workshop. A collaborative paired practice learning environment enhances motor skills acquisition (Rader et al., 24). Dividing the cognitive load of paired learners between procedural practice and observation encourages overt communication, which helps to identify and overcome errors, leading to the continuous improvement and construction of new knowledge of both learners. A formative debriefing was conducted following each workshop during which the nurses could share their insights and lessons learned with the other participants. Simulation Workshop. During the first 3-hour workshop, paired nurses practiced PIVC insertion using a software-driven haptic simulator, which is a comprehensive, fully interactive, self-directed learning system for training intravenous catheterization. Graphics provide visual realism, while a force feedback haptic device simulates the sense of touch for an immersive experience. During IV insertion practice with this simulator, nurses selected an IV site (based on the patient case presented), prepared the site using the appropriate supplies, and selected an appropriate gauge catheter. Nurses then conducted the PIVC insertion procedure with the simulated catheter in a haptic device that allowed them to palpate the virtual patient s veins through skin, apply skin traction, and perform PIVC insertion. Nurses were able to view their completed procedure on a computer monitor displaying the visual results of their use of the haptic device. A case review following each simulated procedure provided immediate feedback and reported the nurses procedural performance scores. Nurses were required to achieve competency with two successful PIVC insertions, which was defined as containing no critical errors and a score of 9% or better. A critical error, as defined by the program s software, includes any mistake in the simulated procedure that would negatively affect a successful IV start (e.g., missing or missing a vein, inadequate site preparation, not using gloves during the procedure). Although the PIVC haptic simulator is a technically advanced tool for repetitively practicing the procedural steps of a successful PIVC insertion, it does not offer learners the opportunity to physically practice many aspects of an actual procedure. This limitation results in a low-fidelity simulation experience (Brydges et al., 2). Tourniquet Application and Vein Assessment Exercise. Following the first workshop, the facilitators conducted this 3-minute exercise. The live partner exercise included instruction and practice on proper tourniquet application technique, vein palpation, vein identification, and tourniquet release. Nurses were asked to locate and name the veins of the arm and hand (e.g., basilic, cephalic, metacarpal), reinforcing content from the e-learning course. The skills practiced in this exercise were incorporated into the subsequent workshops. Simulation Workshop 2. The second -hour workshop incorporated the use of a vein board with a hanging bag of simulated blood. This task trainer is composed of simulated veins of various depths, diameters, and visibility within a tissue-like material. When the simulated vein is accessed with a PIVC, a realistic flashback of artificial blood occurs in the flashback chamber of the IV catheter. Nurses used this task trainer with actual PIVCs and the hospital s standard venous access supplies, which increased the fidelity of the simulated practice, compared with the PIVC haptic simulator (Brydges et al., 2). Instruction was provided for guided practice using a 28-item PIVC Insertion Skills Checklist, which was validated by three independent, nationally recognized vascular access experts who were not engaged in the implementation or evaluation of the curriculum (Keleekai et al., 26; Schuster et al., 26). Working in pairs, each nurse completed a minimum of six simulated PIVC insertions during this workshop while monitoring each other s performance and providing feedback for procedural correctness. Simulation Workshop 3. A life-size simulated arm was used during the final -hour simulation workshop. This device not only simulates a healthy adult arm with numerous locations for possible venous access, but it also features controllable blood flow and pressure through the use of a hand pump. In allowing for blood pressure changes based on the nurse s proper or improper tourniquet placement or removal or both, the simulated arm provided a higher fidelity simulation experience, compared with the vein board (Brydges et al., 2). Nurses practiced PIVC insertion skills using the PIVC Insertion Skills Checklist and the hospital s standard venous access supplies. Through guided practice, paired nurses again completed at least six simulated PIVC insertions each on this device. Formal Skills Assessment. The three workshops were followed by a formal skills assessment during which each nurse performed a simulated PIVC insertion procedure in a staged hospital room using the life-sized simulated arm with a confederate patient, who was a live person trained to interact appropriately with the study participant during the PIVC insertion procedure. Having the simulation tool strapped to a confederate patient in bed in an authentic hospital environment represented the highest level of fidelity achieved during the course 42

7 (Brydges et al., 2). Participating nurses were assessed by Professional Advancement Clinical Tracks (PACT) nurses at the hospital using the PIVC Insertion Skills Checklist. PACT is an optional yearly program at the study hospital that requires completion of a predetermined number of activities on a nurse s own time that culminates in a monetary award. PACT nurses were extensively trained as skills evaluators to reliably use the PIVC Insertion Skills Checklist (Schuster et al., 26). After formal skills assessments were conducted, the live course concluded with a summative group debriefing and course evaluation. EVALUATION OF THE CURRICULUM: NURSE SATISFACTION AND ORGANIZATIONAL OUTCOMES Nurse Satisfaction Many outcome evaluation frameworks exist that offer standardized approaches to determine the effects of educational offerings on learners. For this program, the authors selected an expanded continuing medical education outcomes evaluation framework (Moore et al., 29, p. 3, Table ), which includes participation (level ), satisfaction (level 2), learner knows (level 3A), learner knows how (level 3B), learner shows how (level 4), learner performs (level 5), learner improves patient health (level 6), and learner improves community health (level 7). Within this framework, level 2 evaluations provide one method of evidence of a program s educational influence and whether participants anticipate using the knowledge and skills they acquired. Evaluations were completed by nurses immediately following their completion of the e-learning course and after attending the simulationbased live course. Each evaluation consisted of questions ( Likert-scale and one comparative rating scale) that measured nurses perceived value of the learning program s design, effectiveness, job applicability, and transfer of knowledge to the real-world environment, and their overall satisfaction with the course. In addition, three open-ended questions allowed participants to provide optional suggestions for course improvement. Reliability coefficients (Cronbach s alpha) were calculated for the e-learning (alpha =.9; n = 59) and live (alpha =.87; n = 27) courses. Because of an oversight during the study, one randomized study group did not receive the live course evaluation. Of the 29 evaluations that were submitted for the live course, two were missing one response and were not included in the reliability analysis. Despite the lower number of live course evaluations, the instrument demonstrated adequate reliability for the e-learning and live courses. A total of 88 evaluations were completed (59 e-learning and 29 live courses). Evaluation results of both courses were largely positive with 93% (n = 82) of participants reporting that the courses met their needs and 82% (n = 72) reporting the courses were a good use of their time. Results for the e-learning course are provided in Table A (available in the online version of this article) and for the live course in Table B (available in the online version of this article). The 27% (n = 6) of participants who provided narrative responses to open-ended questions for the e-learning course identified the most useful components as patient safety information (44%, n = 7), audiovisual presentation (9%, n = 3), and documentation information (9%, n = 3). For the live course, 72% (n = 2) of participants provided narrative responses to open-ended questions regarding their perception of the most positive aspects of the course, which included repetitive practice (48%, n = ), review of anatomy and physiology (9%, n = 4), and the instructional design (4%, n = 3). Of the 55% (n = 6) of participants who provided recommendations to improve the live course, suggestions included reducing repetition (9%, n = 3), reducing the course length (9%, n = 3), and modifying the vein board workshop (2%, n = 2). Organizational Outcomes Although the curricular design was firmly grounded in established learning science theoretical principles, the collective trust, commitment, adaptability, and accountability of an interprofessional industry practice team were essential to this project. In an increasingly complex, outcomes-driven health care environment, where organizations are compelled to allocate resources judiciously, the design, implementation, and systematic evaluation of new curricular approaches by nursing education departments may languish. Responding to this issue, interprofessional academic practice partnerships have been suggested to help in both conducting practice-relevant research and translating findings into practice (Rycroft-Malone et al., 2; Todero, Long, & Hair, 25). However, for a hospital not positioned within an academic medical center, it may be advantageous to seek other collaborative partnerships to effectively implement innovative educational strategies and promote research; this was the case in the current industry practice partnership. It has been suggested that meaningful industry partnerships can facilitate transformational change in areas such as hospital design, organization, and technology infrastructure (Hendrich, Chow, & Goshert, 29). Conceptually, the current authors believed that industry partnerships could also help advance the transformational change being advocated for the creation and testing of instruction- The Journal of Continuing Education in Nursing Vol 48, No 9, 27 43

8 ally sound continuing education for nurses practicing in the 2st century. On completion of the project, qualitative reactions to the implementation and evaluation process were solicited from team members. The hospital nurse educators involved described the entire experience of collaboratively modifying, implementing, and evaluating the outcomes of the curriculum as an exciting and rewarding new phase in their professional growth. Specifically highlighted were a greater appreciation for professional collegiality and the motivation to incorporate more deliberate practice into future education opportunities for staff. Although the PACT skills evaluators were unable to provide feedback to nurses during the PIVC insertion skills assessments, they were able to identify consistent areas for staff improvement. Subsequently, the nurse educators have reinforced the appropriate knowledge and skills to correct these deficits in the hospital s IV education program. In addition, the PACT evaluators reported not only an improvement in their understanding of the importance of collecting outcomes data, but also a reevaluation of their own PIVC insertion technique from continued exposure to the skills checklist and conducting observations. The industry educators involved in the project were motivated by the Patient Protection and Affordable Care Act of 2, which demands evidence of continuously improved patient outcomes. These industry educators wanted to explore and validate the possibility of collaborating directly with hospital clinicians to help solve variability issues in real-world procedural practice. Through this nontraditional collaboration, they learned that industry could meaningfully contribute to developing, implementing, and testing broader, practice-based educational programs to help improve clinical practice, going beyond traditional product-specific in-service education. Most important, all parties involved in the project concurred that the novel industry practice partnership was successful because the project was interesting, innovative, relevant to both practice and patient care, and conducted ethically. CHALLENGES Several challenges were faced during the program s development and execution. The original PIVC insertion training program consisted of two 8-hour training days: a live 8-hour didactic PIVC insertion course, followed by a live 8-hour PIVC insertion simulation course. It was identified early in the collaboration that a 2-day training course would not be practical. To address this limitation, a 2-hour e-learning course was developed to accommodate the needs of the participating hospital, replacing the original 8-hour live didactic course. Nurses were given 4 weeks to complete the e-learning course prior to attending the live course. One could consider this a design weakness in that it allowed for a long period of time to pass prior to application of knowledge in the simulation course. To account for the potential risk of knowledge decay, reinforcement of the e-learning content was built into the live training. Logistical challenges were also encountered during program execution, most notably the lack of a consistent location in which to conduct the training and simulation. Both industry and hospital team members collaborated to develop practical solutions to overcome this challenge by creating the necessary elements within the available hospital spaces to make the simulated environment as realistic as possible. A final limitation of the project was the absence of live course evaluations for one group of nurses. However, because the groups were randomized, the authors think that the 27 completed evaluations represent the entire 59 participants who completed all components of the study. To the extent this procedural oversight is viewed as a limitation, the live course evaluation results should be interpreted with caution. CONCLUSION Achieving meaningful educational outcomes with practicing nurses is a complex undertaking, especially when the desired outcome is their reconstruction of knowledge and skills to replace incorrect knowledge and skills. The curriculum outlined was instructionally designed to maintain the selective attention of practicing nurses with diverse learning needs who may not be consciously aware of their own PIVC insertion knowledge and skill deficits. A variety of interactive, multimedia, and hands-on components helped maintain nurses curiosity and interest throughout the program. Similarly, three PIVC insertion simulators were incorporated to cover all elements of the PIVC insertion procedure, which made the skills component more relevant and meaningful. Further, the simulation-based blended curriculum required significant deliberate PIVC insertion practice. This cognitive effort helped maintain selective attention and learner engagement and increased the potential to encode new knowledge and skills into long-term memory for later retrieval and application in clinical practice (Dickerson, 22; Driscoll, 25; Glover, 24; Glover & Murray, 2; Moore et al., 29). The overwhelmingly positive evaluations of the entire program, combined with positive research outcomes 44

9 (Keleekai et al., 26), support the chosen curricular design. In addition, the added professional growth of hospital and industry collaborators, participating nurses, and skills evaluators helped to cultivate a culture that embraces educational outcomes research and innovation in both organizations. Everyone involved in this project has grown in their ability to maneuver through the scientific and logistic challenges of conducting educational outcomes research in a dynamic practice setting. Nursing education departments are being challenged to redevelop nursing curriculum to meet evidence-based best instructional design practices. Given the limited resources of these departments, the cultivation of new allies (Institute of Medicine, 2, p. 33), such as industry partners who are also being challenged to positively affect patient outcomes, should be considered as an effective option to share instructional knowledge and resources and promote evidence-based practice to improve patient care. REFERENCES Alexandrou, E., Ramjan, L., Murphy, J., Hunt, L., Betihavas, V., & Frost, S. (22). Training of undergraduate clinicians in vascular access: An integrative review. The Journal of the Association for Vascular Assess, 7, Brydges, R., Carnahan, H., Rose, D., Rose, L., & Dubrowski, A. (2). Coordinating progressive levels of simulation fidelity to maximize educational benefit. Academic Medicine, 85, Cicolini, G., Manzoli, L., Simonetti, V., Flacco, M.E., Comparcini, D., Capasso, L.,... Eltaji Elfarouki, G. (24). Phlebitis risk varies by peripheral venous catheter site and increases after 96 hours: A large multi-centre prospective study. Journal of Advanced Nursing, 7, Decker, S., Sportsman, S., Puetz, L., & Billings, L. (28). The evolution of simulation and its contribution to competency. The Journal of Continuing Education in Nursing, 39, DeVries, M., Valentine, M., & Mancos, P. (26). Protected clinical indication of peripheral intravenous lines: Successful implementation. The Journal of the Association for Vascular Access, 2, Dickerson, P.S. (22). Rocking the boat: Challenges ahead for continuing education providers. The Journal of Continuing Education in Nursing, 43, Driscoll, M.P. (25). Cognitive information processing. In Psychology of learning for instruction (3 rd ed., pp. 7-). Boston, MA: Pearson Education. Ericsson, K.A. (24). Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Academic Medicine, 79(Suppl.), S7-S8. Gardner, H. (24). Frames of mind: The theory of multiple intelligences. New York, NY: Perseus Books Group. Glover, K. (24). Medical Simulation. In K. Kapp (Ed.), The gamification of learning and instruction field book: Theory into practice (pp ). San Francisco, CA: John Wiley and Sons. Glover, K.R., & Murray, C. (2, Spring). Learning by doing in medical device training: The deliberate difficult practice methodology. FOCUS Magazine, Helm, R.E., Klausner, J.D., Klemperer, J.D., Flint, L.M., & Huang, E. (25). Accepted but unacceptable: Peripheral IV catheter failure. Journal of Infusion Nursing, 38, Hendrich, A., Chow, M.P., & Goshert, W.S. (29). A proclamation for change: Transforming the hospital patient care environment. Journal of Nursing Administration, 39, Institute for Safe Medication Practices. (25). ISMP Safe practice guidelines for adult IV push medications. Retrieved from ismp.org/tools/guidelines/ivsummitpush/ivpushmedguidelines. pdf Institute of Medicine. (2). The future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Jeffries, P.R. (27). Simulation in nursing education: From conceptualization to evaluation. New York, NY: National League for Nursing. Keleekai, N., Schuster, C., Murray, C., King, M.A., Stahl, B., Labrozzi, L.,... Glover, K.R. (26). Improving nurses peripheral intravenous catheter insertion knowledge, confidence, and skills using a simulation-based, blended learning program: A randomized trial. Simulation in Healthcare,, Kolb, D. (984). Experiential learning: Experience as the source of learning and development. Upper Saddle River, NJ: Prentice Hall. Lyons, M.G., & Kasker, J. (22). Outcomes of a continuing education course on intravenous catheter insertion for experienced registered nurses. The Journal of Continuing Education in Nursing, 43, Moore, D.E., Jr., Green, J.S., & Gallis, H.A. (29). Achieving desired results and improved outcomes: Integrating planning and assessment throughout learning activities. The Journal of Continuing Education in the Health Professions, 29, -5. Parker, S.I., Benzies, K.M., Hayden, K.A., & Lang, E.S. (26). Effectiveness of interventions for adult peripheral intravenous catheterization: A systematic review and meta-analysis of randomized controlled trials. International Emergency Nursing, 3, 5-2. Rader, S.B., Henriksen, A.H., Butrymovich, V., Sander, M., Jorgensen, E., Lonn, L., & Ringsted, C.V. (24). A study of the effect of dyad practice versus that of individual practice on simulation-based complex skills learning and of students perceptions of how and why dyad practice contributes to learning. Academic Medicine, 89, Rycroft-Malone, J., Wilkinson, J.E., Burton, C.R., Andrews, G., Ariss, S., Baker, R.,... Thompson, C. (2). Implementing health research through academic and clinical partnerships: A realistic evaluation of the Collaborations for Leadership in Applied Health Research and Care (CLAHRC). Implementation Science, 6, 74. Schuster, C., Stahl, B., Murray, C., Keleekai, N., & Glover, K. (26). Development and testing of a short peripheral intravenous catheter insertion skills checklist. The Journal of the Association for Vascular Assess, 2, Shadish, W., Cook, T., & Campbell, D. (22). Experimental and quasiexperimental designs for generalized causal inference. Belmont, CA: Wadsworth Cengage Learning. Stiegler, M.P., & Gaba, D.M. (25). Decision-making and cognitive strategies. Simulation in Healthcare,, Todero, C.M., Long, R., & Hair, C. (25). Academic-practice partnerships: A tale of two cultures. Nursing Management, 46, Vizcarra, C., Cassutt, C., Corbitt, N., Richardson, D., Runde, D., & Stafford, K. (24). Recommendations for improving safety practices with short peripheral catheters. Journal of Infusion Nursing, 37, Wallis, M.C., McGrail, M., Webster, J., Marsh, N., Gowardman, J., The Journal of Continuing Education in Nursing Vol 48, No 9, 27 45

10 Playford, E.G., & Rickard, C.M. (24). Risk factors for peripheral intravenous catheter failure: A multivariate analysis of data from a randomized controlled trial. Infection Control and Hospital Epidemiology, 35, Wilfong, D.N., Falsetti, D.J., McKinnon, J.L., Daniel, L.H., & Wan, Q.C. (2). The effects of virtual intravenous and patient simulator training compared to the traditional approach of teaching nurses: A research project on peripheral I.V. catheter insertion. Journal of Infusion Nursing, 34, Woody, G., & Davis, B. (23). Increasing nurse competence in peripheral intravenous therapy. Journal of Infusion Nursing, 36,

11 Table A Peripheral Intravenous Catheter Insertion e-learning Course Evaluations (N = 59) Training Course, n (%) Strongly Disagree () Disagree (2) Neither Agree nor Disagree (3) Agree (4) Strongly Agree (5) N/A The objective(s) for this activity were met. (.7%) (.7%) 3 (5.%) 33 (55.9%) 2 (35.6%) The scope of the material was appropriate to meet my needs. The pacing of the activity was appropriate. The use of multimedia or audiovisual aids enhanced the activity. (.7%) (.7%) (.7%) (.7%) 2 (3.4%) (.7%) 4 (6.8%) 3 (5.%) (.7%) 29 (49.2%) 35 (59.3%) 3 (5.8%) Effectiveness, n (%) Strongly Disagree () Disagree (2) Neither Agree nor Disagree (3) Agree (4) Strongly Agree (5) The activity held my interests. I learned new knowledge from this activity. 24 (4.7%) 8 (3.5%) 26 (44.%) N/A (5.%) (3.6% (49.2%) (32.2%) ) 2 (3.4%) 4 (6.8%) 32 (54.2%) 2 (35.6%) Rate your level of knowledge of the topics prior to the activity. 3 (5.%) 22 (37.3%) Excellent Good Fair Weak None 3 (52.5%) 3 (5.%) Rate your increase in knowledge of this content before versus after the activity. (% = no increase and % = a very significant increase.) % % 2% 3% 4% 5% 6% 7% 8% 9% % 3 (5.%) (8.6%) 8 (3.6%) (.7%) 2 (2.3%) 3 (5.%) 8 (3.6%) 3 (5.%) 2 (3.4%) 8 (3.6%) Job Impact, n (%) Strongly Disagree () Disagree (2) Neither Agree nor Disagree (3) Agree (4) Strongly Agree (5) N/A I will be able to apply what I have learned to my job. 7 (.9%) 28 (47.5%) Results, n (%) Strongly Disagree () Disagree (2) Neither Agree nor Disagree (3) Agree (4) Strongly Agree (5) This was a good use of my time. I would recommend this activity to others. 24 (4.7%) N/A (5.%) (.9%) (55.9%) (27.%) 4 (6.8%) 7 (.9%) 3 (52.5%) 7 (28.8%)

12 Table B Peripheral Intravenous Catheter Insertion Live Simulation-Based Training Course Evaluations (N = 29) Training Course, n (%) Strongly Disagree () Disagree (2) Neither Agree nor Disagree (3) Agree (4) Strongly Agree (5) The objective(s) for this activity were met. a The scope of the material was appropriate to meet my needs. The pacing of the activity was appropriate N/A 7 (37.9%) (58.6%) (3.4%) 4 (3.8%) 9 (3%) 2 (69%) 7 (24.%) Effectiveness, n (%) Strongly Disagree () Disagree (2) Neither Agree nor Disagree (3) Agree (4) Strongly Agree (5) The activity held my interests. (3.4%) I learned new knowledge from this activity. 7 (58.6%) N/A (6.9%) (4.4%) (48.3%) 2 (6.9%) (34.5%) 7 (58.6%) Excellent Good Fair Weak None Rate your level of knowledge of the 4 (3.8%) 2 topics prior to the activity. a (4.4%) (37.9%) (3.4%) % % 2% 3% 4% 5% 6% 7% 8% 9% % Rate your increase in knowledge of this content before versus after the activity. (% = no increase and % = a very significant increase.) b 3.4 (%) 3.4 (%) 2.7 (6%) 6.9 (2%) 3.8 (4%) 6.9 (2%).3 (3%) 3.8 (4%) 3.4 (%).3 (3%) Job Impact, n (%) Strongly Disagree () Disagree (2) Neither Agree nor Disagree (3) Agree (4) Strongly Agree (5) N/A I will be able to apply what I have learned to my job. 7 (24.%) Results, n (%) Strongly Disagree () Disagree (2) Neither Agree nor Disagree (3) Agree (4) Strongly Agree (5) This was a good use of my time. I would recommend this activity to others. Overall, I was satisfied with the combination of online and classroom simulation-based learning. a Data missing =. b Data missing = 2. (3.4%) 22 (75.9%) N/A (27.6%) (7.2%) (5.7%) (3.4%) (3.4%) (3.4%) 5 (7.2%) 4 (3.8%) 8 (27.6%) 9 (3%) 5 (5.7%) 4 (48.3%)