The majority (70% to 80%) of hospitalized patients require the placement of a vascular access device for intravenous therapy (Alexandrou et al., 2012; Zingg & Pittet, 2009). Peripheral intravenous (PIV) catheters allow venous system access for the infusion of fluids, medication, blood, or blood products (Hagle & Mikell, 2014). PIV catheter placement is one of the most frequent invasive skills performed by nurses working in hospitals (Ravik et al., 2017). Accurate placement and management of PIV catheters require significant knowledge, skill, and clinical judgement to reduce PIV-associated risks. If not managed correctly, PIV complications such as dislodgement, infection, phlebitis, occlusion, and/or infiltration/extravasation may occur (Infusion Nurses Society [INS], 2016; Weinstein & Hagle, 2014). Although theoretical and practical acquisition is a core component of nursing curricula, many nursing students and graduate nurses alike lack confidence in their PIV knowledge and skill (ECRI, 2019; Fink et al., 2008; Ravik et al., 2017; Wenger, 2015).
This descriptive, exploratory study examined PIV education delivery (i.e., content, time, and methodology [didactic, skills, simulation, clinical]) in U.S. and Canadian nursing programs. A team of researchers explored the current state of education provided to prelicensure nursing students, guided by the following research questions:
- To what extent do U.S. and Canadian nursing schools cover PIV content in the nursing curriculum?
- To what extent are nursing students allowed to start PIVs on patients in the clinical setting; if yes, are there limits on the number of PIV attempts?
- Does the primary responsibility to educate nurses regarding PIV lie with the nursing school (students) or the health system (graduate nurses)?
- What is the level of PIV competence expected of graduate nurses?
Delivery of quality, safe patient care is a cornerstone of nursing practice. Unfortunately, landmark studies, such as the Institute of Medicine's (2000) To Err Is Human: Building a Safer Health System, demonstrate that despite our best efforts health care is fraught with errors. In 2005, the Robert Wood Johnson Foundation funded a national study to prepare future nurses with the knowledge, skills, and attitudes to continuously improve the quality and safety of patient care (Quality and Safety Education for Nurses, 2019). ECRI, an organization dedicated to protecting patients from unsafe medical technologies and practices, released the “Top 10 Patient Safety Concerns for 2019,” which included #9: “infections from peripherally inserted IV lines” (ECRI, 2019, p. 12). ERCI (2019) noted, “PIVs can expose patients to a significant risk of infection—one that is underreported, under recognized, and often ignored…. Increased awareness of PIV catheter-related infections, coupled with routine active surveillance and follow-up reporting, can help reduce the risk” (p. 12).
ECRI (2019) also identified the safety concern, “developing and maintaining skills” (#7), resulting from provider lack of confidence and competence performing procedures and/or using medical equipment (p. 10). Research links the lack of PIV education as one of the top reasons for PIV catheter complications and early catheter removal (Fakih et al., 2012; Keleekai et al., 2016; Unbeck et al., 2015). PIV complications can lead to increased length of stay (Helm et al., 2015), poor patient outcomes, and inflated patient costs (Helm et al., 2015; Keleekai et al., 2016; Taylor, 2015).
A study of U.S. and Canadian health care institutions found great variation in the PIV education and competency assessment of practicing nurses (Hunter et al., 2018). The majority of participating health care institutions felt nurses' PIV education was a shared responsibility between schools of nursing and health systems. Despite the fact that health care institutions expect graduate nurses to function at a novice level for PIV insertion, care, and maintenance, only four of 10 (43%) participating health systems included PIV education in their nursing orientation program and even fewer (18%) included it as part of the nurse residency program. Six percent of health systems indicated they did not provide any PIV education to their graduate nurses (Hunter et al., 2018). Finally, PIV competency assessment (i.e., psychomotor skill) was evaluated annually by fewer than two of 10 (16%) health care institutions or when a nurse transfers to select units (10%) (Hunter et al., 2018).
The insertion, care, and maintenance of PIV catheters requires application of complex knowledge and skills. Kavanagh and Szweda (2017) noted that:
knowledge development in clinical practice requires experiential teaching and learning through facilitated, situated cognition with reflection. Students, faculty, academic leaders, and service providers all share ownership in the success or failure of our new graduate nurses and their ability to develop a safe, effective practice.
When faculty teach students the skill of inserting a PIV catheter, they often do so using a linear approach (i.e., gather supplies, asses and prepare skin, insert catheter, connect fluid). Although this approach helps students to develop the psychomotor skill, it does not integrate the systematic approach needed to enhance clinical judgement as it pertains to PIV catheters. Knowledge and understanding of the complex PIV system, including anatomy (e.g., catheter-to-vessel ratio) and physiology (e.g., flow dynamics distal to central), combined with factors that contribute to PIV failure are critical to reducing PIV-associated risks.
PIV Skill Development
The literature highlights concerns regarding the inconsistencies in PIV education and the limited opportunities for psychomotor PIV training for many new graduate nurses (Hunter et al., 2018). The INS 2013 IV Safety Practice Survey results found that more than half (57%) of the RN participants (n = 345) noted they were not taught how to perform the psychomotor skill of PIV placement in nursing school (Vizcarra et al., 2014). Seventy-one percent of these nurses reported receiving on the job training, whereas 11% reported they developed their PIV skills via the “see-one, do-one, teach-one” method. This limited PIV education likely contributes to reduced confidence in PIV skills. Studies found that graduate nurses identified PIV therapy as one of the top three skills they are least comfortable performing (Fink et al., 2008; Wenger, 2015). Lyons and Kasker (2012) further highlighted that even experienced nurses lacked confidence in their PIV catheter skills.
Furthermore, a lack of PIV education is one reason for PIV catheter complications and early PIV catheter removal (Fakih et al., 2012; Keleekai et al., 2016; Unbeck et al., 2015). Clay et al. (2017) demonstrated that less than 10% of medical and nursing students could identify a PIV catheter requiring replacement. PIV catheter insertion is a skill that graduate nurses are expected to grasp and comprehend, yet many are challenged to master this complex skill (Ravik et al., 2017). The current literature suggests that the delivery of a didactic PIV education program in combination with hands-on training results in significant improvements in PIV therapy outcomes (Alexandrou et al., 2012; Larsen et al., 2010; Lian et al., 2017; Lyons & Kasker, 2012; Vizcarra et al., 2014; Wilfong et al., 2011).
Lack of confidence and skill, as well as the pressure to initiate PIV access, can lead to unacceptable multiple PIV insertion attempts resulting in increased risk of patient harm. Data suggest that only 57% of patients experience a successful PIV catheter placement on the first attempt (iData, 2013), with most requiring at least two attempts (Hadaway, 2012). Multiple failed attempts result in vessel damage that limits future access and increases complication risk.
The acceptance of multiple attempts as the norm represents a type of “normalization of deviance,” a “progressive acceptance by a group of people of small incremental changes that result in a lower level of safety” (Odom-Forren, 2011, p. 216). Reasons for departure from standard practice may include lack of knowledge of the standards or seeing providers deviate from the standard of care (e.g., removing the finger of the glove during PIV insertion) (Odom-Forren, 2011). Eventually, deviations in practice are deemed acceptable and become the new normal. Use of an enhanced PIV curriculum by both nursing schools and professional development staff in health care institutions has potential to improve patient safety by reducing PIV complications and associated costs. This also has the potential to raise the confidence and skill level of nursing students and practicing nurses.
Nursing programs face many challenges in their curricular efforts to produce a nurse generalist who will have the requisite skills and knowledge upon graduation to successfully navigate the fast-paced world of patient care. Numerous sources of information guide the development of nursing curricula. These include accreditation standards (e.g., American Association of Colleges of Nursing (AACN) baccalaureate Essentials (2008), National League for Nursing (NLN) Commission for Nursing Education Accreditation (CNEA) Standards (2016), Accreditation Commission for Education in Nursing (ACEN) accreditation standards (2019), Canadian Association of Schools of Nursing (CASN) Standards (2014), and the National Council of State Boards of Nursing(NCSBN) NCLEX® test plan (2019). To raise PIV knowledge, competence, and confidence of nursing students, it is expected that nursing curricula are grounded in professional standards. In the case of vascular access and infusion therapy, specialty organizations have published consensus statements, guidelines and standards including INS Infusion Therapy Standards of Practice (INS, 2016), Oncology Nursing Society (ONS) Access Device Standards (Camp-Sorrel & Matey, 2017), Canadian Vascular Access and Infusion Therapy Guidelines (Canadian Vascular Access Association [CVAA], 2019), and the Association for Vascular Access (AVA) Consensus Statements (Davis et al., 2016). These specialty organizations are dedicated to improving patient outcomes through promotion of vascular access and infusion therapy best practices. Professional organizations consider the quality and strength of the evidence in the development of practice guidelines and standards. Levels of evidence are assigned based on the study design, validity, and relevance to patient care. Many practice standards rely on key opinion leaders, clinical experts who serve as mediators in the development of these practice recommendations.
NCSBN Licensure Examination
The NCSBN is responsible for the development and maintenance of the NCLEX-RN. The NCLEX test plan is based on the results of a national survey of a representative sample of 12,000 newly licensed RNs about the frequency and importance of performing nursing care activities (NCSBN, 2018). This test plan is revised every 3 years to “measure the competencies needed to perform safely and effectively as a newly licensed, entry-level RN” (NCSBN, 2019, p. 1). Survey results guide the development of the NCLEX test plan, including the distribution of content. Pharmacologic and parenteral therapies, including PIV therapy, comprised 12% to 18% of the items. Specifically, the nurse is expected to effectively monitor an intravenous infusion and maintain the PIV site. In addition, in the content area “Reduction of Risk Potential,” one of the activity statements is the insertion, maintenance, and removal of a PIV line (NCSBN, 2019).
Using a descriptive exploratory design, this study investigated how U.S. and Canadian colleges/schools of nursing educate students regarding PIV knowledge and skill. Participants were recruited to complete a 12-item questionnaire assessing the content, delivery method, clinical opportunities, and time dedicated to PIV education provided in the U.S. and Canadian colleges/schools of nursing. As an incentive, participants were offered the opportunity to enter a drawing for a $50 Amazon gift card by entering their contact information on a separate online site.
Researchers first obtained contact information for U.S. and Canadian nursing programs from the membership list for the AVA. To ensure a representative sample of both baccalaureate and associate degree programs, researchers also obtained nursing program information from the State Boards of Nursing in each of the 50 states. A Canadian nurse researcher obtained the contact information from Canadian programs. A web-based search of the nursing program websites provided the contact information for the nursing deans and directors or their representative. Finally, researchers reviewed the list of accredited programs from the AACN Commission on Collegiate Nursing Education, NLN CNEA, ACEN, and CASN. The result was a list of 633 U.S. (representing all 50 states) and 111 Canadian colleges/schools of nursing (representing all 10 provinces).
Following institutional review board approval, deans and administrators of U.S. and Canadian colleges/schools of nursing were sent an email inviting their school to participate in the electronic survey. To ensure accuracy of the responses, deans and directors were encouraged to forward the survey link to a faculty member most familiar with the PIV curriculum in their program. The recruitment email contained a link to a consent form that described the purpose and associated benefits and risks of participating. Consenting participants were taken to the 12-item online survey.
To encourage participation, researchers distributed a short video describing the study to the AVA electronic mailing list. AVA members were asked to reach out to the colleges/schools of nursing in their area. Finally, another member of the research team shared the opportunity to participate with attendees at the annual AVA meeting.
Representatives from 171 (27%) U.S. and Canadian nursing schools completed the PIV curriculum survey. Of the 171 participating schools, the majority (n = 112) represented baccalaureate degree (BSN) or equivalent programs (66%), 25 (15%) represented accelerated BSN programs, 29 (17%) represented 2-year associate degree (ADN) or equivalent programs (e.g., CEGEP Quebec), and five (3%) participants represented other types of nursing programs (e.g., diploma or Master of Science in Nursing Clinical Nurse Leader).
Participants were asked whether their curriculum included content on PIV and central vascular access. The majority of participating schools included PIV (87%) and central infusion therapy content (82%) at some point during the nursing program. Participants identified areas of PIV content and whether it was taught in the classroom (didactic), laboratory/simulation, or clinical settings. Areas receiving the most attention in the classroom included anatomy and physiology of the vascular system, types of parenteral solutions, patient education, and legal implications. Content taught more frequently in the laboratory/clinical setting included PIV catheter device types, catheter care, infection control, and venous visualization techniques. These topics were further reinforced in the clinical setting, particularly frequency of PIV monitoring, complications, and patient education. Table 1 demonstrates the PIV content covered and delivery method used (i.e., didactic/classroom, laboratory/simulation, clinical settings).
PIV Content Coverage and Delivery Modality in the Nursing Curriculum (N = 171)
When specifically asked about the use of case examples to demonstrate legal issues related to PIV placement, care, and documentation, the majority did not use such cases (65%). Most (73%) of the participants indicated that if they had access to a web-based, interactive PIV resource for student use, they would require students to complete the activities and use the time normally spent on PIV content to reinforce PIV concepts.
Coverage and Delivery of PIV Content in the Nursing Curriculum
When asked about the courses in which PIV content was introduced and reinforced, most participants indicated it was introduced in the fundamentals and skills courses, with fewer participants introducing this content in medical–surgical courses (Figure 1). Participants reinforce PIV content in pediatrics, medical–surgical, obstetrics, and critical care and to a lesser extent in the leadership course.
Courses in which peripheral intravenous education is taught and reinforced throughout the curriculum. Note. Med/Surg = medical–surgical.
Time Spent on PIV Content
Participants were asked the amount of time dedicated to PIV content throughout the curriculum. Programs spent less than 1 to 2 hours of didactic class time (75%), with more instruction time (1 to 5 hours) dedicated to PIV in the laboratory/simulation setting (82%). Instruction was further reinforced in the clinical setting. In addition to classroom and laboratory/simulation, 90 (52%) of the participants indicated they incorporated a web-based, interactive PIV program.
Participants were then asked whether nursing students were able to start PIVs on patients in clinical settings. Ninety-one (61%) indicated nursing students in their program were able to initiate PIVs in the majority of clinical settings. Forty participants (27%) indicated students could initiate PIVs in some, but not all settings, and 18 (12%) indicated their students were unable to start PIVs in any clinical settings. The types of specialty units where students were least likely to initiate a PIV include pediatrics, community-based (e.g., home care), and psychiatric settings. Participants shared that individual health care institutional policies dictated students' ability to insert PIV catheters, rather than the nursing program. Even in schools where students were allowed to insert PIV catheters, most programs (72%) limited the number of attempts to two, which was the same limit for experienced nursing staff.
Participants indicated that nursing student PIV competence upon graduation was at the novice (56%) or advanced beginner level (35%). When asked about who has primary responsibility to educate nurses regarding PIV therapy, more than half of nursing program representatives (60%) thought it was a shared responsibility between the nursing school and health system/institution. Thirty-three percent thought it was the primary responsibility of the nursing school, and another 8% suggested it was the responsibility of the health system or institution.
The insertion of a PIV access device is one of the most common invasive procedures currently performed in health care, and it is perceived as a simple procedure (Vizcarra et al., 2014). Given the frequency of this invasive procedure and potential negative health outcomes when not appropriately managed, learning both the knowledge and skill associated with PIV is critical to patient safety.
Findings from this study demonstrate that PIV content coverage and practice opportunities comprise a small portion of the nursing didactic curriculum (1 to 2 hours) and laboratory/simulation instruction (1 to 5 hours). Simulation settings provide a safe environment in which to practice the skill of PIV insertion; however, students may find it difficult to transfer that knowledge to the clinical setting (Ravik et al., 2015). More concerning than time spent on PIV content are the limited opportunities to perform PIV catheter insertion in the clinical setting. Twelve percent of participating nursing programs indicated their nursing students were unable to initiate a PIV catheter during their clinical rotations. PIV knowledge and skill must be connected. When skills are learned only mechanically, the complexity of the knowledge behind the skill is not taken into consideration.
As noted previously, nursing knowledge development requires experiential teaching and learning through facilitated, situated cognition with reflection (Kavanagh & Szweda, 2017). Nurse educators are challenged to frame PIV content from both a “knowing that” and “knowing how” lens (Ravik, 2019). “Knowing how” to start a PIV focuses on the manual, psychomotor skill requiring manual dexterity and hand–eye coordination (Gomez & Gomez, 1987; Oermann, 1990). “Knowing that” involves a complex interplay between theoretical and practical knowledge, along with ethical and moral considerations (Benner, 1984; Ravik, 2019).
Changes to the NCLEX-RN examination include item types intended to measure clinical judgement more comprehensively; therefore, teaching clinical judgement related to PIV is important. NCLEX-RN plans to incorporate Next Generation NCLEX (NGN) item types such as hot spot (identify one or more areas on a picture or graphic) and exhibit, ordered response items (candidates rank order or move options), audio clips (using headphones), and graphic options (must select among a series of graphics instead of text), candidates may see items that evaluate their ability to assess and place PIV catheters (NCSBN, 2019). It is possible that candidates may see items that evaluate their ability to assess and place PIV catheters.
Perhaps nursing curricula should better emphasize advancing nursing students' knowledge of PIV care and maintenance early in the nursing curriculum to enhance clinical judgement. Once achieved, the focus can be shifted to PIV catheter insertion skills. However, a focus on care and maintenance may further limit clinical opportunities to practice PIV catheter insertion skills (Ravik et al., 2017). Although there is a growing body of literature regarding best practices for teaching PIV catheter insertion skills (Ravik, 2019; Ravik et al., 2015, 2017), gaps remain.
Adoption of reflection in parallel with skill performance may lead to enhanced learning. Ravik (2019) noted that “intelligent practice” involves intentional reflective practices to enable students to generate clear ideas of how to transfer the knowledge gained from the laboratory and simulation setting to the clinical area. Nurse educators are encouraged to facilitate intelligent practice in nursing students to ensure accurate skill performance, as well as the ability to adjust to individual patient needs. Likewise, health system nurse educators or individuals responsible for nurse residency programs are in a unique position to further develop graduate nurses' PIV knowledge and skill via ongoing professional education and competency assessment. The synergistic effect of the nursing curriculum, combined with the ongoing professional education, has the potential to improve not only the PIV confidence of graduate nurses but the skill as well.
Vascular access specialty organizations are an important source of evidence-based, best practices for both nurse educators and health care organizations alike. The AVA, CVAA, and INS provide web-based resources, including position papers, standards, and guidelines—many of which are available at no cost. Nursing faculty are encouraged to join these professional organizations to stay current on the latest evidence-based practices. Nursing texts often reference standards of practice for infusion therapy including vascular access.
Strategies to Enhance PIV Education
Strategies that nursing faculty could use to raise student awareness of PIV best practices is to invite a vascular access/IV team health care professional as a guest lecturer. These expert clinicians frequently are members of AVA, CVAA, and/or INS and are familiar with the vascular access/infusion therapy standards, guidelines, and position statements (Hunter et al., 2018). A second strategy faculty can use to enhance awareness of PIV and patient safety concerns is incorporation of legal case studies.
Faculty may enhance PIV learning opportunities by assigning students to clinical areas where PIV catheter insertion frequently occurs, such as outpatient surgery centers, emergency departments, and the radiology department. Another strategy would be to assign nursing students a day when they can work directly with a member of the vascular access team at the health system where clinical is completed. Such focused clinical experiences would expose them to clinical experiences often reserved only for expert PIV clinicians. Clinical objectives for this type of experience could include exposure to (a) best practices for infusion therapy, (b) patient safety (e.g., infection prevention) initiatives, (c) workflow management and triage, (d) device selection, (e) clinical decision making, (f) documentation, and (g) risk management considerations.
The organizations dedicated to vascular access and infusion therapy (e.g., AVA, CVAA, INS) recognize the need for improved PIV education and resources for health care providers (Table 2). In the past year, these organizations have launched educational portals for both members and non-members that provide continuing education modules to enhance nurses' knowledge of vascular access and infusion therapy ( https://www.avainfo.org/page/ava-academy; https://www.learningcenter.ins1.org/). The latest evidence on vascular access care and maintenance, legal/ethical concerns, infection control practices, and building vascular access competencies across the continuum are included. These provide access to the latest PIV evidence-based practice and other resources to support PIV knowledge foundation for proper skill development (AVA, 2019; INS, 2019). Unfortunately, some of these resources may be cost prohibitive to nonmembers and may be more appropriate for a more advanced provider. Ideally, vascular access and infusion therapy organizations would collaborate to assist prelicensure nursing programs to ensure an evidence-based curriculum to enhance PIV knowledge and skill acquisition. In fact, there are many recent innovative PIV simulation aides to improve PIV insertion skills that, the adoption of intelligent practice pedagogy, may also enhance overall PIV knowledge and skill.
Vascular Access Resources for Nurse Educators
Future studies are needed to determine the effectiveness of an enhanced PIV curriculum on improving the confidence, competence, and skill acquisition of nurses and other members of the health care team responsible for PIV insertion, care, and maintenance.
The majority of hospitalized patients experience PIV therapy at some point in their hospital stay and nurses are the most frequent provider to initiate PIV therapy. Research suggests that many nursing students and new graduate nurses feel less than confident in their PIV skills. Kavanagh et al. (2017) noted that faculty, students, academic leaders, and service providers all share ownership in the success or failure of graduate nurses' ability to develop safe, effective practice (p. 57). This is particularly relevant to PIV knowledge and skills. It is important for nursing students to understand the complexity of PIV content, including anatomy and physiology, pathophysiology, pharmacology, and assessment, before attempting to demonstrate PIV skill acquisition (Benner et al., 2010). Nursing students are eager to engage in hands-on nursing skills, especially the insertion of a PIV catheter. Unfortunately, emphasis on PIV skills undermines focus on learning the complexities of PIV care and maintenance and infusion therapy.
Nurse educators need to ensure that students are fully prepared to apply the knowledge learned when engaging in this complex skill. Strong academic practice partnerships are well suited to ensure a seamless transition for graduate nurses. Likewise, those responsible for nurse residency programs and continuing professional education/competency assessment must support new graduates whose PIV knowledge, skill, and confidence may be low. Including PIV content and skill development in such programs is important for patient safety and positive patient outcomes. For a task that remains ubiquitous to patient care while carrying a high volume, high-risk designation, PIV education should be enhanced in prelicensure curricula. Vascular access and infusion specialty organizations provide resources to advance both generalist nursing knowledge and the knowledge of practicing health care professionals. Use of these resources along with advanced PIV simulation aids can support student learning and may lead to increased confidence of graduate nurses.
Although the sampling method for this study included both prelicensure associate and baccalaureate degree programs from the United States and Canada, there is no way to determine the geographic representation of the sample. Likewise, use of a convenience sample limits the generalizability of the findings. Finally, lack of published, evidence-based PIV student standards and guidelines makes consistent application of teaching learning methods regarding PIV difficult.
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PIV Content Coverage and Delivery Modality in the Nursing Curriculum (N = 171)a
|Content Coverage Frequency (Most to Least)||Didactic/Classroom % (n)||Laboratory/Simulation % (n)||Clinical % (n)||Web-Based Interactive PIV Program % (n)||Content Not Covered % (n)|
|Parenteral solutions||77% (133)||70% (120)||72% (123)||9% (15)||1% (2)|
|PIV complications||71% (121)||71% (121)||70% (119)||2% (16)||< 1% (1)|
|Patient education||71% (122)||68% (116)||71% (122)||6% (10)||2% (3)|
|PIV catheter care||60% (102)||77% (132)||68% (117)||11% (18)||1% (2)|
|PIV infection control devices (e.g., chlorhexidine-impregnated disc/dressing)||53% (91)||78% (134)||68% (117)||11% (18)||2% (4)|
|Frequency PIV monitoring||63% (107)||68% (117)||70% (120)||8% (13)||< 1% (1)|
|PIV access devices types/designs||58% (100)||78% (133)||61% (104)||11% (19)||< 1% (1)|
|Legal Implications (e.g., monitoring, documentation)||69% (118)||63% (107)||61% (104)||7% (12)||2% (4)|
|A&P of vascular system||75% (129)||52% (89)||36% (62)||7% (12)||5% (8)|
|Venous visualization techniques||39% (66)||59% (101)||50% (86)||10% (17)||11% (18)|
|Methods to enhance venous visualization techniques||35% (60)||53% (90)||49% (83)||8% (13)||15% (25)|
Vascular Access Resources for Nurse Educators
|Association for Vascular Access (AVA)||AVA Academy (https://www.avainfo.org/page/ava-academy)|
|Vessel Health and Preservation: The Right Approach for Vascular Access (Enhanced Edition) (https://www.avainfo.org/page/VHP)|
|Canadian Vascular Access Association (CVAA)||Online Learning Resources (http://cvaa.info/en/education-portal/online-learning-resources)|
|2019 Canadian Vascular Access & Infusion Therapy Guidelines (http://cvaa.info/en/education-portal/national-guidelines-2019)|
|Infusion Nurses Society (INS)||INS LeaRNing Center (https://www.learningcenter.ins1.org/)|