Transition to practice: Student nurses’ experience of venepuncture and peripheral intravenous cannulation learning

Abstract

Objective

This study explores final-year nursing students’ experiences with venepuncture and peripheral intravenous cannulation, focusing on both educational and clinical practice settings.

Methods

This study is qualitative descriptive design. Data were collected from three focus group sessions using a semi-structured interview approach. Interviews were transcribed verbatim, and data analysis was guided by Braun and Clarke’s six-step model for thematic analysis.

Results

Eight final-year nursing students participated, with each student attending one focus group session. Data analysis resulted in four main themes 1) Practice, practice, practice 2) Not the way it’s done here 3) Luck of the draw and 4) Experiential learning. The results highlight what hindered and helped students learn these skills in both the educational and clinical environment.

Conclusion

Improvements are recommended which can be made to the teaching of nursing students on these skills. The findings of this study can inform educational programmes which incorporate these types of skills.

Resumen

Objetivo

Este estudio explora las experiencias de los estudiantes de último año de enfermería con la venopunción y la canulación intravenosa periférica, centrándose tanto en entornos educativos como de práctica clínica.

Métodos

Este estudio es de diseño descriptivo cualitativo. Los datos se recopilaron a partir de tres sesiones de grupos focales utilizando un enfoque de entrevista semiestructurada. Las entrevistas se transcribieron palabra por palabra y el análisis de los datos se guió por el modelo de seis pasos para el análisis temático de Braun y Clarke.

Resultados

Participaron ocho estudiantes de último año de enfermería y cada estudiante asistió a una sesión de grupo focal. El análisis de datos dio como resultado cuatro temas principales 1) Práctica, práctica, práctica 2) No como se hace aquí 3) Suerte en el sorteo y 4) Aprendizaje experiencial. Los resultados resaltan lo que obstaculizó y ayudó a los estudiantes a aprender estas habilidades tanto en el entorno educativo como en el clínico.

Conclusión

Se recomiendan mejoras que se pueden realizar en la enseñanza de estas habilidades a los estudiantes de enfermería. Los hallazgos de este estudio pueden informar programas educativos que incorporen este tipo de habilidades.

What is known

• •

  Venepuncture and peripheral intravenous cannula insertion are one of the most commonly performed invasive procedures in healthcare.

What it contributes

• •

  Understanding the experiences of student nurses in their training can help inform future iterations of educational programmes. The findings of this study can inform educational programmes which incorporate these types of skills.

Introduction

In healthcare, venepuncture and peripheral intravenous cannula (PIVC) insertion are the most commonly performed invasive procedures.¹ A competent and successful venepuncture, the process of collecting blood samples, is essential for safe and effective patient care.² PIVC insertion and management can be a stressful experience for patients and so it is necessary for appropriately trained practitioners to ensure proficient, quality care,³ as this procedure can result in harm and impact patients adversely.⁴ In Ireland, the undergraduate nursing and midwifery curriculum, has been updated to include the teaching of these clinical skills.⁵ Previous research has identified that student nurses had low confidence in performing both skills in the clinical environment.⁶ Similarly, new graduates may not be sufficiently ready to perform clinical procedures in the clinical environment.⁷

The teaching of skills, such as venepuncture and PIVC insertion, should include pedagogical approaches with a theoretical and practical component.¹ This type of framework involves self-directed learning and assessment, incorporating feedback,¹ which provides an educationally sound approach in facilitating students to perform adequately, ensuring high-quality patient care. Currently, in the Irish context, the curriculum delivers parts of this framework. Students receive the theory regarding the skills from an e-learning package developed by the national health authority. The students, thereafter, observe and demonstrate the skill in a simulation environment.⁵ However, two aspects of the framework disseminated by Ahlin et al.,¹ self-directed learning and assessment, are not currently part of the Irish curriculum. With this understanding, we developed an objective structured clinical examination (OSCE) to assess students and provide feedback on their performance of the skill of PIVC insertion in a simulation centre. In addition, the research team designed an earlier research study which provided students with extra simulated practice sessions with the added task of self-evaluating their recorded performance of the skill. This earlier study evaluated the knowledge, attitude, and performance of students and although the study demonstrated improved educational outcomes, there was also room for improvement.⁸ Considering this, we suggest that the current curriculum which is endorsed by the Office of the Nursing and Midwifery Services Director and adopted by Higher Education Institutions⁵ and the framework by Ahlin et al.,¹ can both be enhanced. Although both provide a cornerstone to the learning of these skills, we suggest that there are other approaches that we need to consider ensuring students experience more effective skills teaching. Furthermore, we thought such approaches could come from the perspective of the student.

The aim of this study was to explore the experiences of nursing students in their learning of the skills of venepuncture and PIVC insertion in both environments, the educational setting, such as in the simulated environment and the clinical setting. Exploring the experiences of those undertaking the training first hand may provide deeper insights into the teaching approaches that are currently delivered and may identify new approaches that can help improve students' learning experiences and outcomes. It was also considered necessary to focus on this student group, as this teaching programme was just recently introduced into the national undergraduate curriculum. It was opportune to delve into their experiences so that future students may benefit from current student reflections. Identifying which teaching approaches and supervision practices work well and what needs improvement.

Theoretical framework

A scoping review found that social theories of learning have been used, albeit sparingly, in the education of healthcare professionals, such as those in nursing, medicine, and pharmacy.⁹ Mukhalalati et al. have called for an increase in the effective use of such theories in the educational programmes of healthcare professionals.⁹ The work presented in this paper was guided by sociocultural learning theory. This theory, derived by psychologists such as Vygotsky, assumes that learning is developed through social interaction.¹⁰ The clinical skills that students learn and how they perform them are dependent on the cultural and social constructs in which they are situated.¹¹ How this theory guided this study is the focused approach it took to addressing students' experiences in both the educational and clinical environment and to ensure both settings were considered throughout the qualitative interviews. Ewertsson et al.¹¹ elaborate that considering nursing students learn skills in two different social environments, the educational and the clinical context, there is a requirement to facilitate the knowledge transfer between these environments. This study set out to delve deeper into the phenomenon of student learning to identify potential gaps which could be filled to facilitate effective knowledge transfer. The simulated environment plays an important role in preparing students for the real-world.¹² It allows students to practice psychomotor skills in a safe environment and helps them develop their confidence.¹³ It also improves clinical skills.¹⁴ However, another important aspect of nursing education is clinical practice. Clinical placements offer students opportunities to use the knowledge and skills they learnt in the educational setting in practice.¹¹ By undertaking research to gain greater understanding into the experiences of students, we may identify where further training or support is required. We aim to ascertain what may need to be improved or integrated into the current teaching of these skills by obtaining the perceptions of those undertaking the complete learning programme across the two social settings.

Methods

Study design and participants

This study was a qualitative descriptive study. Final year nursing students from one Irish university were invited to take part (n = 69). Nineteen students consented to the qualitative study however, only eight students participated. All participating students received their instruction on venepuncture and PIVC in November 2022 and they commenced their nine-month internship clinical placement in January 2023, this study was completed in June 2023.

Data collection

Data was collected qualitatively using focus groups. We organised three focus group sessions, two in-person sessions and one virtual session. Students were initially invited to attend pre-planned in-person focus group sessions, where they could attend the session which suited them best. Thereafter, a virtual session was organised to accommodate more students. Three students attended the first focus group session, four attended the second and one student attended the virtual session. More students had signed up for the virtual focus group session but did not attend the session. The focus groups took a semi-structured interview approach based on the objective of the research study. We devised a list of potential questions, yet our goal was to allow the focus group discussions to be guided by the students, and for them to speak openly. For the purposes of the research, it was important to ensure we explored the students’ experiences in both the educational setting and clinical practice. Therefore, during the interviews we did, at times, ask students probing or confirmatory questions to ensure we had a good grasp of their experiences. Semi-structured interviews allowed this, as it provides more freedom to the researcher to follow-up on aspects that are considered relevant to the participants.¹⁵ However, it also allows the researcher the ability to focus the interview on areas considered important to the research aim.¹⁵

For all interviews, two co-moderators joined the primary researcher. The primary researcher was familiar with the participants as they had previously participated in an earlier educational research study. One co-moderator was to help guide the interviews and the second was to keep written notes and timekeeping. The co-moderators, a nurse educator and an advanced nurse practitioner, were not familiar with the students. Students were informed and gave their approval for the interviews to be recorded. The first and second focus group session lasted over an hour each whereas the third session, which was conducted virtually, lasted 20 minutes.

Data analysis

Initially we transcribed all interviews verbatim and re-read them several times to ensure correct transcription. The final transcriptions were transferred into a qualitative data analysis software NVivo¹⁶ to help organise and interpret the data. To identify, analyse and report themes from the interviews the data was analysed using thematic analysis, with guidance from the Braun and Clarke six-step model,¹⁷ as detailed in Table 1. To ensure rigor the study team was guided by Lincoln and Guba’s criteria for trustworthiness (credibility, transferability, dependability, and confirmability) throughout the data collection and analysis process.¹⁸

Table 1.

Thematic analysis guided by Braun and Clarke's (2006) six step model.¹⁷

Step 1	Listened to the focus group interviews recordings and transcribed them. Became familiar with the data and identified areas which might become codes or themes, such as the mention of having the educational instruction earlier in their coursework, wanting better realism with simulation, and noting what made a good or poor facilitator.
Step 2	Read through the entire dataset. Using NVivo, coded the statements by students; some statements were put into more than one code.
Step 3	A pattern was noted with the codes, and they were then grouped into a broader theme.
Step 4	We further reviewed the themes ensuring our codes taken from the data worked with the themes. On review of the initial themes, we combined some themes and split others. We initially had eight main themes with many subthemes but on consistent review four main themes remained.
Step 5	The four themes were named alongside their subthemes. We provided a summary analysis of each theme, endeavouring to explain the purpose of the theme in relation to the overall research question.
Step 6	We included within the thematic narrative, extracts of the data or quotations as evidence for our thematic areas.

Ethical considerations

This research project was given ethical approval by the participating University’s Ethics Committee (reference number 2022.03.006).

Results

The data analysis resulted in four main themes 1) Practice, practice, practice 2) Not the way it’s done here 3) Luck of the draw and 4) Experiential learning. Each of these themes illuminate the students’ experiences in learning the skills of venepuncture and PIVC in both the educational and clinical settings.

Theme 1 - practice, practice, practice

The first theme noted from these focus groups sessions was the reference to ‘practice’. Students expressed their desire and appreciation for additional experience in both simulation and clinical settings. They referred to nursing as a practical profession and would value more focus on the practical side of their education.

“more focus… in general needs to be on the practical side of things” (Student 4 (S4))

Practice was noted in both the simulation and the clinical environment, therefore in this theme we noted two subthemes: practice in the simulated environment and practice in the clinical environment.

Practice in the simulated environment

During the interviews students explained that when in the simulation laboratory, practice helped them gain their confidence in performing the skill on a patient. With some of the confidence coming from students becoming more familiar and comfortable with the procedural, step-by-step process of the skill. Additionally, students’ confidence was bolstered by their independence in learning how to complete the procedural skill in its entirety on the simulators and manikins. This familiarity with the procedural process that the simulation sessions gave also allowed students to be aware of the process in the clinical environment.

“for learning the kind of basics around it” (S5)

“the simulation is really good for … the method the exact method but that’s where it gives you confidence” (S4)

“doing it by yourself ….. so I had to get, do everything, that helped my confidence as well” (S1)

Students defined confidence as having belief in their ability to execute the skill on a patient, they shared that it allowed them to “put their hands up” to request opportunities to perform the skill in the clinical setting. This independent management of completing the skill from beginning to end in the simulated environment further developed their self-efficacy. This self-efficacy building is reflected in the following quotes.

“I had no confidence to do it… and then I practised again, I did the OSCE and then after that I was like right I can do it” (S7)

“definitely gave me the… reassurance for yourself that you can do it by yourself when the time comes” (S8)

Although the simulation sessions appear to help with confidence, it is further enhanced in the clinical environment when students performed the skill successfully. However, if opportunities weren’t available in the clinical environment simulation was noted as an alternative. The initial educational programme as per national requirements⁵ meant that students received one simulated practice session, which the students considered as “not enough”. Students believed that increased practice helped make their learning more “concrete” and desired to accomplish more in their studies, referring to their muscle memory and learning the fine motor skills.

“if you do it so many times you’ll never forget… it’ll just be like second nature, muscle memory” (S5)

“getting your first one (on a patient) it’s good confidence boost.” (S7)

“if you can’t get a real person I would definitely take the simulation over it… you’re practicing your technique, you’re solidifying… your muscle memory” (S4)

Practice in the clinical environment

The national health authority requests students to complete five successful attempts in a twelve-week period.⁵ Students voiced the number of opportunities (or lack thereof) they got and were required to get in the clinical environment. They identified that even when they received opportunities to perform the skill, there was a time gap, they could be completed a month apart or all on the same day, which hindered their learning. Students voiced their desire to perform their five procedures and then build their proficiency by continuing to carry out the skills.

“such a major gap between…. when you’re actually getting that opportunity to do it again” (S4)

“you’ll get 5 cannulas over 9 months” (S3)

“I want to get it just completed so then any time I get another opportunity is just surplus and it just enhancing the skill” (S6)

Students shared that they needed to be very proactive and felt that this need to push was very influential over whether they got opportunities to practice the skill in the clinical environment. The staff were also made aware of the students' need for these competencies due to this proactive approach. Despite students showing initiative to learn these skills they voiced how difficult it was for them to get their opportunities.

“you have to… put yourself forward” (S7)

“very very proactive” (S3)

“I only have four at this stage, successful, ….. it's June now and it took that long and that was with me pushing it” (S6)

Theme 2 - not the way it’s done here

Students recounted experiences where they found that there were differences in how they were taught the procedural skill to how they observed the skill being performed in practice. They shared that different nurses perform the skill differently. For some students even when they performed the skill in practice, how they were taught by one staff was corrected by other staff. Students did perceive that these differences may be due to staff being proficient or expert in the skill and that they may have developed their own techniques. Students revealed it was not good to learn in this way.

“they literally might not do the same as we’re learning it here” (S4)

“someone told me something was wrong, but it was just the way another nurse did it” (S1)

“people who’ve been doing something for 20 odd years they’re really good at skills they cut corners and maybe it works out fine but when you’re starting off you kind of need to develop the core parts of it” (S3)

The resistance of certain registered nurses to expand their jobs to encompass these competencies was expressed by students. Students shared that some nurses stated that they don’t perform the skill and would refer to other professionals.

“someone else’s job” (S5)

“literally the word was I don’t do cannulas” (S4)

“they bleep the doctor every time” (S1)

Students perceived the benefits of being able to perform the skill and voiced concerns and frustrations regarding delayed patient care because of the avoidance of taking on these skills. This is reflected in the following quotes.

“there’d be patients that wouldn’t have gotten their antibiotics at six o’clock because cannulas came out” (S1)

“good to have this skill” (S6)

“it’s so handy to have… when you have a patient that needs bloods… I’ll do them instead of waiting for someone…it’s so annoying to have to wait for other people” (S5)

Theme 3 - luck of the draw

As noticed in the earlier theme practice, practice, practice an area of frustration voiced by students included the difficulty in getting opportunities in the clinical environment to perform these skills. According to students, where they were assigned to work in a clinical setting and who their supervisor was, were “luck of the draw”. We noted two subthemes to this main theme: luck of the draw – place and luck of the draw – person.

Luck of the draw – place

For some students they could be in an environment which provided ample opportunities to perform the skills under supervision and for others they received placements where opportunities were scarce if not non-existent. Students suggested a solution to this ad hoc approach. They suggested that every student be formally allocated for a short, but focused time on wards or clinics where PIVC insertions were carried out frequently. Such an approach would facilitate ample opportunity to practice this skill with a competent clinician. Some students did recount experiences where placement coordinators arranged or attempted to arrange for them to spend a few hours or part of the day in such areas to attempt to obtain these opportunities. However, this was difficult as other students were also in the area and they were competing for the same opportunities.

“it’s the luck of the draw then what placements you’re on that whether or not you may or may not get them” (S4)

“the * clinic for venepuncture… they had… a day for each of us like every Tuesday one of us or two of us could go” (S8)

“they’re trying to facilitate it but there’s no official way of them doing” (S3)

Students voiced their frustration regarding having to choose between additional learning opportunities on their internship placement, which is the final clinical placement before graduation. When on their internship placement students are employees of the hospital. They shared that when opportunities to perform PIVC insertion and venepuncture arose their ability to participate depended on other work and professional responsibilities allocated to them.

“we start doing our cannulations from the get go in internship but at the exact same time you’re already starting doing a number of competing competencies…. and it’s just hard juggle those… you’re supposed to be doing this, but you’re also supposed to be doing that” (S3)

Students perceived that introducing the teaching of these skills earlier into their nursing programme could assist with this issue of juggling competencies. That the teaching of these skills should be introduced when they are supernumerary, which are practice placements where students are not employees and are not part of the staff complement. They are there for learning purposes only.

“it’s probably easier when you’re supernumerary to do it then” (S3)

“I think if we had done it in third year I wouldn’t be thinking oh I’ve to do a handover, oh I’ve to bring a patient to here and here. I’d have more time to want to do it… because you wouldn’t have as much… on our shoulders” (S1)

Luck of the draw – person

Alongside students sharing that it was a luck of the draw on where they were placed, students also believed it was the luck of the draw with who they got to supervise them. ‘Patience’ was a characteristic in which students voiced they needed from supervisors, that they would “allow you time to do it”. However, they shared it was not always present, students reported feeling rushed by staff or that staff would take over. Students valued preceptors or supervisors who were interested or good at teaching.

“luck of the draw with… where you’re placed, it’s a luck of the draw on who you get… you could have somebody who has just no interest teaching a student or… they’re not very good at it” (S3)

“there’s a few, I’m sure there’s loads, that are really really good. .at teaching” (S1)

“she was so good… going through.. all the theory before we started and… even if I went for a vein she (would question me)… what about this one… that was good” (S5)

Another positive trait illuminated was a supervisor who was present, students desired more structured supervision and facilitation where there would be continuity between what they learned in the clinical laboratory through simulation and clinical practice. These students recounted how their learning needed to be structured.

“I wish there was more people there to specifically say right.. I want to do… a certain amount of practice ones with you, I’m taking all these students off” (S4)

“Yeah someone that’s assigned like a clinical facilitator” (S3)

Theme 4 - experiential learning

Throughout the focus group sessions students reflected on the teaching approaches that they experienced during their training and elaborated on what worked well for them, what they believed may need to be improved on and the processes that they felt should be put in place for the benefit of future students. Students were asked to discuss their experiences in relation to their standard PIVC and venepuncture educational programme within their curriculum. Students shared that the theoretical component of the training was good. This consisted of an e-learning package and an in-person lecture from a vascular access clinician. However, students reported that there was not enough practice in their skills session in the simulation laboratory including too much reiteration of theory already learned in the online session or at the lecture. Students felt that the practical session was rushed.

“I do think the lectures and stuff we had before were beneficial” (S8)

“It was only for a few hours,… it was very rushed” (S5)

The realism of the simulation was critiqued by the students, they voiced a lack of authenticity and that the task trainer was not reflective of an actual patient and the complexity that can be encountered in clinical practice. Students wanted to make the simulation more complex. The following student quotes encapsulate this sentiment.

“you… nearly know where to go” (S8)

“it’s too different from… the actual real thing” (S4)

“you never see a manikin with bad veins… they all have good veins” (S3)

“simulation 2.0..frailer arms…. different skin tones” (S6)

The use of technologies, specifically video technologies was discussed by the students. Students spoke about their participation in an earlier randomised control trial which included additional simulation sessions and allowed the experimental group to self-evaluate their video-recorded performance.⁸ Students perceived this recorded self-evaluation as positive and suggested that it should be brought into the current programme and that this approach may potentially reduce the number of practice sessions required.

“I was in the group that recorded… I got to watch myself back which I think was very good because you're… watching with the tick box and you're (saying) oh, sugar I actually forgot to do that and that… I think that would be a good thing to bring into the college side of it” (S7)

“it adds to the practice sessions …. it probably reduces the number of practice sessions you need until you get the skill actually down” (S3)

In keeping with the video technology concept, students valued the videos provided for them by faculty such as the e-learning package developed by the national health authority. Students appreciated having the learning materials for revision, such as before their OSCE. Students were also intrinsically motivated to source videos online or in social media applications. Yet, despite videos being beneficial they could not replace simulated practice for the tactile experience.

“I looked up one on YouTube” (S6)

“It was great to have videos and… slides to go back over especially when… we were coming back to do any practice bits or especially coming up to the OSCE” (S2)

“I didn’t get to feel the stuff in the video …. how to hold them and get a feel for them” (S6)

As part of their final year module which was during the students nine-month internship clinical placement, students were assessed on the skill of PIVC insertion via an OSCE. Students shared how they found this style of assessment useful. Considering students ongoing appreciation for the simulated sessions we did further question them on whether they would participate in self-directed practice i.e. booking a session for themselves in the simulated environment with the equipment and task-trainer available to practice. Some students voiced that they would attend self-directed practice. We then further questioned students if this motivation to attend self-directed practice sessions was dependent on having an exam. Divergent views were expressed on the necessity of the exam as a motivator for certain students, some believed that the act of studying for exams would serve as a source of motivation. Students voiced that although good intentions, they may not use such available approaches without an “incentive”.

“I like the idea of booking in because then you could say… right I’m off that day, book it in, go for an hour, half an hour and practice” (S6)

“Especially coming up to our cannulation exam” (S5)

Students were questioned on their opinions of feedback. Students felt that having someone there was beneficial, both to provide feedback and to also provide tips on the skill. Students appreciated the process which occurred during their training such as self-evaluating themselves during the video-recorded simulation sessions and then getting feedback from an educator after the OSCE.

“I think feedback, doing it yourself and then getting feedback kind of like an exam situation would be a better way of teaching it” (S7)

In relation to feedback in the clinical environment students wanted supervision to initially be very hands on but to gradually become more hands off, where they could practice more independently. Sometimes supervisors could be too nurturing and helpful, this resulted in students not getting to practice the procedural order. Students expressed that this independent approach was dependent on the students’ level of confidence.

“(staff can be) too comforting, too helpful” (S2)

“to practice trying to do all the steps yourself, they’re like an extra set of hands but it makes it harder” (S6)

“it depended on my level of confidence I think at the start I really wanted somebody who would talk me through everything nearly or… I needed that bit of reassurance for myself whereas as time goes on I don’t need as much” (S8)

Finally, while students were asked in the focus group interviews to discuss their experiences of both skills of venepuncture and PIVC when speaking about their skill acquisition in clinical practice they focused on the skill of PIVC. This can be considered a finding in itself, that students found this skill the most challenging to access and to learn in clinical practice.

Discussion

This is the first qualitative study to explore students' experience of venepuncture and PIVC education since it was introduced into the undergraduate nursing curriculum in Ireland. The findings in this study illuminated factors and educational strategies that can hinder and help students to effectively learn the skills of PIVC and venepuncture. For student learning and development, feedback to help enhance performance is integral.¹⁹ Students reported the type of supervision or facilitator helped them in the clinical environment. Specifically, when facilitators had patience, time, and the ability to teach. This is not a new finding, Günay and Kılınç reported that students wanted facilitators or supervisors who were present and to carry out the skills together.²⁰ With students reluctant to ask questions when facilitators were stern or distant. In our findings, students appear to initially want a very hands-on experience and for facilitators to be present and to talk through the process. However, students also want to have the independence and time to complete the steps themselves. A barrier to this independence included some facilitators not scaffolding students and allowing for their training to advance alongside them by being overprotective. Scaffolding where the teacher gradually withdraws support as the student gains competency is considered to be a usual teaching strategy in clinical teaching and learning.²¹

The transfer of knowledge learnt from the educational setting to the clinical environment is not automatic, students’ interactions with others is what influences their development.¹¹ This study was guided by sociocultural learning theory and its assumptions are noted within the study. Learning is developed through social interaction, and different social conditions in different settings play a role in the learner’s development.¹⁰ This is reflective in the findings of this study, students learning of the skill was very dependent on who supervised them and where they were placed for clinical placement. Students reported that some registered nurses were unwilling to carry out the skill hence they had missed learning opportunities and experienced large gaps between the number of procedures. It was also reported by students that the procedural approach varied depending on the clinical supervisor or educational facilitator. To address the insufficient supervision that students occasionally encountered, they themselves made a suggestion to lessen the amount of teaching that registered nurses must do in their designated clinical practice. This included a clinical tutor or designated facilitator, to supervise students, provide feedback and evaluate their competency. This would provide continuation of learning from the educational setting to the clinical setting. The introduction of intravenous teams into Irish hospitals²² could be a welcome clinical placement for students to achieve competency and sign off more efficiently, combining both specialised placements and clinical tutors. This recommendation of a clinical tutor was suggested in 2013, as Houghton et al. noted that a clinical tutor may help keep students participating in opportunities for learning.¹²

Students in our study discovered that self-evaluating video performance in addition to receiving feedback from educators after the OSCE would be a helpful method for practice and assessment when it came to feedback in the simulated environment. These two teaching strategies being appropriate for student learning and assessment are also evident in the literature. Lewis et al. reports that students were satisfied with video assessment of a clinical skill and that it was useful.¹⁹ Also, a systematic review reported that the OSCE is a credible assessment method in evaluating clinical competency of undergraduate students with students and faculty reporting it as a fair, valid and reliable approach.²³ The addition of an OSCE to evaluate students was an assessment approach highly valued by the students. One rationale for why students valued the OSCE assessment may be because they received immediate feedback from educators after. In a 2014 study, Rush et al. changed the way students were assessed: they were no longer given feedback on their OSCE several weeks following the exam, but instead received feedback immediately.²⁴ The assessment with immediate feedback was evaluated positively by students and impacted their learning and confidence positively.²⁴ Our study supports that incorporating technology to encourage and manage self-directed practice and including an OSCE to evaluate students’ performance in the skill are pedagogical approaches that should be incorporated into the standard programme for PIVC training.

Our study reveals that students report that repeat practice in both the clinical and simulated environment helped develop their confidence and self-efficacy. This is an expected finding as a mixed-methods study on the concerns of nursing students on their clinical experiences identified that clinical experience heightened students’ confidence in skill performance and behaviours.²⁵ In addition, a qualitative study on the topic of interest by Ravik and Bjørk states that the clinical environment provides students with the complexity and realism of the skill.²⁶ However, in this presented study what was particularly helpful was practice in the simulated environment, as this enabled students to have the confidence to put their hands up and request to perform the skills on patients. Repetitive practice in the simulated environment helps to reduce students’ anxiety which can be barrier to performing skills.¹² Therefore, simulated practice that increases student confidence is found to be useful in learning the technique and in teaching these skills. Findings from this study showed that simulation helped students to become familiar with the step-by-step process and equipment, so that when they observed the procedure in practice they were aware of the process. This pre-rehearsal and procedural learning align well to Benner’s theory where the novice relies on step-by-step learning.²⁷ It also incorporates the development of the student’s metacognition where the student can mentally rehearse the procedure prior to undertaking the learning in practice thus allowing them to take ownership of their learning.²⁸

Having opportunities to practice skills was a recurrent theme in our study. This opportunity to practice can enable students however on the contrary lack of opportunities hinder students performing clinical skills. This finding is supported in other studies^12,29 and in turn influences the students transition to independent clinical practice in relation to these invasive procedures. Our study demonstrates that students want more structured, organised and supported practice opportunities in both simulated and clinical settings. An ad hoc and discovery learning approach was illuminated by the experiences students recounted. Students were required to be self-motivated, to find learning opportunities and to ask to be taught. Sometimes they could not participate in opportunities as they had other duties to perform and learn. This approach is not sustainable, as students need many opportunities to practice their skills.¹¹ One solution may be the recommendations of students, to provide regular, specialised placements. Students expressed their wish to have regular placements such as a day or few hours every week in an area where opportunities are aplenty. This would provide students with ongoing, repetitive practice attempts and would remove the luck they reported with obtaining opportunities. In addition to the specialised placements students also recommend that their training for venepuncture and PIVC insertion is commenced earlier in their programme when they are supernumerary. Students in our study reported having to juggle competencies. These competing learning priorities are also reported in relation to challenges professionals faced in relation to PIVC. These included working conditions such as time constraints when they had a number of tasks to perform at the same time.³⁰ Students learning these skills whilst in supernumerary placements may allow them more flexibility to follow opportunities.

We can ascertain from our study that students are not satisfied with the amount of practice they are receiving in relation to these skills. Similarly, a mixed-methods study reported that students identified the need for ongoing practice with their skills.²⁵ We propose that students receive refresher training on these skills. Although repeating simulation training requires more resources, it may be feasible to develop or design better simulations resulting in more effective simulations.¹⁴ Nurse educators can help prepare students for clinical practice by implementing effective simulation.²⁰ As previously noted, the use of video technology may be a viable solution to implement more effective simulations and reduce the number of simulations required. However, another element of effective simulation may be the realism. Students in our study reported wanting better, more realistic simulations. With respect to the comments on the simulators used and realism there is an opportunity to develop higher quality simulators that have less visible veins. Additionally, using simulators without visible veins would likely motivate educators to introduce vein locating technology such as near-infrared and ultrasound in the curriculum. Students also noted that the complexity of the simulation could develop throughout their training. As per students in a focus group by Hustad et al. the more realistic the simulated scenario the easier they found it to transfer the learning from the simulation to clinical setting.¹⁴ More research is needed to ascertain the most effective approach for teaching students these invasive skills.

We argue that the findings of this focus group study demonstrates that more research is needed to evaluate standardised approaches used with the training of these skills. We suggest that clinical outcomes could include insertion success, in the case of PIVC, the dwell time and a classification of competency to ensure highly skilled practitioners are developed. Although our findings regarding what hindered and helped students learn these skills are reflective of the wider literature, students within this focus groups were quite solution-focused and vocal on what they believed would help future students learn these skills more effectively. For acquiring clinical skills, providing sufficient resources, appropriate guidance and time for practice are necessary to bridge the theory practice gap and integrate theory into practice.³¹ We propose an adaption to the teaching model developed by Ahlin et al.¹ We envisage that this adaption, encompassing additional pedagogical approaches, will further improve students' educational outcomes in relation to these skills. The key stages outlined in this model address the factors that inhibit learning and encompass the suggestions made by students to improve the PIVC and venepuncture educational programme. To reiterate, these suggestions for improvements include, having a clinical tutor bridging the students' learning from the educational setting to the clinical environment where they can follow students throughout their clinical practice and determine competency. This also reduces the likelihood of students learning different techniques and habits with different supervisors. Another solution is to provide specialised placements to ensure students have sufficient opportunities to obtain and maintain their competencies. We recommend a need for educational and organisational changes and to develop an even more standardised approach for training. We present in Fig. 1, a proposal of what this approach may consist of.

Figure 1.

Recommended standardised approach to training venepuncture and PIVC insertion.

Strengths and limitations

This study was guided by Lincoln and Guba’s criteria for trustworthiness to achieve rigor within our qualitative research. Using this framework, each of the following criteria must be met for a trustworthy study, these include credibility, transferability, dependability, and confirmability.¹⁸ Credibility was ensured by having three researchers moderate each focus group and written notes were taken alongside audio recordings. The audio recordings were transcribed by the primary researcher however these were second checked with other moderators to ensure accurate transcriptions. Finally, the codes derived by the primary researcher and emergent themes were also reviewed and accepted by the co-moderators. Each of these steps were performed to ensure an accurate portrayal of the phenomenon was provided.³² These steps also assisted in meeting with the confirmability criterion. To ensure confirmability, researchers need to take measures to show that the findings originate from the data itself rather than being influenced by their own biases.³² Transferability has been addressed in the write-up of this paper as we believe we provide adequate information to the reader on the study’s context e.g., number of participants, the current curriculum in relation to the Irish context, participant exemplars and data collection methods. Addressing this criterion is important so that readers, such as nurse educators in higher education institutes or facilitators and management in hospital settings, can decipher if these findings can be reasonably applied to other settings.³² Achieving the dependability criterion is challenging, but researchers should aim to make it possible for a future researcher to replicate the study.³² A detailed description of the data collection and analysis has been provided. Researcher reflexivity was maintained through the detailed record-keeping of the entire research process.

There are some limitations that need to be considered. The sample size is relatively small, however, there was consistency in the findings within each separate focus group. The attrition of students who initially consented to participate in the study but ultimately did not attend the scheduled focus group sessions may be attributed to their clinical responsibilities during their internships, as the findings within this study suggest that students had to juggle competencies. Also, this study was carried out in one university, and the data was collected at one time point therefore, it raises the issue of generalisability and may not reflect the experiences of other nursing schools and students from previous academic years.

Conclusion

The objective of nursing education is to develop confident and competent nurses.²⁵ We agree, and our goal is to ensure students are performing clinical skills at a competent level and that this learning is transferred from the simulation setting to the clinical environment, so we contribute to the provision of safe care. Ideally, for nursing students they expect the clinical setting to be an effective learning environment with sufficient resources, good clinical teachers, and opportunities to learn and incorporate theory into practice. However, as we and others have identified, this is not the reality.³³ As educators, we need to be more adaptable, given that educational approaches need to respond to the concerns of students.²⁵ By undertaking research and evaluations, it can help guide and develop innovative educational approaches. Positive findings from our study report the usefulness of both simulated practice and opportunities to practice in the clinical environment and the value of immediate feedback. Combined with characteristics of good facilitators, who scaffold student learning and facilitate opportunities to practice. Alternatively, our study also reports on areas which need improvement, such as the lack of simulated practices and clinical opportunities, poor supervision from facilitators who lack the characteristics of a good teacher and the ad hoc nature of learning opportunities. Findings of this study support an adapted version of Ahlin et al.'s teaching model¹ which would provide more innovative pedagogical approaches to the programme and ensure competencies for all nursing students. Finally, this paper may improve the recent introduction of venepuncture and PIVC to all higher education institutes in Ireland. It may assist nurse educators in higher education institutes and facilitators and management in hospital settings improve the educational experience of students in relation to these invasive clinical skills.

Funding

This study was carried out as part of a University of Galway PhD integration fund which funded a full time PhD student.