Introduction

Intravenous therapy (IV) is an important part of the treatment of many hospitalized patients. IV solutions are medications. Administration of medications is part of the controlled acts authorized to nursing. It is the nurse’s responsibility to ensure that the patient receives the ordered solution and additives at the ordered rate. The extravasation of any IV fluid can cause serious permanent harm. Hourly checks are to identify extravasation early (Hoste et al., 2014).

Intravenous solutions often have similar packaging; therefore, great care is required in selecting the right intravenous solution. Particular care is required if the patient has more than one IV line or pump to ensure that lines are not mixed up. When an IV bag is changed or if medications are being added to one of the lines, the line must be tracked right back to the solution container to verify that the additive is being added to the correct line (Palomo et al., 2015).

Intravenous infiltration can lead to problems like discomfort, the need for reinsertion of the intravenous catheters which associated with pain and anxiety from repetitive failed (PIV ) insertion attempts, or compartment syndrome, which can increase not only the period of hospitalization and medical expenses for treatment but also permanent damage in children. These problems can lead to prolonged hospitalization, increased medical costs, higher mortality, and greater morbidity
(Flippo & Lee, 2011).

Nurses play a vital role in the administration of intravenous therapy. Most of the interventions and prevention strategies such as insertion, monitoring and assessing peripheral venous catheter (PVC) sites are part of routine nursing care. Nurses should have accurate knowledge of the preparation and administration of the IV Infusion and IV device. In addition, they should also know about the prevention, treatment, and management of local and systematic complications supported by dynamic evidence‐based practice guidelines. One of the major risks for phlebitis incidence is due to the placement and maintenance of PVC by insufficiently trained staff
(Mohammed & Ahmed, 2017).

Significance of the study

Peripheral intravenous (PIV) therapy is one of the most frequently used therapeutic interventions in the acute care setting. In the acute care pediatric setting, starting and monitoring intravenous (IV) therapy is challenging and poses a significant risk to small infants and children (De Lima Jacinto, et al., 2011), (Walsh &Schad, 2012).

A vein cannula has direct access to the patient vascular system and is a potential route for micro-organisms to enter bypassing the skin and in connection with drugs and /or fluids given. Despite this factual information, Studies indicated that nurses do not regularly assess the peripheral intravenous cannula and are frequently unaware of complications (Zhang et al, 2016). Peripheral intravascular (PIV) complications were reported at rates as high As 28% in children compared to 8.5% in adults. Furthermore, infants and children pose challenges to optimal PIV management because of their limited communication abilities, unpredictable behavior and activity levels, and small vessel sizes (Flippo & Lee, 2011)

Children are particularly vulnerable to these PIV-induced complications. Several studies have suggested that a dedicated IV therapy team may reduce catheter-related complications by standardizing catheter insertion technique, inspecting catheter sites daily, and rotating catheter sites within 72 hours of placement (CDC 2013).

Aim of the study

This study aimed to

Assess pediatric nurses' performance regarding intravenous therapy at Minia University Hospital and Minia General Hospital.

Research questions

• What is the nurses' performance as regards insertion, maintenance, and removal of intravenous line to children in Minia university hospital and general hospital? 
• What are the differences between pediatric nurses' performance at Minia University Hospital and Minia General Hospital?

Research Design

The descriptive study design was used for this study

Setting:

This study was conducted in pediatric and emergency departments at Minia University for Pediatrics and Obstetrics Hospital and Minia General Hospital affiliated to the Ministry of health and population.

Subjects

A convenient sample consisting of 58 nurses (29 of nurses were from the pediatric and emergency departments in Minia University for Pediatrics and Obstetrics Hospital and 29 of them were from the pediatric and emergency departments at Minia General Hospital and over six months.

Data Collection Tools

Three tools were included for data collection

Tool I

A structured interview questionnaire sheet in the Arabic language to gather data of the studied sample and designed by the investigator after an extensive review of related literature and the consultation of the experts in the field of pediatrics and pediatric nursing.

It consisted of two parts

• Part 1: Personal data of nurses: it contained 4 items of selected personal items about nurses as age, qualifications, years of experience, and previous training courses.
• Part 2: Knowledge assessment sheet: it contained 30 questions. Questions in form of close-ended to assess nurse's knowledge about nursing care as regards insertion, maintenance, and removal of the intravenous line to children and the different intravenous therapy complication which might occur to children.

Scoring system of nurses' knowledge:

Scoring system for knowledge of the studied nurses was calculated as the following:

All knowledge variables were weighted as (2) for the complete correct answer and (1) for an incomplete correct answer and, (0) for choosing don’t know or incorrect answer. The total score of nurses’ knowledge was 60.

The nurses’ total knowledge score was classified as the following:

• Very good: (≥75%)
• Good: (50 - < 75%)
• Poor: (<50%).

Tool II

Observational checklist sheet was developed by the researcher that was adopted from Terese and Marlene,(2010), Patricia and Anne,(2008) to assess the nurses' practices for intravenous therapy it contained 12 procedures (149 steps) as infection control (10 steps), hand washing (19 steps), wear personal protective gloves (32 steps), insertion I.V cannulation (16 steps), removal I.V cannulation (9 steps), I.V fluid preparation (9 steps), administration of I.V fluid drug infusions  (7 steps), administration of blood products  (7 steps), flushing of PIVC's  (9 steps), IV fluid considerations via peripheral IV line (12 steps), change of PIVC dressing and securing of cannula (11 steps), and management of I.V therapy complications (8 steps).

Scoring system of nurses' practice

Scoring system for practicing nursing care was calculated as the following:

Performances step was weighted as 0 for not done, 1 for incomplete done, and 2 for completely done. The total score of nurses’ practice was 298.

The nurses’ total practice score was classified as:

• Complete: (≥75%)
• Incomplete: (50- < 75%)
• Not done: (<50%).

Tool IIІ

Nurses' attitudes regarding intravenous therapy: it contained 10 items by using the Likert scale includes three points as agree, uncertain, and disagree. Their attitude as the first line of nursing management for intravenous therapy, wear gloves is the first step in the insertion of the cannula, if intravenous cannula inserted incorrectly, removed it and try again,  etc.

Scoring system of nurses' attitude

Scoring system Nurses' attitude regarding intravenous therapy was calculated as the following:

All attitude variables were weighted as (0) score for disagree, (1) score for uncertain, and (2) score for agreeing. The total score of the nurses’ attitude was 20.

The nurses’ total attitude score was classified as the following:

• Positive: > 60%
• Negative: ≤ 60%

Validity and Reliability

The content validity of the data collection tool was examined by five experts who were affiliated to the Faculty of Nursing, Minia, and Assuit University at the Pediatric Nursing Department. The tool was examined for content coverage, clarity, relevance, applicability, wording, length, format, and overall appearance. Based on experts` comments and recommendations; minor modifications had been made such as rephrasing and rearrangements of some sentences.

Internal consistency was measured to identify the extent to which the items of tools measure the same concept and correlated with each other.  Internal consistency estimate reliability by grouping questions in the questionnaire that measure the same concept. Cronbach’s alpha for reliability testing internal consistency was performed for each section of the structured interview questionnaire and the results were 0.750, 985, and 0.70 for nurses' knowledge, practice, and attitude regarding intravenous therapy respectively.

Pilot study

Random selection of 10% (5 nurses) of the total number of nurses to investigate and ensure the feasibility, objectivity, applicability, clarity, adequacy, and to determine possible problems in the methodological approach or instrument. The results of the pilot study were used to test the proposed statistical and data analysis methods. The tools were completed without difficulty, adding support to the validity of the instrument. Little modification was done e.g. rephrasing and rearrangements of some sentences. The time required for completion of the interview questionnaire didn’t exceed 30 minutes. Nurses involved in the pilot study were included in the main study sample. Pilot testing helped the investigator plan for data collection.

Ethical consideration

For ethical consideration, and approval was obtained from the faculty of the nursing ethical committee and official permission was obtained from the director of the Minia University for Pediatrics and Obstetrics Hospital and Minia General Hospital, and permission from the head of pediatric and emergency departments after explaining the aim and nature of the study. Nurses’ were interviewed on an individual basis to explain the nature and purpose of the study.

Oral informed consent was obtained by the researcher from the nurses before data collection after full explanation for the aim of the study, benefits, and rights for privacy. They also informed that the information obtained will be confidential and will be used be only for the study. Each assessment sheet was coded and nurses’ names didn’t appear on the sheets for anonymity and confidentiality.

Data Collection Procedure

Administrative approval was obtained from the ethics committee, faculty of nursing, Minia University. Official permission was obtained from the concerned hospital authorities to conduct the study after explaining the aim and nature of the study. The researcher was interviewing with nurses. At that time, the purpose and nature of the study were explained by the researcher through direct personal communication before starting to participate in the study and then the data collection.

Nurses' knowledge, practice, and attitude regarding intravenous therapy were assessed by using the structured interview questionnaire and observational checklist. The interview took place in the pediatric and emergency departments at Minia University for Pediatrics and Obstetrics Hospital and Minia General Hospital. The interview conducted for all nurses to fill the personal data and to assess their knowledge regarding intravenous therapy by using a structured interview questionnaire. The time taken to conduct the structured interview questionnaire for each nurse was ranged from 20 to 30 minutes and nurses' practice done by the observational checklist and consumed 30- 45 minutes at a rate of 3 to 5 nurses/ week. Data collection was conducted over six months extending from May 2019 up to October 2019.

Statistical analysis

The collected data were tabulated & statistically analyzed using the software program and statistical package for social science (IBM SPSS 25.0) to evaluate nurses under study. The statistical analysis included percentage (%), mean, stander deviation (SD) and Chi-square ( ).Chi-square ( ) was used to test the association between two qualitative variables. Fisher's exact test used to test the association between two qualitative variables and the sample size is small. Quantitative continuous data were compared by using a t-test in case of comparisons between the mean scores of the two groups. Graphs were done for data visualization using Microsoft Excel. The P-value of ≤ 0.05 indicates a significant result while P-value of > 0.05 indicates a non-significant result

Results

Table (1) Number and Percentage Distribution of The Studied Nurses According to Their socio-demographic data (n= 58).

Table (1) shows that 69.0 % of the studied nurses in MUH and 62.1% of them in MGH were married. Regarding the age group from 20 - < 30 the table shows that 55.2 %, 79.3% of nurses in MUH, and MGH with mean ± SD 25.4 ± 6.0 and 25.7 ± 5.3 years respectively.  As the educational level, 44.8% and 37.9% of the studied nurses in MUH and MGH are technical institute nurses. Less than half 41.4 % of nurses in MUH had experience from 5 < 10 years while 55.2% of them in MGH had experienced less than 5 years. In addition, 51.7% of nurses in MUH and 69.0% of them in MGH didn't attend previous training about intravenous therapy.

Table (2): Relation Between Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital (MGH) According to Their Total and Subtotal Knowledge Regarding Intravenous Therapy (n= 58).

 **Highly statistical significance differences

Table (2): shows that 51.7% of nurses in MUH and 24.1% of nurses in MGH nurses had poor general knowledge regarding intravenous therapy, 34.5% of nurses in MUH and 17.2% of nurses in MGH nurses had poor knowledge about  how to prepare for cannulation, 62.1%  of nurses in MUH and 27.6% of nurses in MGH nurses  had poor knowledge related to cannulation, 37.9% of nurses in MUH and 20.7% of nurses in MGH nurses had poor knowledge about steps after cannulation and 65.5% of nurses in MUH and 37.9% of nurses in MGH nurses  poor in  how to prevent  complications of intravenous therapy with statistical significance differences P-value .05, .05, .025, .005, .036 respectively.

Figure (1):  Between the Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital (MGH) According to Their total Knowledge Regarding Intravenous Therapy (n= 58).

Figure (1): illustrates that 3.4% of nurses in MUH compared to 34.5% of them in MGH had poor knowledge regarding intravenous therapy with highly statistical significance differences P-value .006

Table (3): Relation Between Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital (MGH) According to Their Practice Regarding Correctly performance (n= 58).

* Statistically significance differences     **Highly statistical significance differences

Table (3) presents that, 10.3% of studied nurses in MUH and 27.6% of studied nurses in MGH applied infection control during I.V preparation. 10.3% of studied nurses in MUH and 10.3% of nurses in MGH wash hands before I.V preparation. 79.3%, 51.7% of studied nurses in MUH, and MGH applied PPE. 13.8%, 13.8% of studied nurses in MUH, and MGH applied I.V cannulation with statistically significant differences which P-value 0.015.

51.7%, 27.6% of studied nurses in MUH, and MGH administered I.V fluid correctly. 55.2% of studied nurses in MUH and 48.3% of nurses in MGH administered blood products correctly. 41.4%, 31.0% of studied nurses in MUH, and MGH flushed of PIVC's. 31.0% of studied nurses in MUH 24.1%  of nurses in MGH done completely fluid considerations via Peripheral IV line. 62.1%, 41.4% of studied nurses in MUH and MGH changed of PIVC dressing and securement of cannula correctly and 72.4% of studied nurses in MUH and 51.7% of nurses in MGH managed of I.V therapy complications

Figure (2): Comparison  Between the Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital (MGH) According to Their Total Practice Levels Regarding Intravenous Therapy (n= 58).

Figure (2): illustrates that 69.0% of nurses in MUH and 51.7% of them in MGH had incomplete practice regarding intravenous therapy with no statistical significance differences P-value .117

Table (4): Relation Between the Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital (MGH)According to Their Attitude Regarding Intravenous Therapy in (n= 58).

4- If you tried to enter the cannula and were not sure of the appropriate place, would you remove the catheter and try again?

5- After two failed attempts to enter IV, the best thing you can do is continue to try until you get the vein?

6- It is very important when securing the axis of the cannula on the skin to ensure that the tape does not cover the insertion site?

7- The most important step when stopping intravenous therapy is documenting the date and time and those professionals who removed cannula from the patient?

It is not necessary to wear gloves when stopping IV because there is no risk of exposure to blood or body fluids?

9- By maintaining sterilization, can acute IV complications be prevented?

10- The intravenous cannula must be removed according to the hospital's policy without regard to any patient-related reasons

* Statistically significance differences     **highly statistical significance differences 

Table (4): shows that, there were no statistically significant differences between nurses who are working in Minia University Hospital (MUH) and those who are working in Minia General Hospital (MGH) regarding their Attitude about Intravenous Therapy except statement about "not necessary to wear gloves in stops I.V therapy" about  75.9% of nurses who are working in Minia University Hospital (MUH) compared to 37.9% of them in Minia General Hospital (MGH) said that they agree about this statement with statistically significant differences which P-value .004

Figure (3): Comparison Between the Studied Nurses in Minia University Hospital (MUH) and Minia General Hospital (MGH) According to Their Total Attitude Levels Regarding Intravenous Therapy (n= 58).

Figure (3): illustrates that more than three quarters of nurses in Minia general hospital had positive attitude regarding intravenous therapy with statistically significant difference which P-value 0.04.

Table (5): Relation between Personal Data of The Studied Nurses with Their Total Knowledge Levels Regarding Intravenous Therapy in Minia University Hospital (MUH) and Minia General Hospital (MGH) (n= 58).

* Statistically significance differences     **Highly statistical significance differences

Table (5): presents that, 6.3% of nurses aged between 20 – 30 years in Minia University Hospital and 43.5% of nurses aged between 20 – 30 years in Minia General Hospital had very good knowledge regarding intravenous therapy with statistically significance differences which p – value .02 and 20.0% of bachelor nurses in Minia University Hospital and 62.5% of bachelor nurses in Minia General Hospital had very good knowledge regarding intravenous therapy with statistically significance differences which p – value .01. Also, 12.5% of nurses had experience less than 5 years in Minia University Hospital and 43.8% of nurses had experience less than 5 years in Minia General Hospital had very good knowledge regarding intravenous therapy with statistically significance differences which p – value .003.

Table (6):  Relation between Personal Data of The Studied Nurses with Their Total Practice Levels Regarding Intravenous Therapy in Minia University Hospital (MUH) and Minia General Hospital (MGH) (n= 58).

* Statistically significance differences     **Highly statistical significance differences 

Table (6): shows that 15.0% of married nurses in Minia University Hospital and 5.6% of married nurses in Minia General Hospital had complete practice regarding intravenous therapy with statistically significance differences which p – value .019 and 33.3% of nurses had experience 10 - < 15 years in Minia University Hospital and 14.3% of nurses had experience 10 - < 15 years in Minia General Hospital had complete practice regarding intravenous therapy with statistically significance differences which p – value .007.  Also, 20.0% of nurses in Minia University Hospital who attended previous training and 5.0% of nurses in Minia General Hospital who attended previous training had complete practice regarding intravenous therapy with statistically significance differences which p – value. 048.

Table (7) Relation between Personal Data of The Studied Nurses with Their Total Attitude Levels Regarding Intravenous Therapy in Minia University Hospital (MUH) and Minia General Hospital (MGH) (n= 58).

* Statistically significance differences     **Highly statistical significance differences

Table (7): presents that, 58.8% of nurses aged 20 – 30 years in Minia University Hospital and 81.8 % of them in Minia General Hospital had positive attitude regarding intravenous therapy with statistically significance differences which p – value .005 and 52.9% of health institute nurses in Minia University Hospital and 36.4% of them in Minia General Hospital had positive attitude regarding intravenous therapy with statistically significance differences which p – value .028.

Table (8): Correlation between selected personal Data of the Studied Nurses with Their Total Knowledge, Practice, Attitude Levels Regarding Intravenous Therapy in Minia University Hospital (MUH) and Minia General Hospital (MGH)

Table (8): presents that, fair positive association between nurses knowledge score with their educational level and practice level (r=.281; p – value 0.032 & r=.298; p – value 0.023 respectively), fair positive association between practice score with years of nurses experience (r= .386;p – value 0.003) and fair positive association between nurses attitude with their age and years of experience (r= .256;p – value 0.05, r= .253;p – value 0.05).