The interviews lasted an average of 35 minutes, providing rich data regarding the participants' experiences about decisions on PIVC care to prevent the adverse events. Fourteen hospital ward nurses with a range of ages and clinical experience participated in the study. One nurse declined to participate in the study and two did not attend the scheduled interview. No reasons were given for non-participation. Table 1 presents the characteristics of the participants.
1) The ‘fog’ of decision-making in PIVC: Whilst nurses feel responsible for PIVC care, they do not however see themselves as the responsible decision-maker about PIVC insertion and removal. Such decisions are apportioned to physicians. But such demarcations of responsibility are not however clear cut, with frank ambiguities instead about some clinical decisions. Equally lacking is a jointly agreed upon framework of reference that explicitly allocates roles, professionals, and situations about PIVC care:
‘I think it's the nurse's responsibility, the decision to insert a catheter, it's the nurse's as well. Well, or the doctor, because sometimes you cannot insert a PIVC, and the doctor decides to put in a central intravenous catheter.’ Nurse, age 45, surgical ward.
Such ambiguity is reinforced by servile relations between nurses and medical professionals, particularly in cases of urgency, and implicit delegation of tasks. This delegation appears to take place (or is not resented) only when nurses and physicians’ decisions are aligned:
‘If it is a vital issue for the patient, we (nurses) can insert a vascular access without the authorization of the doctor. If you don't [insert the vascular access], they [doctors] ask you why you haven't inserted it. Yet sometimes when you do it, [insert the vascular access], they (doctors) tell you that you've exceeded your competencies.’ Nurse, age 41, oncology ward.
2) The ‘taskification’ of PIVC care: Decisions about care, maintenance, management, and removal of PIVCs were highly fragmented and conducted as tasks rather than embedded within a nursing care process, resulting in a disjointed and often inefficient experience to reduce potentially infectious complications for patients. This 'taskification' may be defined as deficient knowledge of professional practices related to PIVC care, or dissonance between the perception of PIVC care offered and care effectively provided, where tasks rather than quality and safety healthcare are prioritised. One participant described this piecemeal approach to care:
‘We (nurses) work routinely, performing tasks with automatic habits acquired from the ward. You observe the PIVC, disinfect it, you change the dressing and then you leave’. Nurse, age 45, surgical ward.
‘We (nurses) have training. However, we lack an integral view about the management of care. Sometimes, even if you see that the PIVC is in perfect condition, if the patient says that it is hurting, then you should remove the catheter. Some kind of overall awareness is the key to better care.’ Nurse, age 43, surgical ward.
This focus on tasks rather than quality is exemplified by the perspectives of participants about the maintenance of PIVCs. Rather than another essential and valuable component of excellent PIVC care, nurses seemed only concerned about carrying it out appropriately to avoid wasting their time reinserting any catheters gone wrong, without a likely reflection on the patient experience or, even worse, implications towards healthcare-associated infections:
‘...the interest in maintenance is quite low, what interests you as a nurse is that it takes you time not to do the technique (task) again, but not so much on the subject of infections...’. Nurse, age 44, palliative care ward.
‘Yes, there are failures, but not everyone fails in the same place. In maintenance people are less careful. People might fail to see a dirty PIVC or get wet because the patient has showered, and they don't change it...’ Nurse, age 34, traumatology ward.
Paradoxically, the interest in avoiding any waste of nursing time and resources was neutralised by decisions (or at least, aspirations) to ensure that all patients always had PIVCs, if possible. This blanket approach would appear to fit well with the taskification embedded in the continuum of care, as well as removing engagement for potential disputes with other professionals about the need (or lack of thereof) for PIVCs, an area fraught with uncertainty as previously highlighted:
‘I don't want a patient without PIVC, I don't want to, I don't feel safe. I have had some scares and if I can all patients would be carriers of a PIVC. If it were up to me, I would put everyone on a PIVC from the first day to the last day of hospital admission.’ Nurse, age 23, long-stay unit.
3) PIVC care is accepted to be suboptimal, yet irrelevant: The reduction of PIVC care to an array of tasks surrounded by uncertainty resulting in suboptimal care for patients was acknowledged by the nurses, who tacitly accepted such status quo. Underpinning the inaction was the detachment from hospital policies and best practices, strengthened by their perceived flaws and ambiguity:
‘The protocol is outdated and obsolete. I don't think anyone has read it. For example, it recommends routinely changing PIVCs every 96 hours...’ Nurse, age 32, medical ward.
These views about clinical practice guidelines as outdated and therefore irrelevant had further unwanted consequences. Often, the disinterest about the policies and the lack of motivation among nurses to adhere and uphold the mandates included in the protocols turned to active resistance against any changes in practice, and even anarchic behaviours:
‘Yes, there is a hospital policy, but it's kept in a drawer. No one looks at it, no one teaches about it, but we are expected to know that it is the standard of practice. But people do what they want.’ Nurse, age 33, medical ward.
‘Perhaps if the hospital establishes a more accessible hospital policy, with clear and precise recommendations for the PIVC care.’ Nurse, age 25, neurorehabilitation ward.
In addition, PIVCs were seen as having a low impact on patient safety during the management of intravenous therapy:
‘In our ward we have a register of vascular access devices, where the day of insertion and maintenance is recorded. However, I don't do it, I go to the patient and if I have to change the dressing, I do it and that' s it.’ Nurse, age 41, oncology ward.
The haphazard approach to patient safety is reflected in some of the behaviours reported by the nurses, who for example recognise that covering the PIVC insertion site can lead to serious complications for patients, yet they frequently engage in that very same practice:
‘About the issue of covering the catheter insertion site, many colleagues cover the site when they insert or maintain the catheter. This situation threatens patient safety, but we don't care.’ Nurse, age 34, medical ward.
A further dimension of this apparent insensibility to patient safety is the avoidance of patient preferences within decisions included in PIVC care:
‘...It's a relatively simple technique (patient education), which we have very internalized, it seems easy. However, it is difficult to comply with during PIVC care’ Nurse, age 44, palliative care ward.
4) PIVC care gaps may reflect behavioural shortcomings, yet proposed solutions only involve education and training: Perhaps unsurprisingly, these failings are normalised as an inevitable consequence of structural deficits in education or training (‘Nurses base their practice on what they learned in university or on day-to-day experience. They do not keep up to date or ignore the evidence...’ Nurse, age 32, geriatric medicine ward), or capital and human resources:
‘Lack of time is a resource that hinders us to offer best care. This is nurses’ main complaint’ Nurse, age 29, geriatric medicine ward.
‘Sometimes you find patients with a true PIVC ‘disaster’, perhaps due to lack of time or workload. Sometimes you don't devote as much time as you would like to PIVC care’. Nurse, age 45, surgical ward.
The solutions offered by the participants were aligned with the gaps suggested, with ad hoc training (‘Above all, we need training to nurses on the ward, even if they just were mini sessions. Ideally, they would be face-to-face or even online courses explaining how to manage and care for PIVCs.’ Nurse, age 32, geriatric medicine ward) or specialised posts with leadership and expertise to mitigate and bring poor PIVC care to the fore:
‘Role models are necessary to provide support, and make explicit the impact of professionals on PIVC, on the importance of optimal care management.’ Nurse, age 41, oncology ward.