1. Earhart, Ann MSN, RN, ACNS-BC, CRNI(R)
  2. INS President, 2014-2015

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The following speech was delivered at the INS Annual Convention and Industrial Exhibition in Phoenix, Arizona, on May 8, 2014.

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Good morning. I am honored, privileged, and humbled to stand before you. I am challenged and encouraged by leaders before me who have and continue to create a legacy, who inspire and LEAD us, and motivate all to line up to infuse excellence. As the new president of your Infusion Nurses Society, I would like to introduce my theme of "Infuse Knowledge, Confidence, and Competence."


The need for care of the acutely ill and injured was first written about more than 2000 years ago when a Good Samaritan saved the life of a wounded traveler. The first notes of infusion therapy appeared in 1644 with a mention of a new method of introducing medicine into the body by injecting the medicine directly into the veins. The first hospital in the United States was organized in Philadelphia in 1751. The duties of the nurses included monitoring IV solutions so the bottle would not run dry, monitoring blood transfusions, cleaning IV tubing, and hand-sharpening needles. Nurses had limited education regarding IV therapy, receiving instruction on two known risks of IV therapy. The two risks included the metal band loosening on the glass IV bottle and the bottle falling and breaking, and the bottle running empty during infusion of the fluid, both putting the patient at risk for an air embolism. During the 18th century, hospitals had no definable standards for infusion therapy or nurses educated to provide infusion care. Knowledge was passed nurse to nurse.


INS conducted a 2013 survey of its 7020 members to identify patient safety issues, placement practices, and risks associated with infusion therapy. Results from the survey provided information on knowledge, assessment, monitoring, education, and training. Knowledge varied in aseptic technique, understanding of veins, and practice. Of 345 respondents, 57% reported not being taught how to insert a short peripheral catheter (SPC) while in nursing school. Once the nurse graduated and was hired for the first position, 71% of nurses reported receiving "on-the-job training," and 11% reported the "see one, do one" approach for orientation on how to place an SPC.


In 2013, Woody and Davis surveyed nursing schools to assess the type and extent of infusion therapy provided to nursing students. Schools taught IV medication administration, identification of blood transfusion therapy, and how to remove an IV. Some schools did not teach troubleshooting IV problems (13%), administration of blood components (11%), or starting IVs (39%).


Nursing programs across the country vary on course curriculum content for infusion therapy. All programs are encouraged to have theoretical and practical experience, but many site rotations no longer allow student nurses to start IVs or participate in line care. The reason? Patient experience and reimbursement. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) accounts for 35% of the value-based purchasing score, which has a direct impact on the hospital reimbursement from the Centers for Medicare and Medicaid Services. The HCAHPS survey identifies details on specific services, such as patient satisfaction and IV skills. Patient satisfaction scores are directly tied to reimbursement.


How could this affect practicing nurses? Could lack of knowledge lead to lack of confidence and competence? Every shift, every day, nurses make decisions regarding infusion therapy because 90% to 95% of patients have some form of IV access. In 2009, Johansson, Pilhammar, and Willman conducted a study asking nurses about the clinical reasoning behind decisions made to care for patients with IV catheters. The nurses talked about the patient situation, the work environment, and their knowledge and experience with IV maintenance and complication management. The nurses felt caring for patients with IV access was a balancing act between minimizing patient discomfort and preventing complications. The nurses' approaches differed depending on the patient and their knowledge, confidence, and experience with infusion therapy.


What about the patient? The patient tells us the worst part of being sick or having to be in the hospital is the IV. Dale and Howanitz monitored patient satisfaction in 34 096 patients receiving a needlestick and found patients highly satisfied when clinicians were nice. Robinson-Reilly, Paliadelis, and Cruickshank explored the experience of venous access in the oncology setting. Fifteen oncology patients were asked what it was like to have IV access obtained when their treatment depended on it. From the patient perspective:


* The experience is scary but a necessary evil.


* I surrender my trust to be helped.


* I fear a bad experience knowing it will happen again.


* It is the only thing I dread about coming to the hospital.



As nursing leaders in the specialty field of infusion, we are challenged at all levels regarding infusion knowledge, confidence, and competence. The Bureau of Labor Statistics reports 2.7 million registered nurse positions in 2012. Unfortunately, less than 1% of the nurses in the United States currently hold the CRNI(R) certification. Although, as I mentioned earlier, 90% to 95% of patients have some sort of infusion therapy, most nurses do not see themselves as "an IV nurse."


The Institute of Medicine (IOM) advises on strategies to improve health; one of their recommendations in 2010 was for nurses to practice to the full extent of their education and training. This directive provides guidance for all nurses, but more important, for our infusion specialty. As an infusion specialty organization, we provide standards of practice for infusion therapy. The standards are rated according to the strength of evidence, giving the clinician confidence in the evidence supporting their practice. Unfortunately, literature is lacking in many areas of infusion therapy. As leaders in infusion therapy, we need to share our practice and outcomes. This is what I have seen all week with the presenters, oral abstracts, and poster presentations. The next step is publication.


Most recently, the state of Arizona's Scope of Practice Committee was reviewing the scope of practice for nurses placing central lines. Currently, qualified, skilled, competent nurses are placing central lines, but the Scope of Practice Committee was going to retire and stop that practice because no literature supported RNs placing central lines. Current published literature supports advanced practice nurses placing central lines, while a survey of INS members in 2013 identified multiple teams in multiple states with successful nursing line teams in practice from 1 to more than 7 years. These nurses have been identified, are now working on publishing their outcomes, and are coming together to write a position paper on the role of the RN in placing central lines. I encourage all of you to consider publishing your research in our own highly respected Journal of Infusion Nursing.


Confidence will grow as knowledge increases. As I said earlier, self-assurance increases with the strength of evidence. Levels of evidence are based on the strength of evidence, which is based on opinion, process improvement, evidence-based practice, and the type of research.


Knowledge and confidence increase with competency. Competency is the ability to perform the technical, knowledge-based, critical thinking, and interpersonal skills required to do a job. Competency is validated by the process by which it is verified. Think again about performing to the full extent of our education. As infusion nurses, what do we know to be basic nursing knowledge and skill of infusion acquired in nursing school? How is competency validated with infusion therapy? Competency requires an integration of population, culture, safety, and scope of practice. Across the country, leaders look to the IOM not only for nurses to work to the full extent of their education but also for multidisciplinary teams to provide care to patients. As infusion nurses, it is our role and challenge to provide knowledge to these leaders and teams. We need to assist leaders in identifying the importance of the infusion nurse's role in multidisciplinary teams and to provide knowledge on the core competencies of infusion nursing.


To conclude, let's start with our own profession to increase the nurses' knowledge of infusion therapy in caring for a patient. If a nurse administers a medication with a syringe through tissue, muscle, vein, or artery, she or he isn't an IV nurse, that health care professional is an infusion nurse.