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Improving vascular access outcomes: attributes of AVF cannulation success

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Abstract and Figures

Background Arteriovenous fistulas (AVFs) are the preferred access for hemodialysis (HD) yet they are underutilized. Cannulation of the fistula is a procedure requiring significant skill development and refinement and if not done well can have negative consequences for patients. The nurses' approach, attitude and skill with cannulation impacts greatly on the patient experience. Complications from miscannulation or an inability to needle fistulas can result in the increased use of central venous catheters. Some nurses remain in a state of a ‘perpetual novice’ resulting in a viscous cycle of negative patient consequences (bruising, pain), further influencing patients' decisions not to pursue a fistula or abandon cannulation. Method This qualitative study used organizational development theory (appreciative inquiry) and research method to determine what attributes/activities contribute to successful cannulation. This can be applied to interventions to promote change and skill development in staff members who have not advanced their proficiency. Eighteen HD nurses who self-identified with performing successful cannulation participated in audio-recorded interviews. The recordings were transcribed verbatim. The data were analyzed using content analysis. Results Four common themes, including patient-centered care, teamwork, opportunity and skill and nurse self-awareness, represented successful fistula cannulation. Successful cannulation is more than a learned technique to correctly insert a needle, but rather represents contextual influences and interplay between the practice environment and personal attributes. Conclusions Practice changes based on these results may improve cannulation, decrease complications and result in better outcomes for patients. Efforts to nurture positive patient experiences around cannulation may influence patient decision-making regarding fistula use.
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ORIGINAL ARTICLE
Improving vascular access outcomes: attributes
of AVF cannulation success
Lori E. Harwood
1,2
, Barbara M. Wilson
1,2
and Abe Oudshoorn
2
1
Adam Linton Hemodialysis Unit, London Health Sciences Centre, London, ON, Canada and
2
Arthur Labatt
Family School of Nursing, Western University, London, ON, Canada
Correspondence to: Lori E. Harwood; E-mail: lori.harwood@lhsc.on.ca
Abstract
Background: Arteriovenous stulas (AVFs) are the preferred access for hemodialysis (HD) yet they are underutilized.
Cannulation of the stula is a procedure requiring signicant skill development and renement and if not done well can have
negative consequences for patients. The nurses approach, attitude and skill with cannulation impacts greatly on the patient
experience. Complications from miscannulation or an inability to needle stulas can result in the increased use of central
venous catheters. Some nurses remain in a state of a perpetual novice resulting in a viscous cycle of negative patient
consequences (bruising, pain), further inuencing patients decisions not to pursue a stula or abandon cannulation.
Method: This qualitative study used organizational development theory (appreciative inquiry) and research method to
determine what attributes/activities contribute to successful cannulation. This can be applied to interventions to promote
change and skill development in staff members who have not advanced their prociency. Eighteen HD nurses who self-
identied with performing successful cannulation participated in audio-recorded interviews. The recordings were transcribed
verbatim. The data were analyzed using content analysis.
Results: Four common themes, including patient-centered care, teamwork, opportunity and skill and nurse self-awareness,
represented successful stulacannulation. Successful cannulation is more than a learned technique to correctly insert a needle,
but rather represents contextual inuences and interplay between the practice environment and personal attributes.
Conclusions: Practice changes based on these results may improve cannulation, decrease complications and result in better
outcomes for patients. Efforts to nurture positive patient experiences around cannulation may inuence patient decision-
making regarding stula use.
Key words: AV stula, appreciative inquiry, emotional intelligence, hemodialysis
Introduction
The arteriovenous stula (AVF) is the preferred vascular access
for hemodialysis (HD) and is advocated in clinical practice guide-
lines [14]. Unfortunately, despite much attention and effort by
renal organizations to increase stula rates, many countries fail
to meet these evidence-based clinical goals [57]. The nurses ap-
proach, attitude and cannulation skill with AVFs have been
shown to have an i mpact on the patient experience with their
vascular access [812] and on AVF outcomes, in cluding compli-
cations following inltration(s) resulting in the need for a central
Received: October 1, 2015. Accepted: December 30, 2015
© The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA.
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Clinical Kidney Journal, 2016, 17
doi: 10.1093/ckj/sfv158
Original Article
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venous catheter (CVC) [13, 14]. This study addresses an important
question: How do you promote change within an HD unit to
develop skills for cannulation for optimal vascular access?
Previous research conducted by the authors of this article
have identied that some HD nurses are in a state of perpetual
novice and are unable to move on a continuum from novice to
expert with their cannulation skills for AVFs [11, 12]. This can re-
sult in cannulation misses and complications such as increased
bruising, pain, fear and, if this persists, a need for insertion or re-
liance on a CVC. A number of barriers exist in the clinical setting
preventing nurses from developing beyond the perpetual novice
with cannu lation, including the nurses emotional response,
avoidance, patients who refuse certain nurses for cannulatio n,
busy work environments, dialysis schedules and a lack of oppor-
tunity to gain experience with the skill [11]. Many patients do not
want an AVF if they have observed cannulation problems in their
peers such as pai n and bruising [10, 12] and delays in dialysis
treatments. This further contributes to the problem, creating a
vicious cycle: fewer AVFs, less opportunity for skill development,
more unsuccessful attem pts, fewer patients wanting AVFs and
so fo rth (see Figure 1). Improvi ng outcomes through behavior
change appears to be much more complex than providing nurs-
ing education on proper needle insertion technique and patient
education on the benets of an AVF.
We believe that change can occur and the cycle can be broken
by developing staff for more successful cannulation. Knowing
how HD n urses overcome t hese barriers and are succ essful is
helpful in identifying the appropriate interventions to develop
and maintaining skill competency in cannulation. This study
has wide relevance to nephrology, as the results may be applied
to interventions that can reduce AVF complication s for patients
(i.e. bruising, pain) and may assist many renal programs in their
efforts to increase AVF rates that meet established evidenced-
based practice guidelines to improve patient outcomes.
This study used the method of appreciative inquiry (AI). AI is
both an organizational development theory [15] and a research
methodology [16] whereby strengths are positively recognized
and become the foundation upon which changes are based [17,
18]. Essentially, the method uses positive exemplars to examine
what is working and then interventions are implemented based
on those attributes.
The purpose of this study was to nd attributes of excellence
in nursi ng practice around AVF cannulation that could then be
used to cultivate successful intervention s to promote changes
to patient vascular access outcomes, thus creating a more posi-
tive environment/culture for AVFs in the dialysis unit. A qualita-
tive approach will provide data that is rich in description and
context, leading to increased understanding.
Method
This study focused on the rst two steps of AI by asking the ques-
tions What works? and What might be? [16]. This study was ap-
proved by the local research ethics board, and written informed
consent was obtained by the research assistant. Purposeful sam-
pling was used whereby investigators sought parti cipants work-
ing in three HD units (one free-standing unit, two hospital-based)
who had positive experiences with cannulation. The investiga-
tors also sought help from the charge nurses to identify nurses
they felt had positive experiences with cannulation. Nurses
were interviewed once using an interview guide with semi-struc-
tured questions. The questions were framed in AI and based on
how these nurses overc ame barriers to cannulation identied
in our previous study that embodies the perpetual novice [12].
The interviews were audio recorded, transcribed verbatim
and analyzed for common themes using latent content analysis.
The sample size was guided by data saturation, at the point
where no further themes were arising [19]. Reliability and validity
were assessed for qualitative research by using the criteria of
credibility, transferability, dependability and conrmability [20].
The investigators analyzed the data separately and then met as
a group to discuss preliminary ndings and agree on common
themes.
Results
The nal sample included 18 nurses. All but one of the partici-
pants were female (one no answer) with a mean age of 49 years
and an average of 13 years employment in HD, with a mix of
part time and full time (see Table 1). Four common themes re-
presenting successful cannulation were present in the data: (i)
patient-centered care, (ii) opportunity and skills, (iii) teamwork
and (iv) nurse self-awareness (see Figure 2) . Common themes
with supporting quotes are described. Additional quotations
are shown in Table 2. Participants are assigned a number for clar-
ity of data presentation, included in parentheses after the quote.
Patient-centered care
Participants described nursing interventions for successful AVF
cannulation consistent with patient-cent ered care. To produce
Fig. 1. The perpetual novice [11].
Table 1. Demographics
Characteristic
Number of
patients (N = 18) Mean
Range
(years)
Sex
Male ––
Female 17 95%
No answer 1 5%
Age 49 years 3260
Years employed as a registered
nurse
23 years 837
Years employed in hemodialysis 13 years 128
Employed
Full time 10 56%
Part time 8 44%
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the best patient and nurse outcomes, patients were consistently
involved in the cannulation experience, for example . . . I think
just listening to our patients, making them a part of the situation.
As I said, it is their arm (4). Aspects of this theme commonly re-
ported by participants included acknowledgment of the emo-
tional reaction that AVF cannulation can evoke in the patient,
listening and hearing about the patients experience, education
and involving an d negotiating with patients regarding their AVF
care.
There were manyexamples of nurses communicating empathy
to the patient in regardstothe pain and anxiety that can occur with
cannulation. The nurses were attuned to the patients emotional
reactions, and if the nurse was nervous they did not want to trans-
fer this to the patient and increase their anxiety. Their ultimate
goal was to be successful with the cannulation, and if that meant
nding a different nurse to cannulate they did so.
Nurses engaged in patient education on the benets of AVFs
and self-care, anatomy of the stula, the cannulation procedure
and how to manage unfortunate complications such as bruising.
Successful cannulation involved . . . J ust preparing the patient
properly, making sure they know what I am doing, taking my
time and getting everything ready and cannulate them (7).
Below is an example of involving the patient in the assessment
Table 2. Patient exemplars supporting the themes
Theme Quotation
Patient-centered care I listen to the patient because they know sometimes which way the vessel, theyll say you know what, if you aim this
way... and then you start aiming the way they say, I think thats the keylistening to the patient if they are aware
of any helpful hints. It is their arm that is being cannulated, you have to use them as a guide if they can help you and
then you start making your own assessments too. So, between the two of you, if you are in on it together to get a better
outcome. (4)
I think we really should respect patient wishes, because when the patient is nervous, it doesnt help, it just makes it
worse. I think it is just best to get a different nurse that the patient feels comfortable. When the patient is comfortable
with the nurse, I think it works better. (14)
Opportunity and skill I just think that you keep doing it . . . and keep doing those assessments. When I help people or assist them, some
people they are nervous and they just kind of ram the needle in, I do try to encourage people to take their time, use
your ngers and really, really, really get to know that vessel and feel when it goes in. If it goes in and you dont get
blood back, pulling back and then feeling the pops in the vessel, you can get to know if you are very slow and
methodical. You get to know that, oh it was picked in the bottom of the vessel, or maybe in the side of that vessel
because you feel that release. Really, it is taking your time and using the senses that you have. (1)
Even if you are busy you still have to focus on your patient right? I try, you know, ignore everything that is going on
around me and just focus on the patient and stay focused. (5)
Teamwork Well, apparently I have been told that I am pretty good at getting some of the difcult patients. I dont hesitate to ask for
help. I dont hesitate to get in there and needle new stulas. Gotta give it a try. (3)
I am fairly candid with people. Ill say thats a very shallow stula, you will go through it and they will bleed.SoI
remind them when they are in the assessment when they are feeling the bruit and pulse, just feel it. I mean, if its just
under your ngers you do not have to go deep. Im candid to people, not in a mean way, in a supportive way. Ill say
thats a shallow stula, I mean you can say that, thats not interfering. But its all in how you do it. If you were nasty
but if you say hey, Ive done that person and it
s a shallow stula and I chart as such too. You dont want the patient
to go through unnecessary pain and being turned off. Because I know one of the patients wanted to go back to a
central line. (17)
Nurse self-awareness So Im going in and I cause a bruise or I cause a mess. I feel awful for one. But, yeah, if I am condent and I know that I
can, that it is really obvious what I did wrong or what went wrong, say the patient moved or jerked or I jerked or made
a bad call, um, I will attempt one more time. If I was really condent and then I had a problem, I would call somebody
in that I trust. Come and look at this, see what you think and I might do it again after we have assessed, or maybe Ill
go get the ultrasound. (8)
And then, see if they will let me put another needle in because, you know, I do have a personal rule that if I put two
needles in and I am not successful, then I pass it on to someone else. There is nothing wrong with admitting you cant
get it. I have seen nurses where they go, and you are just let someone else try.Its just, you are not having a good day
with that person, so I know always to back away. I have had no problems with that, nothing to do with my ego.
Because I have had patients say you are a great needler, can you come back? So, I know I do a good job, but some
days I cant hit the door. That big of a target and it just doesnt really matter so you just back away. (4)
Fig. 2. Themes for successful cannulation.
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and visualizing their stula below the skin with ultrasound in
order for them to understand why the nurses were cannulating
deep:
We do a lot of teaching, we use the ultrasound a lot and we show the
patient. See this deep on the ultrasound, that means, so your stula
is this deep and it is good here and then it has a narrowing here. We
show them, usually include them . . . (8).
The nurses sought out patients expertise regarding the factor(s)
that led to successful cannulation of their AVF in the past. This
was not the only way nurses gained knowledge of the access. Par-
ticipants also described efforts to review the health record and
often asked their p eers, who had previously been successful
with cannulation, for suggestions and/or advice.
Involvi ng patients in their care often resulted in negotiating
aspects of their care. The most commonly reported negotiation
was who would do the cannulation. Nurses reported there were
times patients requested specic nurses to cannulate. This was
based on patient concerns, which were acknowledged by nurses
to be real or perceived; some were based on past cannulations
and others not. At times, the nurse would discuss the issue with
the patient and negotiate care, while at other times, the nurse be-
lieved having someone else cannulate would put the patient more
at ease and diffuse the situation.
If they are like no, no I just cant handle it, and some people have
had really bad, bad attempts on them and they have a difcult s-
tula or graft. I try to calm the situation. Thats how I do it but . . . if
you know with that person there is absolutely no way and they are
only going to let certain people cannulate, then you dont waste
time, it has been said so many times before, you just say okay Ill
do it. (8)
Opportunity and skill development
This theme incl udes aspects of skill development that are im-
portant for successful cannulation. First, having opportunities
is essential for practicing the skill of cannulation, but this was
difcult in HD units with li mited numbers of AVFs. Performing
a thorough assessment is vital for AVF cannulation, and those
nurses who are successfu l at cannulation have an ability to
focus on the task at hand regardless of the stimuli in the environ-
ment of the dialysis unit. The nurses also engaged in professional
development activities related to cannulation.
The nurses frequently commented I think the way to have
successful cannulations is to have more stulas (13). They be-
lieved that having more accessibility to stulas meant more op-
portunity to consolidate their skil ls and reduce any f eelings
they had of being nervous with skill performance. Most believed
repeatedly cannulating AVFs was essential for their skill develop-
ment and condence. The nurses provided examples where staff
not comfortable with cannulation of AVFs would avoid cannula-
tion, which further impedes their skill development.
The orientation peri od was viewed to be a crucial period in
which to develop cannulation skills. There were variations in
the technique the nurses described for cannulation, b ut many
of them used the technique that they were initially taught. The
approach was to practice and do the procedure many times
until the nurse was con dent in his/her skills.
I think with the orientation thats where it has to start. I think that
continuous exposure on a daily basis throughout the six weeks of
orientation to cannulations that are, pretty straightforward, just to
get you feeling pretty good about that and assessment and taking
your time, pulling up a chair, feeling the vessel and that sort of
thing is really important (10)
Every nurse in the study described a careful assessment
of the stula prior to cannulation was essential for success.
It is best practice and seems rather obvious/basic that a nurse
would do an assessment prior to cannulation; however,
negative cases were described by participants and are presented
below, such as People tend to go in the same spots (7), . . . then
we have a lot of people who are timid and so they will just con-
stantly overcannulate in areas or they are afraid to ask for help
(9), and I take my time. I dont just go in there, like, I see some
people just go in and th ey just jab. I take my time, I make sure
the person is relaxed and, um, as relaxed as they can be . . . (8).
In addition to auscultation and inspection of the AVF, the
most important component of the asses sment was palpation.
With palpation of th e vessel, they were able to visualize the
vessel in th eir mind and this helped them determine where
they needed to cannulate.
I do take pride in doing a full assessment, so I listen to the vessel and
I reall y, really, really depend on my feel. So, I try to visualize the
vessel by the way it feels and like visualize that needle going in. (1)
A successful cannulation also involves gathering information
from various sources such as the health record, other nurses ex-
perience and the patients themselves in order to be prepared for
the cannulation. The nurses; sort of look back and see if I can tell
the history of whats been going on. Talk to the patient as well.
Ask them how things have been going with the cannulation . . .
(10), and be well prepared before all of my patients come in . . .
make sure I know, read the patient treatment parameters . . . the
specics of their stula . . . and have it all written down in front
of me so I know when the patient comes i n that I am already
mentally prepared for it (11).
Participants discussed keeping their skills up to date by at-
tending education sessions, calli ng experts in vascular access
such as the vascular access nurses and watching other nurses
cannulate they believed to be expert. Having the opportunity to
continually perform the skill was the most common method
nurses used to keep their skills current. Only one nurse commen-
ted that if she had not cannulated a stula recently, she would
seek out an as signment change or volunteer to cannulate:
What I do personally is that I do try to cannulate at least once
a day, so I do seek it out (18).
The nurses in this study had highly developed skills and were
able to focus on the task at hand, making cannulation the priority
and setting aside all oth er issues, concerns o r emotion s until
cannulation was successful.
The one time recently there was just too much going on and so I
closed my eyes because I could feel it. I, kind of, zoned out because
I was doubting all these people around and I was starting to feel the
pressure, and I closed my eyes and just popped the needle in (15).
Teamwork
Teamwork in the dialysis unit and knowing that one can get help
from a colleague wh en necessary is an important factor in
successful cannulation. Nurses are sought out who are known
to be an expert with cannulation for a particular patient or
who are considered to be expert regardless of whic h AVF is
being cannulated. There was variation from nurse to nurse i n
how th ey assisted their colleagues; some waited to be asked,
some volunteered help and some mento red their colleagues.
Most of the participan ts described how they mentored new
staff and sought them out, working with them when opportun-
ities for cannulation were available.
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Nurse self-awareness
A high degree of self-awareness was noted among participants.
They not only were aware of the emotional response that pa-
tients have to cannulation but were also aware of their own reac-
tions to cannulation. They approached cannulation with a plan
and also established self-rules regarding how many unsuccessful
attempts they would allow themselves. The nurses also seemed
to be aware of their skill and comfort levels with new and/or
difcult stulas. They expressed the importance of know your
limits (10).
The skill of cannulation can conjure up emotional reactions
within the nurse, which includes an acknowledgement of the
pressure of being successful, causing pain to patients and h ow
an unsuccessful attempt affec ts their condence with the skill.
However, successful cannul ation c an evoke a strong positive
emotional reaction and job satisfaction with the nurse such as:
I just had a couple, three, successful cannulations today and it is ex-
hilarating when you get it, its kind of a rush actually when you get a
successful needle (12)
Participants had awareness of their skills, comfort level and self-
rules about how many times they would cannulate a stula
before asking another nurse to try and cannulate. There is a pol-
icy in the HD unit with a recommended number of total attempts,
however, the nurses followed rules that were consistent with
their own beliefs about the process.
When it comes to a difcult patient, I usually locate the more ex-
perienced staff to come and help. I will start and try to feel and go
where I can go and if the patient is starting to feel uncomfortable,
I sto p. I will only do two at a maximum unless I know for sure
that I am going to get the third one in. I never go past three, I always
go two and go to somebody who has got more experience or more of
an expert (6).
Discussion
Successful AVF cannulation en compasses much more than the
technique of needle insertion into a vessel, depen ding rather
on the contextual inuences and interplay of the practice envi-
ronment and the personal attributes of the nurs e. The results
provide evidence for patient-centered care as an enabler to suc-
cessful AVF cannulation. The care environment where this study
took place emphasizes patient-centered care [21]. A patient and
family care advisory committee is in place to create a better un-
derstanding of the patient experience and works in collaboration
with patients on the planning, delivery and evaluation of renal
care. Also in the environment where the study took place is a pro-
fessional practice model that provides the foundation for how
nursing care is delivered and has been documented to benet
nurse and patient outcomes [22, 23]. At the core of the model is
patient-centered care [24], which may have impacted the results
of this study.
Participants in this study were able to overcome perso nal
and unit barriers to be successful with cannulation. In organiza-
tional development terms, when these situations occur, they are
positive deviances from the norm and are important for organ-
izational change. The nurses who identify with successful can-
nulation demonstrated high levels of emotio nal intelligence
(EI). EI is a form of social intelligence that acknowledges the feel-
ings and emotions of others and themselves and uses this infor-
mation to guide thoughts and actions [25]. EI is an important
competency in physician [26, 27] and nurse [28] leadership.
There are ve main elements of EI: self-awareness, self-regula-
tion, motivation, empathy and social skills [29]. The ndings of
this study include examples of the nurses being aware of their
emotions as well as the patients emotional reaction, such as
fear and anxiety. Participants indicated that they are able to
self-regulate by doing a thorough assessment, visualizin g the
stula, having a plan prior to cannulati on and knowing th eir
limits. They are motivated and expressed an ability to focus on
the task despite performing the task in the busy environment
of a dial ysis unit. The nurses described positive interpersonal
relationships with patients (patient-centered care) and nurse-
to- nurse teamwork and mentoring. Nurses who have not yet
acquired these skills may be able to develop them. The solution
may not only be education about the technical aspects of how to
cannulate but, rather, emphasis on nurse-to-nurse interpersonal
relationships and nurse-to-patient therapeutic relationships that
form the foundation for patient-centered care and nurse mentor-
ship, teamwork, EI and giving and receiving feedback. This could
be successfully accomplished through the development of clinical
narratives in either simulation and/or role playing.
Another barr ier to cannul ation that the nurses in this study
were able to overcome was the pressure of time imposed by HD
schedules [11, 12]. This group of nurses completed an assessment
prior to cannulation, believing that in itial success with needle
placement would save time later as a result of miscannulations.
This study supports the use of assessment of the stula as a stand-
ard of care, performing one that is thorough, yet not overly time
consuming, such as the One-Minute Check [30]. In addition, the
use of ultrasound-guided cannulation has been evaluated to add
13 min to the time required for cannulation [31].
The nurses in this study received initial training in their
orientation period on cannulation. They were rst taught the the-
oretical components of cannulation then they could practice the
skill on a simulated practice arm. We have not used high-delity
patient simulators for cannulation training. Included in this teach-
ing is how to use ultrasound to assist in cannulation, but real-time
ultrasound cannulation is not currently taught in the general
orientation. Also during orientation, the new nurses observe a can-
nulation and then cannulate on what would be considered easier
AV stulas. Continuing education on cannulation, use of the ultra-
sound machine and real-time ultrasound cannulation continues
ad hoc for professional development. The opportunity to repeatedly
perform and practice cannulation was a key factor in the develop-
ment and maintenance of their skills. If particular units have few
stulas and a large staff, and thus few opportunities for cannula-
ti
on, efforts are needed to increase the opportunities for cannula-
tion. This could be accomplished by way of simulated cannulation
situations or by moving staff within different sites in the organ-
ization during orientation and beyond where staff can focus on
the skill. Some organizations have chosen to focus on a core
group of nurses to do cannulations. This has the advantage of re-
ning the skills for experts. However, others believe cannulation
is an essential skill for every HD nurse and thus opportunities for
skill development among all staff are required.
Successful cannulation for new or difcult stulas requires
support on a variety of levels: environmental, staff a nd equip-
ment. Cannu lation needs to be plann ed ahead of tim e with a
quiet e nvironment in the dialysis unit and appropriate equip-
ment available (i.e. bedside ultrasound i f available) to enable
the nurse to perform a thorough assessment. Support staff
such as the vascular access nurse or an expert nurse available
to help problem solve and support the bedside nurse during the
needling also contributes to successful cannulation.
Use of the ultrasound machine to assist with cannulation in
this stu dy was mixed. Some nurses reported it being helpful
and some did not. It is recommended at our site that nurses
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use the ultrasound, however, it is not used consistently, even for
rst cannulations of the stula. There is limited research on the
use of ultrasound guidance for cannulation of an AVF. However,
what is currently available supports the use of ultrasound to
im prove cannulati on [3134]. A prospe ctive t rial is currently
under way in an outpatient HD unit [35]. No clinica l practice
guidelines exist for the use of real-time ultrasound AVF cannula-
tion. The recommendation to use ultrasound guidance for central
venous cannulation/insertion has been extrapolated to include
real-time use with AVF cannulation [35]. Regardless of the clinical
evidence for its use, the harm is minimal and it can be an added
tool to help guide the cannulation that may improve patient out-
comes. Nurses in this study often said I cannulate how I was
taught. Therefore, it may be prudent to i nclude teaching staff
to cannulate with real-time ultrasonography during their orien-
tation as a means to inuence how the next generation of people
who cannulate AVFs are taught.
This study was undertaken to understand more about what
contributes to successful nurse cannulation of the AVF in an
effort to identify factors associated with success (Table 3)that
can be used to teach other nurses and improve the cannu lation
experience for patients. Improving this skill could, in t urn, break
the cycle of the perpetual novice. Interventions that decrease
inl trates, bruisi ng and pain and in crease n urse and patient
condence in nurses skill will result in more pos itive patient ex-
perienceswithAVFsandmorepositivetalkamongpatients
about AVFs. Historically, the constant si te needle insertion tech-
nique gained acceptance by word of mouth from patients posi-
tive cannulation experiences [ 36]. In the long term, this may
improve AVF rates and decrease reliance on CVCs for dialysis.
Unfortunately, there will always be some degree of stula pro-
blems such as missed cannulations, pain and/or bruising. We
need to move beyond the noti on that successful cannul ation
only ref ers to the insertion of needles and acknowledge that
success applies to the entire patient and nurse cannulation
experience.
Conclusion
Organizational development can be used to break the cycle of the
perpetual novice in efforts to improve the patients cannulation
experience for AVFs by focusing on strategies to build support
and acknowledge and improve factors such as patient-centered
care, teamwork, opportunities for skill development and EI.
Acknowledgements
The authors thank Cathy Parsons, Professional Practice Con-
sultan t at St Josephs Health Centre in London, ON, Canada, for
her expertise in AI.
Funding
This study was funded by the Canadian Association of Nephrol-
ogy Nurs es and Technologists/Amgen 2014 Canada Research
Project Grant.
Conict of interest statement
The results presented in this article have not been pu blished
previou sly in whole or part, except in abstract format. The
authors do not have any conict of interests such as sharehold-
ing in or receipt of a grant, travel award or consultancy fee from a
company whose product features in the submitted manuscript or
a company that manufactures a competing product.
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Table 3. Strategies to promote changes in cannulation
Patient
Prepare the patient for cannulation in advance by explaining the procedure and what to expect
Discuss ways the patient can cope with the cannulation, i.e. relaxation techniques, slow deep breaths, distraction with music
Environment
Plan in advance for rst or difcult cannulation
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Cohesive teamwork
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Opportunity to practice skills
Mentoring program for cannulation
Use ultrasound to assist with cannulation and consider real-time ultrasonography for cannulation
Support staff available for assistance during dif cult cannulation
Acknowledge the patient and nurse emotional response to cannulation
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AVF Cannulation | 7
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... Previous research conducted by Harwood et al. 17 and Wilson et al. 18 have identified that some HD nurses are in a state of "perpetual novice" and are unable to move on a continuum from novice to expert with their cannulation skills for AVFs. This results in cannulation misses and complications such as increased bruising, pain, fear and, if this persists, a need for insertion or reliance on a CVC. ...
... This results in cannulation misses and complications such as increased bruising, pain, fear and, if this persists, a need for insertion or reliance on a CVC. 17,18 Probably this can be understood as justification to results obtained by Parisotto et al. 19 in the performed international observational study (n = 7058; 171 HD units) demonstrating that area puncture was the dominant technique in use (65.8% of patients), which had a greater association with VA failure (Hazard ratio (HR): 0.78 (0.61-1.00) buttonhole and rope ladder vs area). 19,20 The nursing recommendations for the management for VA in adult HD patients from the Canadian Association of Nephrology Nurses and Technologists (CANNT) enhances that cannulation competency is best determined by the vascular access coordinator or vascular access nurse, and that they should develop local strategies to improve cannulation skills leading to fewer missed cannulations and, ultimately, improve patients and nurses experiences. ...
... This further contributes to the problem, creating a vicious cycle: fewer AVFs, less opportunity for skill development, more unsuccessful attempts, fewer patients wanting AVFs and so forth. 17,18 Improving outcomes through behavior change appears to be much more complex than providing nursing education on proper needle insertion technique and patient education on the benefits of an AVF. A successful cannulation for new or difficult AVF needs to be planned ahead of time with a requiring quiet environment in the HD unit and appropriate equipment available to enable a thorough assessment based on defined decision models that can support the HD nurse counseling to the patient needing HD. 17 Managing Access by Generating Improvement in Cannulation (MAGIC) is a joint Vascular Access Society of Britain and Ireland (VASBI) and British Renal Society Vascular Access Special Interest Group (BRS VA SIG) quality improvement project supported by Kidney Quality Improvement Partnership (KQuIP) in the UK. ...
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The cannulation of an arteriovenous fistula (AVF) by the hemodialysis (HD) nurse is challenging. Despite it being the focus of extensive research, it is still one of the majors causes of damage making it prone to failure. A considerable number of Clinical Practice Guidelines (CPGs) for the management of vascular access (VA) have been published worldwide over the past two decades. This review aimed to assess all information available in the selected CPG regarding AVF cannulation for HD providing a comprehensive analysis in order to interpret possible future cannulation approaches. A total of seven CPGs were described in a coding table separated in seven subthemes: Initiation of cannulation, preparation, technique, needle selection, surveillance, pain, and education. Our analysis outlines current CPGs for HD VA cannulation with lack of good evidence support for the majority of the recommendations, showing that, there is an urgent need for international collaboration and coordination to ensure relevant and high-quality evidence. Future CPGs must consider recommendations with better grading of evidence aiming patient-centered care and nurse decision models that can potentially represent better AVF cannulation outcomes.
... Harwood [11] performed a qualitative research study to explore this with haemodialysis nurses. They identified multiple aspects that contribute to successful needle insertion, including: ...
... Needling is a little-explored phenomenon that is about more than the physical act of inserting the needle [11]. Research is urgently needed to examine the patient's experience of needling, which leads to successful needling and how to best develop a good needling technique. ...
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This tool is being used by our dialysis nurses before cannulating the Arteriovenous Fistula (AVF). Once they will identify problems based on the scoring system, it will be escalated to the member of the vascular access team. It is strongly suggested to assess the arteriovenous fistula before cannulation by physically examining the AVF or by the use of ultrasound-guided assessment method.
... Whilst there is broad acceptance that cannulation varies with different cannulators, there is a paucity of studies exploring how we can reduce this variation and promote 'good' cannulators. Harwood et al. 52 conducted a qualitative study with nurses, to identify what led to successful cannulation. They found this went beyond just technical skill, including patient-centred care, teamwork and self-awareness of the cannulator. ...
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Introduction Cannulation is an essential part of haemodialysis with arteriovenous access. Patients’ experiences of cannulation for haemodialysis are problematic but poorly understood. This review aims to synthesise findings related to patients’ experiences of cannulation for haemodialysis from qualitative studies, providing a fuller description of this phenomenon. Methods Eligibility criteria defined the inclusion of studies with a population of patients with end-stage kidney disease on haemodialysis. The phenomena of interest was findings related to patients’ experiences of cannulation for haemodialysis and the context was both in-centre and home haemodialysis. MedLine, CINAHL, EMBASE, EMCARE, BNI, PsycInfo and PubMed were last searched between 20/05/2019 and 23/05/2019. The quality of studies was assessed using the using Joanna Briggs Critical Appraisal Checklist for Qualitative Research. Meta-aggregation was used to synthesise findings and CERQual to assess the strength of accumulated findings. Results This review included 26 studies. The subject of included studies covered cannulation, pain, experiences of vascular access, experiences of haemodialysis and a research priority setting exercise. From these studies, three themes were meta-aggregated: (1) Cannulation for haemodialysis is an unpleasant, abnormal and unique procedure associated with pain, abnormal appearance, vulnerability and dependency. (2) The necessity of cannulation for haemodialysis emphasises the unpleasantness of the procedure. Success had multiple meanings for patients and patients worry about whether the needle insertion will be successful. (3) Patients survive unpleasant, necessary and repetitive cannulation by learning to tolerate cannulation and exerting control over the procedure. Feeling safe can help them tolerate cannulation better and the cannulator can invoke feeling safe. However, some patients still avoid cannulation, due to its unpleasantness. Conclusions Cannulation is a pervasive procedure that impacts on patients’ experiences of haemodialysis. This review illuminates further patients’ experiences of cannulation for haemodialysis, indicating how improvements can be made to cannulation. Registration PROSPERO (CRD42019134583).
... Some authors have recognised that there are currently no clear clinical guidelines for the use of USGC of the AVF and have concluded more research is needed (Harwood, Wilson, & Oudshoorn, 2016). It is agreed that education is needed for renal nurses, a cornerstone for USGC as a relatively novel technique (Coventry et al., 2019). ...
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Does point-of-care ultrasound (POCUS) improve the communication between clinicians? – A systematic review Abstract Background: Point-of-care ultrasound (POCUS) is increasingly used as a non-invasive vascular access assessment method by renal nurses in Australia. Its purpose is to assess arteriovenous fistulas prior to cannulation and to guide cannulation itself. It has been shown that renal nurses can be trained to acquire the advanced skills to use this method competently, however it is not known if they communicate their observations to other healthcare professionals such as vascular access nurses, interventional radiologists or vascular access surgeons in tertiary hospitals. Aim: This systematic literature review sought to determine if it has previously been reported that renal nurses who use POCUS, communicate specific patient findings. Method: The systematic literature review was performed using nursing and medical databases comprising MEDLINE, Embase, Web of Science and CINAHL Plus with Full Text. Results: There is a paucity of knowledge about renal nurses communicating observations made using POCUS devices with other healthcare professionals. A PRISMA checklist has been used to validate the results of this systematic review. Conclusions: Despite evidence that renal nurses are increasingly using POCUS, it is unknown if they share their observations with other clinicians to advance care of their patients. An observational study is warranted to examine the communication processes in this respect. This information could prove to be useful in the context of advancing vascular access care for this patient group and could inform clinical practice.
... In a meta-analysis [20], comparing RL with BH, it was not concluded which CT has been associated to better AVF survival outcomes. However, as already described in MuST study, similar survival curves are observed in both RL and MuST, indicating that MuST is as similarly safe to use as RL [6] and both showed better results compared to BH . ...
... Some authors have recognised that there are currently no clear clinical guidelines for the use of USGC of the AVF and have concluded more research is needed (Harwood, Wilson, & Oudshoorn, 2016). It is agreed that education is needed for renal nurses, a cornerstone for USGC as a relatively novel technique (Coventry et al., 2019). ...
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Background: Point-of-care ultrasound (POCUS) is increasingly used as a non-invasive vascular access assessment method by renal nurses in Australia. Its purpose is to assess arterio-venous fistulas (AVFs) prior to cannulation and to guide cannulation itself. It has been shown that renal nurses can be trained to acquire the advanced skills to use this method competently; however, it is not known if they communicate their observations to other healthcare professionals such as vascular access nurses, interventional radiologists or vascular access surgeons in tertiary hospitals. Aim: This scoping review sought to determine if it has previously been reported that renal nurses who use POCUS communicate specific patient findings. Method: The scoping review was performed using nursing and medical databases comprising MEDLINE, Embase, Web of Science and CINAHL Plus with Full Text. Results: There is paucity of knowledge about renal nurses communicating observations made using POCUS devices with other healthcare professionals. A PRISMA checklist has been used to validate the results of this scoping review. Conclusions: Despite evidence that renal nurses are increasingly using POCUS, it is unknown if they share their observations with other clinicians to advance care of their patients. An observational study is warranted to examine the communication processes in this respect. This information could prove to be useful in the context of advancing vascular access care for this patient group and could inform clinical practice.
... Result obtained by [17] who revealed that cannulation is learned skill that generally improves with practice and years of experience this is accepted with our results which explained that nurse's practice about VA cannulation improved significantly after nursing interventions implementation. The results come in the same result of [18] who used four intervention programs for teaching nurses Arteriovenous fistulas (AVFs) cannulation, they found represented improvement in successful fistula cannulation and practice changes based on these results may improve cannulation, decrease complications and result in better outcomes for patients. On contrast results obtained by [19] indicated that while nurses are well trained on cannulation techniques; there were barriers to perform successful cannulation because of the pressure of time imposed by HD schedules. ...
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... Some nurses remain in a state of a 'perpetual novice' resulting in a viscous cycle of negative patient consequences (bruising, pain), further influencing patients' decisions not to pursue a fistula or abandon cannulation. The risk of a miscannulation could be reduced with appropriate training of nurses and creating a practice environment that is patientcentered and cultivates teamwork 96,97 . ...
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Vascular access planning is critical in the management of patients with advanced kidney disease who elect hemodialysis for kidney replacement therapy. Policies put in place more than two decades ago attempted to standardize vascular access care around the model of optimal-i.e, arteriovenous fistula-and least preferred-i.e., central venous catheter-type of access. This homogenized approach to vascular access care emerged ineffective in the ever increasingly heterogeneous and complex dialysis population. The most recent vascular access guidelines acknowledge limitations of standardized care and encourage tailoring vascular access care based on patient and disease characteristics. In this article we discuss available literature in support of patient-tailored access care based on differences in vascular access outcomes by biologic and social factors-age, sex and race. Further, we draw attention to the overlooked dimension of patient-reported preferences and shared decision making in the practice of vascular access planning. We discuss milestones to overcome as requisite steps to implement effective shared decision making in vascular access care. Finally, we take into consideration local practice co-factors as major players in vascular access fate. We conclude that a personalized approach to hemodialysis vascular access will require dynamic care specifically relevant to the individual based on biological factors, fluctuating clinical needs, values and preferences.
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