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Evaluating methods for the use and decontamination of needleless connectors: A qualitative inquiry

  • Emily N. Larsen
    Correspondence
    Corresponding author. Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Level 2, Building 34, Cnr. Bowen Bridge Rd and Butterfield St, Herston QLD 4029, Australia. Fax: +617364658332
    Affiliations
    School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia

    Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia

    Patient-Centred Health Services, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia

    Alliance for Vascular Access Teaching and Research Group, Griffith University, Brisbane, Queensland, Australia

    School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Queensland, Australia
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  • Deanne August
    Affiliations
    Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia

    Alliance for Vascular Access Teaching and Research Group, Griffith University, Brisbane, Queensland, Australia

    School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Queensland, Australia
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  • Samantha Keogh
    Affiliations
    Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia

    Alliance for Vascular Access Teaching and Research Group, Griffith University, Brisbane, Queensland, Australia

    School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
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  • Julie Flynn
    Affiliations
    School of Nursing and Midwifery, University of Southern Queensland, Ipswich, Queensland, Australia
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  • Amanda J. Ullman
    Affiliations
    Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia

    Alliance for Vascular Access Teaching and Research Group, Griffith University, Brisbane, Queensland, Australia

    School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Queensland, Australia

    Children's Health Queensland, Brisbane, Queensland, Australia
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  • Nicole Marsh
    Affiliations
    School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia

    Nursing and Midwifery Research Centre, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia

    Patient-Centred Health Services, Menzies Health Institute Queensland, Griffith University, Brisbane, Queensland, Australia

    Alliance for Vascular Access Teaching and Research Group, Griffith University, Brisbane, Queensland, Australia

    School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Queensland, Australia

    School of Nursing, Queensland University of Technology, Brisbane, Queensland, Australia
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  • Marie Cooke
    Affiliations
    School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia

    Alliance for Vascular Access Teaching and Research Group, Griffith University, Brisbane, Queensland, Australia
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  • Alexandra L. McCarthy
    Affiliations
    School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Queensland, Australia

    Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
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  • Claire M. Rickard
    Affiliations
    School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia

    Alliance for Vascular Access Teaching and Research Group, Griffith University, Brisbane, Queensland, Australia

    School of Nursing, Midwifery and Social Work, University of Queensland, Brisbane, Queensland, Australia

    Herston Infectious Diseases Institute, Metro North Health, Brisbane, Queensland, Australia
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      Highlights

      • Needleless connectors are a safety device for staff (reducing needlestick injuries) and patients (barrier to infection).
      • Needleless connector practices are repeated routines/‘rituals;’ participants were not always aware of best practice or guidelines.
      • Nomenclature surrounding needleless connector brands and function is diverse and confusing for practitioners.
      • Participants were more careful with needleless connectors attached to central venous devices, compared to peripheral devices.

      Abstract

      Background

      Needleless connectors (NCs) are essential devices designed to provide safe, needle-free connection between venous access devices, syringes and infusions. There is a variety of designs, and associated decontamination products and practices; the resulting confusion can cause detrimental patient outcomes. This study aimed to explore nurses’ attitudes, techniques, and practices around the use and decontamination of NCs in clinical practice.

      Methods

      Qualitative inquiry was conducted with seven focus groups of 4–6 participants each in the cancer and surgical units of a large tertiary hospital in Australia between January and March 2019. Participants comprised nurses who had taken part in a recent clinical trial of NC decontamination. Focus group sessions were recorded, transcribed and synthesised using content analysis.

      Results

      Seven focus groups were conducted (total, N = 30 participants), lasting 16–20 min. Six major themes were identified surrounding needleless connector use and decontamination: ‘safety and utility’; ‘terminology and technological understanding’; ‘clinical practice determinants’; ‘decontamination procedures and influencers’; ‘education and culture’; and ‘research and innovation’.

      Conclusion

      The participants articulated positive attitudes towards needleless connector use for needle-stick and infection prevention, however rationales for care and maintenance practices demonstrated limited understanding of guidelines (e.g., disinfection time) and specific NC function (e.g., positive, negative pressure). The findings indicated the need for targeted, standardised needleless connector education, to enhance staff confidence, improve consistency of care and ensure patient safety.

      Keywords

      Introduction

      Vascular access devices (VADs) are used internationally to administer essential intravenous fluids, medications, blood products and other treatments (e.g., chemotherapy). Needleless connectors (NC), also referred to as ‘hubs’ or ‘bungs,’ [
      • Chernecky C.
      • Macklin D.
      • Casella L.
      • Jarvis E.
      Caring for patients with cancer through nursing knowledge of IV connectors.
      ] are plastic ports fastened to VADs which form a closed system, while also maintaining an entry point for connection with syringes and infusion administration sets [
      • Moureau N.L.
      • Flynn J.
      Disinfection of needleless connector hubs: clinical evidence systematic review.
      ]. Since their introduction, a number of NCs have been developed and released, with different designs (e.g., negative, positive, and neutral pressure; clear and opaque) [
      • Hadaway L.
      Needleless connectors for IV catheters.
      ].
      While the adoption of NCs has reduced the incidence of needle stick injuries and clinician exposure to blood borne viruses [
      • Tarabay R.
      • El Rassi R.
      • Dakik A.
      • Harb A.
      • Ballout R.A.
      • Diab B.
      • et al.
      Knowledge, attitudes, beliefs, values, preferences, and feasibility in relation to the use of injection safety devices in healthcare settings: a systematic review.
      ], their use is also associated, in some instances, with catheter-associated bloodstream infections [
      • Mahieu L.M.
      • De Muynck A.O.
      • Ieven M.M.
      • De Dooy J.J.
      • Goossens H.J.
      • Van Reempts P.J.
      Risk factors for central vascular catheter-associated bloodstream infections among patients in a neonatal intensive care unit.
      ]. One study found 50% of NCs attached to catheters were contaminated with common skin and respiratory micro-organisms [
      • Slater K.
      • Cooke M.
      • Whitby M.
      • Fullerton F.
      • Douglas J.
      • Hay J.
      • et al.
      Microorganisms present on peripheral intravenous needleless connectors in the clinical environment.
      ]. Adequate decontamination of the connector surface prior to each access is therefore an integral component of safe intravenous treatment, in addition to strategies to maintain NC function, as per practice guidelines [
      • O'Grady N.P.
      • Alexander M.
      • Burns L.A.
      • Dellinger E.P.
      • Garland J.
      • Heard S.O.
      • et al.
      Guidelines for the prevention of intravascular catheter-related infections.
      ,
      • Loveday H.P.
      • Wilson J.A.
      • Pratt R.J.
      • Golsorkhi M.
      • Tingle A.
      • Bak A.
      • et al.
      epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
      ],
      Healthcare workers have previously demonstrated positive perceptions of safety devices such as NCs [
      • Tarabay R.
      • El Rassi R.
      • Dakik A.
      • Harb A.
      • Ballout R.A.
      • Diab B.
      • et al.
      Knowledge, attitudes, beliefs, values, preferences, and feasibility in relation to the use of injection safety devices in healthcare settings: a systematic review.
      ] Despite this, practice varies and guideline compliance is poor, placing patients at risk of infection [
      • Smith J.S.
      • Kirksey K.M.
      • Becker H.
      • Brown A.
      Autonomy and self-efficacy as influencing factors in nurses' behavioral intention to disinfect needleless intravenous systems.
      ]. This could in part be due to the many elements of this seemingly ‘simple’ procedure, including the variety of antiseptic products (e.g. 70% isopropyl alcohol (IPA) with or without chlorhexidine gluconate [CHG]), decontamination techniques (e.g., passive cap versus active swab methods) and duration of antiseptic cleaning and dry time [
      • Slater K.
      • Fullerton F.
      • Cooke M.
      • Snell S.
      • Rickard C.M.
      Needleless connector drying time—how long does it take?.
      ,
      • Flynn J.M.
      • Rickard C.M.
      • Keogh S.
      • Zhang L.
      Alcohol caps or alcohol swabs with and without chlorhexidine: an in vitro study of 648 episodes of intravenous device needleless connector decontamination.
      ] Easily recognisable phrases such as “Scrub the Hub”™ (Becton, Dickinson and Company) have accustomed healthcare workers to the concept of NC decontamination [
      • Hadaway L.
      Needleless connectors: improving practice, reducing risks.
      ,
      • Slater K.
      • Cooke M.
      • Scanlan E.
      • Rickard C.M.
      Hand hygiene and needleless connector decontamination for peripheral intravenous catheter care—time and motion observational study.
      ], however, less is known about how nurses interpret and action best-practice NC decontamination. A recent time-and-motion study identified that while 99% of nurses attempted NC decontamination, less than 4% complied with the recommended 15- second scrub duration (local policy of time-in-motion study site) [
      • Slater K.
      • Cooke M.
      • Scanlan E.
      • Rickard C.M.
      Hand hygiene and needleless connector decontamination for peripheral intravenous catheter care—time and motion observational study.
      ]. Exploration of nurses' attitudes and beliefs could explain these differences in practice, such as reasons for compliance or the lack of compliance for procedures. These findings could in-turn inform strategies for improving behaviours for optimal NC management. The aim of this qualitative inquiry was therefore to explore nurses' attitudes, techniques, and practices around the use and decontamination of the NCs. The knowledge gained will assist policy makers and educators in targeting educational strategies to improve compliance with evidence-based practice, while highlighting opportunities to simplify products and practices.

      Methods

      Research question

      What are nurses’ attitudes, techniques, and practices for NC use and decontamination?

      Design

      This qualitative inquiry comprised focus groups that explored the attitudes, techniques, and practices of NC use within the healthcare context [
      ,
      ]. Inductive analysis of content was undertaken, informed by Braun and Clarke's six phases [
      • Braun V.
      • Clarke V.
      Using thematic analysis in psychology.
      ], structured according to Elo et al. [
      • Elo S.
      • Kyngäs H.
      The qualitative content analysis process.
      ] This methodology provided opportunities for discussion and exploration of shared experiences; which enabled open conversation with knowledge transfer about NC care and maintenance [
      ,
      ]. The COnsolidated criteria for REporting Qualitative research (COREQ) checklist for interviews and focus groups provided a framework for this report [
      • Tong A.
      • Sainsbury P.
      • Craig J.
      Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.
      ].

      Setting and participants

      A purposive sample of registered nurses employed at a single large tertiary referral hospital between January–March 2019 were recruited. This professional group was selected as they were the primary users of NCs in the clinical environment. Surgical (gastro-intestinal, trauma, vascular) and cancer care speciality wards were approached to contribute as these clinical specialities had recently participated in a pilot randomised controlled trial comparing the use of three NC decontamination products to prevent catheter-related bloodstream infection in Central Venous Access Devices (CVAD) (ACTRN12615001120561, https://www.anzctr.org.au/) [
      • Rickard C.M.
      • Flynn J.
      • Larsen E.
      • Mihala G.
      • Playford E.G.
      • Shaw J.
      • et al.
      Needleless connector decontamination for prevention of central venous access device infection: a pilot randomized controlled trial.
      ]. Initially, nursing directors and managers were consulted for permission to contact nurses, and to arrange for a suitable time and place to undertake focus groups (near the participating ward). Invitations were emailed to potential participants, which also offered recipients to nominate a proxy if they were unable to participate. On the day of the focus group, in-person invitations were also extended to nurses rostered to work on participating wards. Inclusion criteria required staff to have had regular experience in the care and maintenance of NCs for VADs. Participation was entirely voluntary and informed written consent was obtained before the start of each session.

      Standard operating procedures and products

      As a way of contextualising current practice, a brief review of the local hospital policy for NCs was completed. NCs were Smartsite® Needle-Free Valve (negative fluid displacement, opaque internal fluid dynamics) and Max Plus® (positive fluid displacement, clear internal fluid dynamics) (both Carefusion/BD, San Diego); recommended for attachment to peripheral intravenous catheters, and CVADs, respectively. Decontamination of the NC was with a 70% IPA wipe (0.6 ml, Reynard, New Zealand) applied vigorously to the NC for five seconds (and allowed to dry); 2% chlorhexidine gluconate in 70% IPA, and 70% IPA caps had recently been tested at the site [
      • Rickard C.M.
      • Flynn J.
      • Larsen E.
      • Mihala G.
      • Playford E.G.
      • Shaw J.
      • et al.
      Needleless connector decontamination for prevention of central venous access device infection: a pilot randomized controlled trial.
      ]. NCs were routinely replaced every seven days, proposed to occur with primary dressing change. Administration sets/fluids attached to the NC (if any) were to be discarded at the time of NC replacement. The policy did not permit blood sampling through VADs (including CVADs).

      Focus groups and interview guide

      Small focus groups of 4–5 participants were conducted in dedicated training rooms, near the clinical area, with a closed door for privacy. Sessions were planned for 30 min or less during shifts with adequate overlap of staff so as not to compromise workloads. One of the investigators (EL) moderated the sessions, while a second researcher (JF) noted group dynamics and non-verbal behaviours. Sessions were limited to one per day; this was done to reduce the likelihood of one group's discussion influencing the facilitators impression of the next group.
      The moderator initiated each group discussion with semi structured questions as a guide (see Table 1). These topics of interest and questions were developed by the larger investigation team (EL, SK, JF, AU, NM, MC, CM) based on available NC literature and previous qualitative research in vascular care [
      • Moureau N.L.
      • Flynn J.
      Disinfection of needleless connector hubs: clinical evidence systematic review.
      ,
      • Flynn J.M.
      • Rickard C.M.
      • Keogh S.
      • Zhang L.
      Alcohol caps or alcohol swabs with and without chlorhexidine: an in vitro study of 648 episodes of intravenous device needleless connector decontamination.
      ,
      • Hadaway L.
      Needleless connectors: improving practice, reducing risks.
      ,
      • Ryder M.
      Evidence-based practice in the management of vascular access devices for home parenteral nutrition therapy.
      ,
      • Lockman Justin L.
      • Heitmiller Eugenie S.
      • Ascenzi Judith A.
      • Berkowitz Ivor
      Scrub the hub! Catheter needleless port decontamination.
      ,
      • Keogh S.
      • Flynn J.
      • Marsh N.
      • Mihala G.
      • Davies K.
      • Rickard C.
      Varied flushing frequency and volume to prevent peripheral intravenous catheter failure: a pilot, factorial randomised controlled trial in adult medical-surgical hospital patients.
      ].
      Table 1Interview guide for Needleless Connector Focus Groups.
      Questions and Prompts
      • 1.
        What do you think are the most important characteristics of a needleless connector?
      • 2.
        Are there any special techniques needed when using/accessing needleless connectors?
        • a.
          Prompt: Medications, blood taking, continuous fluids.
      • 3.
        Keeping ‘Infection Control’ in mind, what practices do you employ in your clinical practice when handling needleless connectors?
      • 4.
        What methods/techniques of decontamination do you currently use and how effective do you think these methods are?
        • a.
          Prompt: ease/difficulties of adherence to hospital policy? How did you choose these practices/what informs these practices?
      • 5.
        Do you have any troubles/concerns when using needleless connectors in your day-to-day practice?
        • a.
          Prompt: methods of trouble-shooting complications.
      • 6.
        Are you aware of any recent research or new evidence related to needleless connectors?

      Data generation

      At commencement of the focus group, moderators reviewed research objectives, the need to maintain confidentiality of discussions, and participants were given the opportunity to ask additional questions and clarify understanding of the processes. Non-identifiable participant demographics (years of experience in nursing) were collected by self-report. Permission was sought verbally for audio-recording and the recording device always remained in view. A selection of NCs was provided and used as prompts to develop discussions and demonstrate practice. The interview questions (see Table 1) guided discussions; although the sequence and prompts were adapted to suit the conversation. Each session was complete when key points from the interview guide had been discussed and participants had no further comments. Thirty minutes were allocated for each focus group; however, sessions could run over time if required. Following interviews, de-identified audio-taped recordings were transcribed by an external transcription service. Any identifiable participant characteristics, locations or references were removed from the transcripts, after which recordings were permanently deleted.
      Research team meetings and discussions were held at regular intervals between sessions, to review initial responses and identify interim and final themes. Member checking was not conducted as individual participants identity remained anonymous and confidential. Data collected during this study were treated confidentially; coded transcripts and notes are safely stored at the participating hospital.

      Research team reflexivity statement

      Focus groups were facilitated by two female independent postgraduate-qualified clinical nurse researchers (EL, JF), with extensive experience in vascular access research. EL is an experienced qualitative researcher and focus group facilitator. The researchers consider that they could have a bias of interest related to NC knowledge, but had no authority or reporting relationship with any participants, allowing for an open and honest discussion.

      Analysis

      Inductive content analysis was informed by Braun and Clarke's six phases [
      • Braun V.
      • Clarke V.
      Using thematic analysis in psychology.
      ], structured according to the process suggested by Elo et al. [
      • Elo S.
      • Kyngäs H.
      The qualitative content analysis process.
      ] This process included (i) familiarisation with transcripts (DA, EL), (ii) initial coding (DA); (iii) searching for themes (DA, EL); (iv) reviewing themes (DA, EL, SK); (v) refining and naming themes (DA, EL, SK); (vi) producing report (DA, EL). De-identified transcripts were uploaded into NVIVO data management software (Version 12, 2018), data were reviewed line by line by (DA, EL) and open codes were identified. Codes were then grouped into themes (DA, EL, SK). In addition, results were reviewed for specific nomenclature related to NC, to identify unique language for vascular access consumables [
      • Elo S.
      • Kyngäs H.
      The qualitative content analysis process.
      ,
      • Onwuegbuzie A.J.
      • Dickinson W.B.
      • Leech N.L.
      • Zoran A.G.
      A qualitative framework for collecting and analyzing data in focus group research.
      ]. The entire research team were consulted regarding themes, and significant statements to achieve consensus.

      Results

      Seven focus groups (total of 30 participants) were conducted each lasting 16–20 min. Participants were predominantly female (90%) and were in first 10 years of nursing (74%) (see Table 2). Experience (years in nursing) was balanced among focus groups, except for Focus Group (FG) 4 (all participants <5 years in nursing).
      Table 2Participant demographics.
      Rolen (%)
      Gender
      Female27 (90)
      Male3 (10)
      Years in nursing
      0–514 (47)
      6–108 (27)
      11–151 (3)
      16–203 (10)
      ≥213 (10)
      No information1 (3)
      Disciplines
      Surgical17 (57)
      Cancer13 (43)
      The findings demonstrated some inconsistencies in staff practices, knowledge and education related to NCs. The element of safety provided by NCs (for both staff and patients) was important to participants, however the appropriate use and disinfection of NC was influenced by internal and external factors such as perceived level of risk, and prioritisation of other clinical duties. Overall, six primary themes were identified.

      Theme 1: Safety and utility

      Elements of NC safety and utility were raised in all seven focus groups; this often arose from the first question (what do you think are the most important characteristics of a needleless connector?).
      Participants perceived NC use as a benefit to themselves (e.g. reduction in the risk of needle-stick injuries) and their patients (e.g. barrier to infection; air-block). While most respondents reported positive safety elements, the use of NC was also perceived by some participants to increase possible patient risks, e.g., by becoming contaminated and thereby increasing the risk of bloodstream infection at the time of access.“I think if [NC is] just really dirty you run the risk of pushing those germs back into the bloodstream.” (FG 1) (negative)
      Positive and negative elements were similarly raised for NC utility. The usefulness of a universal connection (i.e., Luer-lock) to optimise compatibility with syringes and other vascular access consumables was clearly articulated. However, the merit of this in practice was challenged with phrases such as “popping off,” “slipping off,” and “flips out” common when participants were describing connection of other consumables (e.g., syringes) to the NC. This was perceived as a risk factor for potential contamination. Conversely, ease of cleaning was perceived as a positive NC element.“[If using NC] You’re not running around looking for the right type of syringe that connects to it” (FG 1) (positive)“It [NC] can possibly slip off and actually I guess can be contaminated after.” (FG 5) (negative)

      Theme 2: Terminology and technological understanding

      Participants spoke frequently of the visual and technical aspects of NCs, with a total of 23 terms used by participants during sessions. These terms were grouped into five codes i) appearance-shape (“long one”), ii) appearance-colour (“purple one”), iii) industry or technology (“bi-valve”), iv) function (“hub”) and v) other (“don't know what they are called”) (see Table 3). Terms were often used interchangeably throughout a group discussion with apparent mutual shared understanding. However, when terms related specifically to technological function (e.g., positive pressure), most participants could provide no further explanation of what these terms and functions meant, and what impact it would have upon the NC (e.g., fluid dynamics).
      Table 3Labels and terms for needleless connectors (n = 23).
      Appearance-shapeAppearance-colourOtherIndustry or technologyFunction (specific or general)
      Long shape

      Long one

      Thick bung

      Big purple

      Long shape
      Clear one

      Clear with blue internal

      Purple colour

      White cap

      Big purple

      Blue one
      “Difficult one, I have look at the packaging”

      “Don't know what they are called”
      Connectors

      Hub (‘scrub the hub™’)

      Negative pressure

      Positive pressure

      Neutral pressure

      Bi-valve

      Power ones

      SmartSite™

      MaxPlus™ or Maxi

      Luer-lock
      Connectors

      Bung

      Bung on burette

      Hub (scrub the hub)

      Negative pressure

      Positive pressure

      Neutral pressure

      Bi-valve

      Power ones

      Theme 3: Clinical practice determinants

      Participants reported several factors that affected their NC practices. These included: other pressing clinical duties (and patient factors) that influenced their prioritisation of tasks within the available time, differences in perceived risk related to device types, and various visual cues which prompted NC replacements. Time constraints influencing NC care (e.g., routine changes and decontamination), related to competing clinical duties (and emergency situations) were common. Other factors such as time pressure from patients also influenced care practices:“[During emergency] I just didn't get enough time and obviously prioritise that [emergency] over the [potential] infection” (FG 6)
      Participants articulated that CVADs including peripherally inserted central catheters (PICCs) were more carefully decontaminated and accessed due to perceived increase in bloodstream infection risk and “out of respect” (FG 7). A conflicting idea expressed by others was “I treat [all VADs] like CVADs” (FG 5).“PICCs, you see them as being a long-term thing whereas cannulas we see them as short-term. I don’t know if that makes us think differently [about NC use].” (FG 1)
      Finally, NC connector replacements were not only prompted by guidelines (every 7 days, as per hospital policy) but also by clinical cues such as NC occlusion/clotting and visual prompts (e.g. soiling).“if [patient has] a blood transfusion … then [NC are] quite dirty … I hope I would try to get a new one and replace it.” (FG 3)

      Theme 4: Decontamination procedures and influencers

      Topics emerged related to (i) how, (ii) how long, and (iii) why NC decontamination was actioned. This included: ‘the action (and area) of decontamination; ’ ‘time for clean and dry; ’ ‘indications to decontaminate; ’ and ‘NC location’.
      The trademarked phrase “Scrub the Hub”™ (Becton, Dickinson and Company) was commonly repeated, and “ritual” practices particularly in relation to the active twisting/friction decontamination motion emerged. The sound of decontamination (e.g., “squeaky”) also emerged as an indicator that NC decontamination was being done effectively. Time for decontamination and drying was also a common topic for discussion. While some staff confidently identified local hospital guidelines, many staff were either unsure, or used clinical judgement (rather than time recommendations) to guide their practice.
      Decontamination was generally prompted by standard practices (i.e., with each access), cues including blood or other soiling (visual cue), and as a response to possible contamination while they were accessing the NC.“I get really paranoid if I’ve cleaned it [NC] and then think I did I just bump that [NC]?” (FG 1)
      Participants were also conscious of the potential influence of NC location (VAD anatomical location) and that risks might differ dependant on this location. For example, externally connected NCs (e.g., those attached to administration sets and other consumables) were deemed lower risk:“Yeah, like if they’re lying in a bed, needing to change them all the time, they’re getting stuff all over their cannula.” (FG 2)

      Theme 5: Education and culture

      Several inconsistencies were reported for NC practices (related to both self and perceived in others), which suggested differences in education and/or culture (local unit) specific practices within the larger institutions (including professional disciplines). Educational experiences, particularly relating to participants' time as students, were commonly reported. Participants were also conscious that practices varied between recommended practices, practices taught at other institutions, and actual practice within their own hospital. Overwhelmingly, participants reported being compliant with ‘what they were taught/told’.“I think it’s the education you get. I won’t use alco wipes on the PICC or the CVAD connectors because I was taught to use the chlorhex[idine] wipes.” (FG 1)
      Guideline changes, and product availability also appeared to result in inconsistencies in care practices over time. Accepted practices and behaviours (culture) similarly evolved; one such example was the practice of regularly disconnecting and reconnecting the same administration line to the NC point.A lot of our grads … haven't come through that culture, so they don't do it [disconnect/reconnect the administration sets to the NC]” (FG 2)
      Participants were able to articulate these changes, and report how their practice had adapted as a result. Finally, participants were cognisant of variations in practice, specifically comparing practices to other health professional disciplines. This related to both the use of additional VAD consumables (such as three-way hub connectors) and practices in disinfection.“But I think nurses [compared to medical], certainly, are more inclined to cannulate, put a three-way tap on [with NC], because we’re the ones that are using it.” (FG 2)

      Theme 6: Research and innovation

      Finally, research and innovation, which invariably emerged from the interview question “Are you aware of any recent research or new evidence related to needleless connectors?” was a minor theme, with responding participants noting that they: were unaware of any research being conducted, unaware how research could change their practice, or found the research interesting but did not think it influenced their practices substantially. [These responses were in context of the parent effectiveness evaluation trial; some comments were related to general research.]“I always thought that was really interesting - not interesting enough for me to actually go home and research it but I thought it was interesting” (FG 1)

      Discussion

      Overall, the focus groups revealed several factors influencing nursing attitudes, techniques, and practices surrounding NC care. Overwhelmingly, staff presented positive attitudes towards NC use and disinfection (particularly for patient and clinician safety), however beliefs and practices sometimes inconsistent and did not reflect current scientific evidence. Beliefs related to technique and practice were formed either from previous education and peer knowledge (rather than policy or published evidence), or from a self-assessment of patient risk based on pre-understandings. While staff discussed problem solving practices, their actions did not appear connected to established policies and procedures. For example, while the local guideline listed clear indications for NC changes, participants used phrases such as “hope I would try” and “I would probably change.” This suggests participants did not understand the complexity of NC care; and the risks they posed to patients. A recent survey of Australian nurses suggests this knowledge gap is not uncommon, with many nurses relying on senior, experienced nurses to drive best-practice [
      • Slater K.
      • Cooke M.
      • Whitby M.
      • Rickard C.M.
      Needleless connector nursing care–Current practices, knowledge, and attitudes: an Australian perspective.
      ]. When considering the Capability-Opportunity-Motivation-Behaviour (COM-B) [
      ] model of behaviour, participants demonstrated that opportunity and motivation exist to conduct NC care competently, however ‘capability’ was hampered by insufficient knowledge and misinformed decision-making processes.
      Staff demonstrated confidence with disinfection related to the technique and audible cues of effective cleaning (e.g., ‘twisting,’ ‘squeaky’). A similar phenomenon was reported in a systematic review of hand hygiene practices, which found that cues (particularly visual cues), rather than memory of best-practice, prompted action and improved compliance [
      • Smiddy M.P.
      • O'Connell R.
      • Creedon S.A.
      Systematic qualitative literature review of health care workers' compliance with hand hygiene guidelines.
      ]. In contrast, confidence and knowledge was lower for decontamination time (to clean, to dry) and agent (e.g. 70% isopropyl alcohol). Language around time to decontaminate and dry was non-committal (‘probably’; ‘not sure’); this confidence with technique rather than timing or agent could relate to inconsistencies in teaching or knowledge burden. Interestingly, staff demonstrated general attachment to trademarked popular nomenclature such as ‘ANTT®’ (Aseptic Non-Touch Technique) [
      Aseptic non touch technique.
      ], ‘Scrub the Hub™’ [
      • Trademarks J.
      Scrub the hub - trademark details.
      ], and ‘5 Moments’ (of hand hygiene) [
      World Health Organization
      WHO guidelines on hand hygiene in health care.
      ]. This consistent use of popular language suggests that large educational campaigns, often presented repetitively to staff, were effective in influencing attitudes surrounding the importance of such actions. This suggests that future campaigns targeted at NC education, distributed at a macro-level and regularly repeated, could be beneficial; these campaigns should not only focus on trademark phrases, but also encouraging retention of the related content (e.g. decontamination duration). Plans for future work, should however, also include considerations for campaign fatigue (e.g. campaigns losing their effectiveness overtime) [
      • Seto W.H.
      • Yuen S.W.
      • Cheung C.W.
      • Ching P.T.
      • Cowling B.J.
      • Pittet D.
      Hand hygiene promotion and the participation of infection control link nurses: an effective innovation to overcome campaign fatigue.
      ].
      Notably, abundant nomenclature for NC product or labels could influence attitudes and practices. Nomenclature varied between participants and appeared to reinforce confusion, particularly related to the function of various NC. Some participants alluded to different functions (e.g., positive pressure) however few explained specific indications for various NC designs, demonstrating a superficial level of knowledge. The finding was consistent with a recent cross-sectional online survey, which found only 25% of respondents correctly identified a ‘negative pressure’ NC (from a description of NC characteristics) [
      • Slater K.
      • Cooke M.
      • Whitby M.
      • Rickard C.M.
      Needleless connector nursing care–Current practices, knowledge, and attitudes: an Australian perspective.
      ]. This misinterpretation of terms and generalisation of NC may lead to poor understanding of purpose and function, presenting potential risks for patients, as not all NC are designed for the same purpose [
      • Chernecky C.
      • Macklin D.
      • Casella L.
      • Jarvis E.
      Caring for patients with cancer through nursing knowledge of IV connectors.
      ]. This variety of language and product descriptions however is common for VADs, with similar terminology confusion recently forming from midline- and long-peripheral- catheters [
      • Qin K.
      • Nataraja R.
      • Pacilli M.
      Long peripheral catheters: is it time to address the confusion?.
      ]. New and updated guidelines should prioritise clear and consistent definitions for device characteristics (e.g. neutral, positive pressure) and related procedures, to alleviate this confusion.
      Management of blood in the NC, though not identified as a unique theme, frequently emerged as a point of conversation, and crossed multiple themes including ‘clinical practice determinants’ and ‘decontamination and infection.’ This cognisance of the presence of blood within the NC (and the larger catheter) might relate to the risk of fibrin sheath (and thrombosis formation) affecting the development of bloodstream infection [
      • Baumgartner J.N.
      • Cooper S.L.
      Influence of thrombus components in mediating Staphylococcus aureus adhesion to polyurethane surfaces.
      ]. Alternatively, it could again relate to the concept of visual and audible ‘cues,’ which appeared to strongly influence practice. This finding highlights a key priority area for education and quality improvement, as many contaminated NCs do not appear visible ‘dirty.’ A recent randomised controlled trial investigating NC disinfection for peripheral intravenous catheters, found 51% of analysed NCs grew common skin microorganisms [
      • Slater K.
      • Cooke M.
      • Fullerton F.
      • Whitby M.
      • Hay J.
      • Lingard S.
      • et al.
      Peripheral intravenous catheter needleless connector decontamination study—randomized controlled trial.
      ], undetectable to the naked eye.
      The results clearly demonstrated that participants were aware and appreciative of the safety functions of the NC (e.g., barrier and needle-free system); however, beliefs surrounding NC practices were inconsistent. Modifying these beliefs and practices (behaviour change), is likely to require a multi-faceted approach [
      • Whitby M.
      • Pessoa-Silva C.
      • McLaws M.-L.
      • Allegranzi B.
      • Sax H.
      • Larson E.
      • et al.
      Behavioural considerations for hand hygiene practices: the basic building blocks.
      ]. While nurses consistently demonstrated an attitude of beneficence towards their patients, it is clear more work is required to help nurses more consistently translate their values into practice. A recent systematic review found that non-compliance with NC disinfection was more often related to external factors (e.g. high workload burden, and availability of disinfection wipes at the bedside) [
      • Moureau N.L.
      • Flynn J.
      Disinfection of needleless connector hubs: clinical evidence systematic review.
      ]. Despite this, our findings suggest internal factors also play a role. Most notably, misunderstanding, particularly related to NC function and design, was common. This confusion potentially affects safe decontamination, and therefore infection risk. To date, research surrounding NCs has primarily focussed upon the agent, time and action of disinfection of NCs [
      • Flynn J.M.
      • Larsen E.N.
      • Keogh S.
      • Ullman A.J.
      • Rickard C.M.
      Methods for microbial needleless connector decontamination: a systematic review and meta-analysis.
      ], with recommendations well-articulated in national guidelines [
      • O'Grady N.P.
      • Alexander M.
      • Burns L.A.
      • Dellinger E.P.
      • Garland J.
      • Heard S.O.
      • et al.
      Guidelines for the prevention of intravascular catheter-related infections.
      ,
      • Kluwer Wolters
      Infusion Nurses Society
      Infusion nurses society: infusion therapy standards of practice.
      ]. In contrast, there is a paucity of research and guidance related to the NC function and design (e.g. positive, negative, neutral), likely related to the rapid changes in products and terminology occurring in this area [
      • Hadaway L.
      • Richardson D.
      Needleless connectors: a primer on terminology.
      ]. While our findings suggest that participants were ‘interested’ in NC research and innovation, there was no indication that they felt involved in the decision-making process around consumables choice. Furthermore, participants appeared unmotivated to undertake additional independent inquiries into NC function or design; this could further reflect a lack of time/capacity under current workloads. Including nurses and other clinicians in the testing and selection of NC in the future may carry benefits, by not only encouraging better understanding among this cohort, but also helping to make informed purchasing decisions based on practical understanding of daily clinical duties.

      Limitations

      This study, while presenting unique findings, has several limitations. The scope of this study was restricted to a nursing perspective; an interdisciplinary (e.g., medical physician) and patient perspectives could provide additional insights. However, nurses are the primary users of NC within this patient population. Additionally, this study was conducted at a single large tertiary hospital, affecting its generalisability to other settings. Despite this, several clinicians were able to compare and contrast with other healthcare institutions (in which they had formerly worked clinically), adding to the external validity of the findings.

      Conclusion

      NCs, while necessary in modern nursing practice, continue to be a potential risk factor for vascular access-associated bloodstream infection. Understanding staff attitudes and beliefs are key to ensuring consistency and maintenance of best practice; with future work needed on education related to NC function to ensure more consistent practices for decontamination.

      Ethics

      This study was approved by the Royal Brisbane and Women's Hospital Human Research Ethics Committee (HREC/15/QRBW/553) and Griffith University (Ref. 2016/410).

      Authorship statement

      All authors have made substantial contributions to the design, conduct, analysis and write-up of the results. Each author has given approval of the final submitted manuscript [Authors’ contributions: CR , JF , AU , SK, NM, MC, and SM conceived and designed the study. CR, JF, AU , SK, NM, MC, SM and EL and secured funding. EL, DA, SK conducted data entry and analysis, EL, DA, SK, JF, AU, NM, MC, SM, and CR prepared and approved the final version of the manuscript.

      Conflict of interest

      EL's affiliate ( University of Queensland ) has received, on her behalf: an investigator-initiated research grant from Eloquest Healthcare, unrelated to this work; EL was also awarded scholarship for conference attendance, by Angiodynamics, unrelated to this work.
      DA's employer has received on her behalf consultancy payments for educational lectures based on her research and clinical expertise from 3M and received flights and accommodation to present her research and clinical expertise from Johnson and Johnson Pacific and the Neonatal Nurses College Aotearo; unrelated to this work.
      SK's employer has received, on her behalf, an investigator-initiated research grant from Becton Dickinson, unrelated to this work.
      JF has no conflict of interest related to this research.
      AU's former employer ( Griffith University ) has received, on her behalf, investigator-initiated research grants and speaker fees from 3M, Becton Dickinson and Cardinal Health, unrelated to this work.
      NM: Griffith University or The University of Queensland has received on her behalf: investigator-initiated research grants and unrestricted educational grants from Becton Dickinson, Cardinal Health and Eloquest Healthcare; and consultancy payments for educational lectures/expert advice from Becton Dickinson and 3M.
      SM has no conflict of interest related to this research.
      CMR's employers ( Griffith University or The University of Queensland ) have received on her behalf: investigator-initiated research or educational grants from Becton Dickinson-Bard; Cardinal Health, Eloquest Healthcare; and consultancy payments for educational lectures/expert advice from 3M, Becton Dickinson-Bard.

      Funding

      This work was supported by investigator-initiated grants from Cancer Council Queensland , Queensland Health (Nursing and Midwifery Research Fellowship), and the Australasian College for Infection Prevention and Control. The randomised controlled trial, with which this study was associated [
      • Rickard C.M.
      • Flynn J.
      • Larsen E.
      • Mihala G.
      • Playford E.G.
      • Shaw J.
      • et al.
      Needleless connector decontamination for prevention of central venous access device infection: a pilot randomized controlled trial.
      ], received donated product (alcohol caps, ICU Medical). No commercial entity had any role in the conception, design or funding of this qualitative study, or in the preparation of the manuscript.

      Provenance and peer review

      Not commissioned; externally peer reviewed.

      Informed consent

      Written informed consent was obtained by all participants prior to involvement.

      Acknowledgements

      The authors would like to acknowledge the staff of the Royal Brisbane and Women's Hospital for their participation and support of this study. We also thank Zhang Li, Geoffrey Playford, Vineet Chopra, Nicole Gavin, and Tricia Kleidon for their assistance in applications for funding.

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