Nurses' Experience on Peripheral Intravenous Catheter Insertion, Care and Complications in Pediatric Patients

Nurses' Experience on Peripheral Intravenous Catheter Insertion, Care and Complications in Pediatric Patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Nurses' Experience on Peripheral Intravenous Catheter Insertion, Care and Complications in Pediatric Patients Ratna Shila Banstola, Ramchandra Bastola, Sachiko Inoue This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7264006/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Peripheral intravenous catheter (PIVC) is a common invasive procedure carried out by nurses which is more challenging in children. Given the lack of exploration of nurses' experiences related to PIVC initiation, care and management of complications in children, this study aimed to explore paediatric nurses' experience on PIVC initiation, care and management. Methods Exploratory qualitative study was conducted in Nepal. Three focus group discussions were carried out among 14 nurses working in paediatric in-patient unit of a government teaching hospital between November and December 2023, and thematic analysis was done. The Consolidated Criteria for Reporting Qualitative Research guideline was used. Results Nurses face difficulties in initiating PIVC in children which is increased by parental pressure and emotional response; staff turnover and shortage; the wish for vein visualization technology was explored. Significant number of children develop complications and timely recognition, parental involvement and infection prevention are important to reduce possible risk factors. We identified three interrelated themes: 1) Responsibility and challenges in initiating and maintaining PIVC in children. This theme explains four sub-themes; responsible, mix experience of own and parents' emotional response, difficulty in initiating, and facing multiple challenges. 2) Complications of PIVC and possible risk factors: this theme contains four sub-themes; complications in children, possible risk factors experiences, need of parental involvement, and importance of timely recognition. 3) PIVC care practice, realization of gap and hindrances experienced: it includes knowledge and practice gap, evidence-based practice need, staff-patient ratio, patients' socio-economic status, supply and economic barrier to health care and management practice, and complication management and possible preventive ways. Conclusion Nurses feel responsible to PIVC maintenance. Nurses has realization of lack of routine care and standard practice including infection prevention, which is linked to resource limitations, staff shortage, turnover, and patient affordability. Findings have practical implications for nurses, healthcare-team, and hospital for quality care of pediatric-patients. Nurses' experience peripheral intravenous catheter hospitalized children pediatric nurses Introduction Peripheral intravenous catheter (PIVC) is one of the most frequently performed invasive procedure in health care settings all over the world [ 1 ]. Despite the necessity and proved benefits of PIVC in treatment and recovery, it is painful and threatening procedure for children [ 2 ]. Compared to adults it is more complex in children because of their smaller and delicate veins that easily collapsed or get swells up, their unpredictable movements, and difficulty in communication (health care provider's difficulty to make children understand or children cannot express their level of discomfort to the provider) [ 3 – 5 ]. Mostly the nurses being responsible in carrying out this procedure daily in pediatrics are to deal with anxiety, painful experiences and distress of both the parents and children [ 2 , 6 ]. The PIVC failure, frequent occurrence of complications and need for repeated cannulation adds to the negative experience of children, parents and nurses [ 2 , 4 , 6 , 7 ]. A study from Bhutan has reported that 46% of PIVC in children was not successful at first attempt [ 8 ]. An Australian study reported difficult vein access and multiple attempts not only increases distress in young child and parents but most often lead to avoidance and delayed treatment [ 9 ]. Even the successful cannulation at first attempt get complicated earlier in children than in adults [ 2 , 10 ]. The mostly reported complication of PIVC in children are phlebitis and infiltration followed by extravasation, occlusion and infections [ 5 , 11 , 12 ]. These complications lead to pain, anxiety, extended hospital stay, and increased healthcare costs [ 4 , 6 – 8 ]. In the demanding healthcare system today, healthcare professionals are expected not only to master the insertion, care, and management of vascular access devices and decisions but also the field introduce multiple unexpected challenges [ 13 , 14 ]. Nurses are on the front lines of patient care and play a crucial role from initiation to ongoing care and maintenance, management, and prevention of complications of PIVCs [ 7 , 10 ]. For quality care, the nurses require not only knowledge and technical proficiency but also the ability to deal with and manage the challenges such as distress, anger, and frustrations of parents and children [ 13 , 15 ]. The emotional stress of managing their workload along with challenges in interacting with anxious parents, families, and children is the most demanding care environment for nurses and healthcare teams [ 2 , 16 ]. Given that pediatric nurses face unique challenges it is more important to understand the nurses’ perspectives and experience [ 15 ]. While most of the previous studies have assessed the complications related to PIVC and its associated factors in patients, still less among pediatric patients and very scarce previous work from developing countries [ 17 – 25 ]. Though some studies examined the knowledge and practice of nurses on PIVC care [ 20 , 26 , 27 ], the gap is realized in addressing pediatric nurses' firsthand experiences and insights related to PIVC care and management in patients. Two studies were found in our search and that is Taşdelen et al. explored the thoughts, anxiety factors, and experiences of pediatric nurses on the success and failure of first-time PIVC insertion [ 2 ]. Hjelmgren et al. explored nurses' experience in pediatric blood sampling and revealed that nurses in pediatric hospital care face a big challenge and often feel frustrated due to unsuccessful blood samples in children [ 28 ]. The lived experience and perspective of pediatric nurses on factors that lead to PIVC failures, the challenges they encounter, approaches to managing and preventing PIVC complications, and the overall emotional and professional impact of these experiences are important to explore. Hence to fill the gap, this study explored pediatric nurses’ perspectives on PIVC insertion and management, the difficulties they encounter, and their strategies for preventing and managing complications. Nurses' experience can provide a valuable base in planning targeted training and support for nurses and health care teams in pediatric settings of a resource-constrained country. Ultimately can lead to improvements in the clinical protocol, education, and support system for nurses, and can enhance patient outcomes and health care quality. Methods Study design and participants An exploratory qualitative study was conducted with nurses working in paediatric in-patient unit of a government teaching hospital in Nepal. The Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guidelines for qualitative study were followed [ 29 ]. The pediatric unit has 40 beds including 6 bedded PICU, and 14 registered nurses working in pediatric ward were recruited via purposive sampling technique. The nurses who had at least 6 months of work experience in pediatrics were included in the study. The age range of the nurses was 25 years to 46 years. All the 14 nurses' had the academic qualification of baccalaureate in nursing and work experience in pediatric ward was 9 months to 10 years. Their participation was voluntary and informed written consent was obtained for the participation in this study. Data collection The data was collected through focus group discussion (FGD) between September and November 2023. Formal permission for data collection was obtained from the hospital authority, then the coordination with the ward in charge was done by the researcher (RSB). With the help of the ward in charge, the initial meetings with the nursing staffs were done to explain the purpose of the research. The researcher (RSB and RB) were familiar with the staff, therefore it was easier to obtain their agreement in participation. The participants were assured that their identity would not be disclosed and the data would be used for research purposes only. The FGD was carried out in the ward (nurses’ room) at their convenient time. Three FGDs were conducted, Group One included 6 staffs, Group Two included 5, and Group Third included 3 staffs. The audio recording was done with the consent of the participants. And field note was taken during FGD. One FGD took 50 to 60 minutes and subsequent FGD was done until data saturation was met i.e., until no new information was obtained. The FGD guideline included 8 main questions and their probing; such as, who carry out PIVCs in your ward? How is your experience related to PIVC insertion?; Can you please discuss the difficulties experienced related to PIVC initiation and management in children?; Can we discuss here about practice of PIVC care in this department and your perspective?; What are the PIVC-related complications you have witnessed or experienced in pediatric patients?; In your opinion, what are/might be the possible causes of complications related to PIVC in children?; How have you managed the IV complications in pediatric patients?; What can nurses do to prevent or reduce the complications of PIVC in pediatric patients? Ethical considerations Ethical principles outlined in the Declaration of Helsinki for the study included human participants were taken into account in all conduct of this study. Written informed written consent was obtained. Confidentiality and privacy of the participants was assured and maintained. Ethical approval was obtained from the Institutional Review Committee of Pokhara Academy of Health Sciences (183/079, 2nd June 2023). Data analysis Thematic analysis of the data was done following six phases of thematic analysis according to Braun and Clarke [ 30 ]. The researchers transcribed the information obtained from FGDs. Then it was read and reread to gain an understanding of the participants' perspectives. Most relevant information was highlighted and coded, again recoding was done by synthesizing and grouping the similar. It was a rigorous process that was done by each of the researchers simultaneously as well as independently. We worked together to find the most appropriate themes from those codes keeping in mind that the data obtained from the participants exactly matches the themes and no information was overrepresented or overlooked. The themes were reviewed finalized, and agreed upon by all the researchers. The result was communicated and discussed with the participants for their approval, which enhanced the trustworthiness and credibility. Findings Study explored nurses’ experience with peripheral intravenous cannulation, complications, and care practice in children. A summarized breakdown of the qualitative data revealed three main themes: 1) responsibility and challenges in initiating and maintaining PIVC in children; 2) Complications of PIVC in children and possible risk factors perceived; and 3) PIVC care practice, realization of gap and hindrances experienced. Nurses feel PIVC insertion and care as their crucial responsibility in pediatric care. Nurses encounter multiple challenges that are linked to emotional responses and patient outcomes. Difficult vein access, dislodgement, pressure from parents, and mixed experiences of success and failure are mostly reported. Various causes of difficulties were expressed, such as, nurse-patient ratio, 2–3 nurses in a shift for 40-bed units that also include PICU. Therefore, the workload and time hinder the nurses’ ability and wish for care and counseling to parents before and during PIVC. Lack of counseling is felt to cause parents getting angry, verbalizing negativism, and dissatisfaction with the nurses’ care. Need for special devices/technology for vein visualization was also raised. Staff shortage also affecting on nurses' feeling of success and satisfaction with the procedure. The difficulty is also linked to communication and the child's level of understanding. Nurses also emphasized nursing graduate preparation, and need for mentoring new staff, and problem of staff turnover (Table 1 ). Table 1 Theme 1: Responsibility and challenges in initiating and maintaining PIVC Sub themes Codes Transcripts Responsible Mix experience of own and parents' emotional response Difficulty in initiating Facing multiple challenges related to human resource, turnover of trained staff and need of technology Feeling Responsibility Success and failure Stress, worry, anxiety Anger, frustration, quarrel Upset, facial expression Feel happy when success Affect subsequent procedure Wish cooperative work environment Cooperative, quiet environment Difficult vein access Counseling to parents Child's characteristics Pressure from parents and others Want to work without pressure Special devices, Vein visualization technique Staff shortage, Lack of trained person/staff, Staff turnover, Nurse graduates' preparation “Most specifically nurses do and nurses are responsible. If sometimes no vein is accessed, we inform resident doctors, and doctors put in scalp” (N5, N6, N7, N8, N9, N10, N11, N14). "When vein is not visible the visitors make facial expression and sound, the child cries. In such we get upset and it affects subsequent success” (N7, N11, N13). “If more than one prick needed then they become angry, we wish to work in quiet cooperative environment” N10, N11, N12 “Those come for chemotherapy, or the child with thalassemia come monthly for blood transfusion and we feel difficulties and feel sorry” (N4, N12). “We usually do cannulation in treatment room keeping the parent/guardian inside. Most of the time we have to ask the parent to hold the child and keep still from moving the extremity where we are going to place cannula. And it is difficult to keep parent and tell them to hold because they are already anxious with their child’s illness, they fear and worry with procedure, on the other how they hold is not as we wish, the child moves and it is very difficult” (N4, N7) “It is more difficult in toddlers compared to infant, and also school age child do not listen to us, they refuse and they are bigger/grown up to control to hold” (N2, N8, N9) "Critical child, obese or child with immune condition and prolong hospitalization is difficult" (N1, N5) "Nephrotic child already swollen, or if child is dehydrated and high fever the veins get bulge after prick" (N5, N11, N14) “We heard there are devices to better visualization but we do not have such new technology in our practice. We wish if we have, it would be very better for us and for our children" (N9). "The important issue is trained human resource and it is best if staffs or trained person hold and support the child during cannulation” (N8, N13). “During study period, students do cannulation mostly in adult patients. So we should teach new nurses and assist them to cannulate in not critical and cooperative child with well visualized vein in initial period. We need to build their confidence" (N9, N5, N11). "It is better if there is no turnover of nurses, if experienced staff leave we have problem" (N9, N12). Table 2 Theme 2: Experience of complications of PIVC in children and possible risk factors Subthemes Codes Transcripts Complications in children Possible risk factors experienced Parental involvement Importance of timely recognition Common complications Risk factors Different medicines Period of medication Fluid infusion plus IV push Medicine administration Mobility of child, playful Anatomical site and vein Duration of hospitalization Critical care unit Realization of asepsis Need to change practice Hygiene, parental care and involvement Missed to recognize pain Timely recognition “We find the problems such as, redness, swelling, pain and fever and common complication is phlebitis and infiltration here. Those getting IV medicine such as, vancomycin has more incidence of phlebitis and those getting both IV fluid infusion and IV medicine have developed infiltration more” (N7, N8, N9). “Extravasation also occurred, once the dobutamine was, I saw patient developed blister. It can occur in chemo also, but thank fully not happened to us yet” (N10, N12). “Those getting vancomycin, ceftriaxone, amikacin, phenytoin, tazobactum, KCL in infusion, and those getting medicine for long time are developing problem” (N1, N2, N3, N7, N8, N9, N13). 'We found more problem in children who are hospitalized for longer duration more than week or those who are very sick and in critical care” (N2, N3, N4, N5, N9, N10, N11, N12). “We can do flush, give medicine in beuro or infusion set if quantity of medicine is more and we should dilute medicines properly, because we found vein damages early with higher concentration IV push" (N5, N7, N8, N9). “Children are playful, they move excessive and do not understand. Therefore, kinking and displacement occurs” (N1, N7, N9, N11) “Usually large veins are good, how it is fixed also determines, I feel brachial and saphenous is good and goes for longer. Cannula in the wrist and in small veins are not good, while, we are careful in scalp vein”(N1, N3, N4, N5, N11). “We also felt that repeated hospital admission, and repeated and longtime cannulation interfere healing of veins and caused failure at cannulation and more complication” (N12, N14). “Infection is also a cause of phlebitis which can be due to contamination with child’s urine and stool. Our practice should be changed, once the vein is visualized and confirmed we swab the site for insertion, then the area that should not be touched after swab, or if so it is better to wear gloves” (N7, N9, N5) “We are using sterile cotton to swab, we try to do minimal prick as far as possible. We try good fixing can be done” (N5, N11, N14). “It is important to follow sterile technique, we should not put cannula in unsterile surface after we open the packet, instead we can put it in the packet of that cannula” (N5, N9, N10) “We can wear surgical gloves, and we should not and we do not do double prick” (N6) “but it is difficult with gloved hand to apply tape” (N1) “I saw 2 days back one child came from other hospital and the bandaging in his PIVC site was too tight and the finger was blue due to compromised circulation. Therefore, I always keep fingers out of bandage and I also show the parents fingers are out” (N1, N4, N5). "While in the part of patient, many of the times cannula in lower extremities is found soaked with urine, some with stool. Parents do not keep bed and surroundings clean. Even the cannula’s cap is kept open” (N2, N3, N5, N10). 'Children are sensitive, they just cry and always it may not be the pain, so we also miss to recognize either actual pain in IV site or it was the child’s fear” (N6). “It is better to apply tape only, bandage covers the inflammation and redness, therefore, it may miss to timely identification” (N9). Nurses reported the most common complications of PIVC in children is phlebitis and infiltration. The displacement and self-removal also causing need for re-cannulation. Impact of these complications on patient comfort, efficacy of treatment, health care resources, stress and worry to parents, and the economic cost for family were noted from nurses' expression. The nurses also expressed that sometimes they miss to recognize actual pain. Further risk factors they have experienced are insertion technique, movement of child, type of medicine, repeated hospitalization, disease condition and immunity, infection, hygiene and cleanliness, how the parents take care of child, and anatomical site and vein. They emphasized that asepsis is important, however, partial lack is also realized (Table 2 ). Nurses expressed their realization of the need for IV site care including adequate dressing, securement, regular monitoring and documentation to ensure early detection of problem. However, there is no routine practice and they do observe when go for medication. They also ask to child and listen to parents for any complain of pain/problem. Despite their realization of importance of IV care, nurse-patient ratio, difficulty in children gaining cooperation were raised as problem. There was mixed responses on knowledge and practice for duration of PIVC. Good to report was their literature search in confirming the duration and make decision on when to change the cannula in children. Nurses reported their inability to adhere to standard practice (for example, changing IV set) for most of their patients linked to supply issue, patient affordability, and resource/financial limitations. The effective of practice they found in managing the complications of PIVC are, immediate removal of cannula, applying ice pack, thrombophob ointment if swelling, and phlebitis. In infiltration or extravasation, before removal of cannula they withdraw the infiltrated fluid as much as possible. They also discussed the importance of timely identification and intervention to prevent worsening complications. The prevention strategies they feel to be followed are maintaining infection prevention through hand washing and maintaining sterile technique before IV cannulation or giving IV medicine/infusion, regular monitoring and documentation of problem, giving more concern to critical children, and education to parents. Nurses expressed their awareness about possible complications of chemotherapeutic drugs and feeling happy for not having such incidences (Table 3 ). Table 3 Theme 3: PIVC care practice, realization of gap and hindrances experienced Knowledge and practice gap Evidence-based practice Staff-patient ratio Socioeconomic status of Patient Supply and economic barrier to health care Management practice Management of complications Possible preventive ways Realization of gap No routine practice Parents responsibility and inform Child's fear, Patient cooperation Realization of gap Staff-patient ratio and workload Medication and observation Literature based practice Infection prevention Practice to prevent complication Changing IV sets Economic condition Supply and support issue Affordability, feel sorry Management of complication Application of ointment Elevation, withdraw, removal Conscious on complication Chemotherapy Aware on complication “We do not practice IV care as routine but if there is cannula swelling, or if child removes, then we do change……plus children are not co-operative” (N1). “We tell parents to inform if there is problem or we see blood in dressing, we change the tape and bandage” (N1, N3, N6). “We do not change tape or do anything to cannula because the child fear with us looking white dress approaching near, they move and if we try to change new dressing/tape it may dislodge. Therefore, we do not do unnecessarily” (N7, N11). "There is no condition to one to one care, there are 40 beds and we nurse are 2–3 in a shift plus we have PICU here, so it is busy and we have challenges. If there are student nurses, we get time to observe” (N10). “It is better to care, however, nurses are very few for each shift, plus child do not co-operate but we see when we do medication. We have to do medication TID or QID therefore, at least one medication at a shift make sure that we observe once in each shift” (N1, N5, N6, N7, N13, N14) “Previously, there was a discussion in the ward if we should change cannula in 72 hours but after literature searches we confirmed that until the cannula is working and no problem, then not needed to change. We keep how long it works” (N5, N6). "Our practice should be changed should not touch after swab and if so it is better to wear gloves either"(N7, N8, N9). “We use syringe for 24 hours and then discard, similarly IV set and Beuro set need to be changed 48–72 hours but this is not always possible” (N1, N5, N7, N9). “This is the government hospital and many patients are poor. If affording family, we change IV set in 3 days otherwise difficult to follow even if we know. How we can….if there is support and supply we can follow the practice” (N5, N9, N10). “In phlebitis we immediately remove the cannula, swab the area with antiseptic solution, apply ice pack and thrombophob ointment” (N1, N2, N3, N5, N8, N11). “Sometimes we feel sorry to ask them to purchase thrombophob, if we have in stock we apply or we just apply ice pack, ice pack also works” (N3, N5). “In care of infiltration, we withdraw the infiltrate and remove the cannula, then we elevate the part" (N7, N8, N9, N3, N4, N10). “In some we put xylocaine gel in a gauze piece and then apply that gauge over the inflamed and painful area” (N4). “We are giving chemo drug mostly the vincristine in our ward for last 1 year and luckily we did not have infiltration or extravasation of chemotherapeutic drugs yet, we are conscious for that” (N2, N5, N9). Discussion Responsibility and challenges in initiating and maintaining PIVC in children Peripheral Intravenous Catheter (PIVC) insertion and its care are vital responsibilities for nurses in pediatric settings. A previous study conducted across 47 countries, including the USA, Europe, Africa, and Australia, also found that nurses inserted most PIVCs in children (71%) [ 7 ]. Similarly, a qualitative study in Spain revealed that although nurses feel responsible for PIVC care, they do not view themselves as the primary decision-maker about PIVC insertion and removal [ 16 ]. In our study, nurses reported encountering several challenges in PIVC insertion and maintenance in children. One key challenge identified was difficulty of cannulation in a children compared to adults, which is linked to the factors such as the child's understanding level, communication difficulties, and their physical build, particularly in sick and critical children. A study among 200 Bhutanese children found that 36% of PIVC insertion failed on the first attempt [ 8 ]. Additionally, Ullman et al. reported more frequent insertion failures, higher pain and distress, and greater number of insertion attempts; and a higher complication rate in children compared to adults [ 7 ]. Staffing and resource limitations also emerged as significant challenges as discussed by the nurses in this study. Nurses also mentioned hearing about advanced technologies for vein visualization, but they lacked access to such devices in their practice. A previous review highlighted the benefits of technologies that assist in locating veins, determining vessel size and depth, and achieving higher success rates of PIVC insertion, reducing procedure time, and alleviating stress for both parents and children [ 15 ]. A Bhutanese study also reported that 82.7% PIVCs were successfully placed after using a trans-illuminator [ 8 ]. In addition, parents' desire of PIVC insertion to be done with proper visualization, such as, with the use of visualizing light or ultrasound, and by an experienced healthcare provider was revealed by the study [ 6 ]. Hence, providing technological assistance and mentorship could support nurses in improving PIVC insertion success rates. As stated earlier, the experience of nurses is a critical factor in ensuring patient safety and satisfaction. However, nurses also raised concerns regarding staff turnover and associated problems. Novice nurses in pediatric settings often rely on senior nurses for guidance and training, but when experienced staff leave, the burden of training new staff increases. Past studies have corroborated this finding, showing that nurses with less than 3 years of experience often lacked the ability to perform successful PIVC insertions [ 31 ]. In contrast, professionals with five years or more experience in pediatric emergency showed significantly higher success rates and faster PIVC insertions on the first attempt [ 32 ]. The need for preparing the nursing graduate to work confidently in pediatric-settings was also raised in our study. This is particularly important because students often practice cannulation in adult wards, but rare or never perform in children. Similarly, a qualitative study among Australian undergraduate nurses also revealed that while universities provide foundational knowledge about PIVC assessment, the practical application of this knowledge and skill development during clinical placement is inconsistent, which can negatively impact patient safety [ 33 ]. The importance of training and competence in PIVC management was further emphasized by parents, who expressed concern about inadequate competencies of healthcare staff, which threatened their children's comfort and safety [ 7 ]. A study conducted among pediatric nurses in Kazakhstan revealed that a lack of knowledge about patient assessment, PIVC insertion, maintenance, and removal was prevalent. Nurses' education, experience, and recent training were significant predictors of their knowledge and directly influenced their confidence in performing PIVC procedures [ 34 ]. Therefore, preparing competent graduates, mentoring new nurses, and preventing staff turnover are important to high-quality care. Nurses also identified a lack of counseling as a challenge, which they attributed to understaffing and heavy workload. As a result, parents voiced dissatisfaction, verbalize anger, and expressed negative emotions towards the nurses’ care. Similarly, Spanish pediatric nurses also expressed while patient education is relatively simple and important, it is difficult to implement during PIVC care [ 16 ]. The desire for a cooperative and calm environment without unnecessary pressure was expressed repeatedly by nurses. Parents too have their concerns. For instances, an Australian study reported that some parents had to stop the procedure themselves, noticing that their child was too distressed. Parents expressed the need of clear communication, so they could better prepare their children, however, nurses are often overwhelmed with lack of time and workload [ 6 ]. A qualitative study in Southern Australia also concluded that multiple PIVC insertion attempts caused distress to children and parents, leading to treatment avoidance. Effective interpersonal skills, offering choices, avoiding frightening language, and referring children with a history of difficult venous access to experienced nurses or specialist would help alleviate distress [ 9 ]. For some solution, a study in Turkey reported that nurses used distraction techniques during the procedure, such as, allowing child to play with a toy, sitting on mother's lap, watching cartoons, and administering oral sucrose [ 21 ]. Though the parents are kept with the child during the procedure, other distraction techniques were not expressed in the present study. We believe that incorporating such methods could make the procedure less threatening and painful for the child, and reduce parents' distress. Hospital authorities can provide regular training and mentorship to staff, ensuring retention of the experienced nurses and creating pleasant work environment to enhance both the nurses' and patient satisfaction. Experience of complications of PIVC in children and possible risk factors Nurses reported encountering various complications of PIVC in children, including redness, pain, swelling, obstructions, displacement, and self-removal all of which require re-cannulation. The most common complications were phlebitis and infiltration, which have been similarly documented in several quantitative studies in different parts of the world [ 4 , 5 , 7 , 10 – 12 , 35 ]. Nurses also noted the impact of these complications on patient comfort, the effectiveness of treatment, health care resources, parental stress and worry, and the economic burden on families. Other studies have similarly highlighted the negative impact of complications on patient outcomes and cost implications [e.g., 8], as well as the resulting delay in treatment and increased stress to children, parents, and to the healthcare professionals [ 4 , 6 , 7 ]. A major concern for nurses was the failure to recognize pain in children due to their tendency to cry when a stranger or healthcare provider approached. Additionally, parents sometimes don’t want to make next prick if it works for now. Past study also indicated that healthcare provider's competence, infection prevention, and pain management were the key determinants of patient satisfaction [ 14 ]. This presents challenging situation, as nurses struggle to recognize actual pain, while parents may feel nurses are not concerned about them. A study among parents revealed that parents were frustrated by lack of attention to their child's pain, and nurses sometimes did not believe and it feels that not being heard, i.e., staff don’t believe when they tell them it is painful, or if asked to give antibiotics slowly to reduce the pain [ 7 ]. Centre for Disease Control and Prevention recommends using antiseptic like 70% alcohol, tincture of iodine, povidone, or chlorhexidine gluconate before PIVC insertion, and emphasized the need for maintaining aseptic techniques [ 36 ]. Wearing at least clean gloves and using of mixture of 70% alcohol and 2% chlorhexidine is also recommended [ 37 ]. Although the nurses expressed that maintenance of asepsis and medication procedures determine the longevity of cannula, they expressed challenges in maintaining it, particularly in emergencies and staff shortages. They got training on maintaining asepsis in cannulation however, due to the color of povidone iodine nurses are feeling inconvenience in proper visualization of the vein and using only 70% alcohol. Nurses also expressed difficulty to apply tape with a gloved hand when they are doing cannulation alone. Past studies also mentioned poor infection prevention practices, such as inadequate hand hygiene, disinfection of insertion sites, improper use of PIVC dressings [ 7 , 38 ]. At this point, healthcare professionals need to have a clear understanding and the commitment to infection prevention practices. Healthcare professionals need to be encouraged and supported to follow infection prevention protocols. Furthermore, parents in our study did not seem concerned about infection prevention, which indicate a lack of awareness of infection prevention. Educating parents and families could help in preventing infections and complications [ 7 ]. Nurses also identified the potential impact of concentrated medications, such as, vancomycin, ceftriaxone, amikacin, phenytoin, tazobactum, and potassium chloride on PIVC complications. Several studies also showed the effect of medicines like vancomycin and ceftriaxone [ 39 , 40 ], piperacillin/tazobactan [ 17 ], and irritating/vesicant drugs and electrolytes [ 41 ] for PIVC complications. Future studies could explore the effect of amikacin, potassium chloride, dobutamine, and phenytoin to add the current understanding. Additionally, risk factors for difficult cannulation, failure, and complications includes the duration of hospitalization, repeated hospitalization, long-term cannulation, infections, immunocompromised condition, malnutrition/obesity, dehydration, and hygiene. Previous studies have confirmed that chronic health problems, immunocompromised status, and long-term hospitalization increase the risk of complications [ 3 , 4 , 11 , 12 , 35 , 42 ]. Nurses also expressed that PIVCs in the lower limbs, in small veins and joints tended to develop problems earlier, which is consistent with past studies [ 4 , 5 ]. Thus the findings from this qualitative study of nurses' clinical experience have added to our understanding and supplemented previous findings. PIVC care practice, realization of gap and hindrances experienced Despite nurse's realization of the importance of PIVC care and documentation, there was a common expression that PIVC care is not integrated into their routine nursing process. Nurses primarily observe and manage the PIVC during the medication administration or change the dressing if there is blood. A study among Australian nurses found a similar gap in the application of theoretical knowledge on PIVC care and management [ 33 ]. A Spanish study identified that PIVC care was often seen as task rather than an integral part of nursing care process, which led to disjointed and suboptimal care [ 16 ]. Understaffing and workloads were recurring themes in nurses' experiences. A Jordanian study reported primary care model was protective for phlebitis compared to the functional care model adopted by nurses [ 35 ]. While, a Spanish study among nurses working in the geriatric ward reported lack of time and workload hindered them from offering the best care and they are not able to devote as much time as they would like to PIVC care [ 16 ]. Some studies have recommended increasing nurse-patient ratio and ensuring sufficient infusion pumps are available to prevent complications [ 39 ]. In our study, nurses expressed that although they have infusion pumps, they still feel insufficient to meet the needs in maintaining drop rates of fluids in children, especially for viscous or irritant medicines that require slow infusion. Therefore, supplies and equipment support could motivate nurses to adhere to the standard practice. Nurses also involve parents during PIVC care process by providing advice and answering questions, and nurses experienced it as convenient approach where one-to-one primary care is not always possible. The CDC also recommended regular monitoring of the catheter sites visually when changing the dressing or by palpation through an intact dressing, and it is also beneficial that the healthcare personnel should encourage patients to report any changes or discomfort in their catheter site [ 36 ]. In an Australian study also the parents expressed that they wanted to be involved, provide them with direction on how to assist, to feel empowered because they know their child best [ 6 ]. Therefore, the involvement of parents can reduce the risk of PIVC complications in children through the identification of the problem earlier. However, routine assessment and care of PIVC by the nurses using a standard guideline in the ward will be the best approach to prevent complications in children. A Turkish study also revealed that despite a high prevalence of infiltration and extravasation, the interventions to address them were inadequate, therefore the need for training and implementation strategies for pediatric nurses was recommended [ 43 ]. We explored that there is no fixed protocol for PIVC assessment or care followed in the ward. Although it is emphasized on evidence-based guidelines (Massey et al., 2023), and it would be better that hospitals establish algorithms to prevent and manage PIVC insertions and complications [ 21 ]. Therefore, the department or hospital authority can work on this and the effectiveness of using a guideline can be studied in the future and the staffs can be supported and motivated to adherence to a set practice in the department. The knowledge-practice gap was evident in IV and burette set changes, a crucial measure of infection prevention. Non adherence was linked to supply shortage, parental affordability and financial limitations. It is also worth mentioning that nurses in our study searching literature for the duration of the cannula and keeping as long as there is no problem, which is a standard recommendation for children as well [ 1 , 13 ]. We revealed that nurses were aware of complications of chemotherapeutic drugs, as they received training on the safe handling and administration of chemotherapy. They were happy to share the experience of no adverse incidents and complications happened yet to their children. Nurses also discussed their experience in effective management of complications. In case of phlebitis, they remove the cannula, clean with 70% alcohol, apply an ice pack and thrombophob ointment, and elevate the area. For infiltration, they first withdraw the infiltrated fluid and do as in phlebitis. They also found beneficial effect of applying xylocaine gel on a gauze piece in reducing pain at PIVC site. Future studies could validate these experiences for cost-effective PIVC management. In partial support lidocaine application before catheterization for pain management was identified by a previous study [ 37 ]. This study added that its application post-removal also reduces pain. A Nepalese study found glycerin magnesium sulfate and heparin benzyl nicotinate effective for paediatric phlebitis [ 44 ]. Additionally, ice pack or cold compress have been shown to alleviate pain during infusion [ 45 ]. A Turkish study supports interventions like cold application, alcohol swabs, and elevation for infiltration [ 43 ]. Overall, the nurses emphasized the need for human and material resources, training and guidance, and a standard protocol to be followed in pediatric PIVC management. The combination of technical challenges, emotional stress, and resource limitations highlights the necessity for support and innovation in pediatric care. Limitations Study explored the pediatric nurses' experience on PIVC management in children, and to our knowledge, it is the first study. This added to our understanding and supplemented the quantitative findings of past studies. Despite these strengths, study has some limitations. Although study was conducted in a tertiary-level government hospital, findings of a single setting may not be generalized to other hospitals. Future studies can consider nurses from multiple centers. The study did not include the experience of nurses working in the neonatal unit. Different approaches to care and management of PIVC complications identified in this study can be validated with future studies. Study brought the issues and challenges related to PIVC insertion, care, and management in children. The findings can be utilized in practice by nurses and pediatric healthcare team to prevent or reduce complications of PIVC. Findings can be implied by hospital authority to plan interventions and support the nurses and clinicians in establishing routine PIVC care and improving quality care for children. Infection prevention practice and a standard protocol for assessment and care of PIVC in pediatric settings are important. Hence, the nursing supervisors, nurse administrators, and hospital authority can support and motivate the nurses and health care team in pediatric inpatient units by supporting staffing and supplies issues, continuous mentorship, establishing a care protocol, and preventing turnover or retaining experienced staff. The effectiveness of the management of PIVC complications practiced by nurses can be studied to validate and utilize as evidence-based cost-effective clinical practice in the future. Conclusion The experience and perspectives of pediatric nurses from a developing country on PIVC initiation and care in hospitalized children has been explored. The findings revealed that nurses are responsible for PIVC initiation and care, while facing multiple difficulties, challenges, and emotional experiences impacting PIVC maintenance in children. The gap in PIVC care practice, infection prevention, routine assessment, and care was realized. Staffing, staff turnover, equipment, and supplies were the hindering factors. Nurses' experience with complications of PIVC in children, possible risk factors, nurses' practice in the management of complications, and possible preventive ways were revealed. The need for routine PIVC care, infection prevention, and prevention of complications of PIVC in children is identified. To enhance staff satisfaction and quality care to their patient, hospital can focus on the support, supplies, mentorship, and retention of experienced staffs. Nurses' expressions also provided an area for future researches as well. Declarations Acknowledgements We thank the hospital authority for the permission to study, and the paediatric nurses for their invaluable participation. Author Contributions RSB: conceptualization; methodology; data collection and curation; writing original draft. RB: methodology, writing-review and editing. SI: methodology; writing- review and editing. Ethics approval and consent to participate Ethical approval for the study was obtained from Institutional Review Committee of Pokhara Academy of Health Sciences (183/079, 2nd June 2023). Formal permission for data collection was also received from the hospital authority. The study was conducted in accordance to the Declaration of Helsinki. Detail information sheet about the study was provided to the participants and then informed written consent was obtained before data collection. Participation in the study was voluntary. Privacy and confidentiality was assured and maintained. Data was used for research purpose only. Consent for publication Not applicable. Conflict of interest There is no conflict of interest to declare. Funding The study was conducted with support of faculty research grant (FRG-79/80-HS-05), University Grants Commission, Nepal. There is no funding for the publication. There was no role of the funding body in the design of the study, including the collection, analysis, and interpretation of data and in writing the manuscript. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request. References Gorski LA, Hadaway L, Hagle ME, Broadhurst D, Clare S, Kleidon T, Meyer BM, Nickel B, Rowley S, Sharpe E, Alexander M. Infusion therapy standards of practice. J Infus Nurs. 2021;44(1S):S1–224. https://www.aspirus.org/Uploads/Public/Documents/Library/Infusion_Therapy_Standards_of_Practice,_8th.1.pdf . Taşdelen Y, Topan A, Şahin ÖÖ. Paediatric nurses' experiences of success and failure in first-time peripheral intravenous catheter insertion: A qualitative study. J Pediatr Nurs. 2024;75:57–63. https://doi.org/10.1016/j.pedn.2023.12.002 . Floriano CM, Avelar AF, Peterlini MA. Time-related factors for peripheral intravenous catheterization of critical children. 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J family Med Prim care. 2019;8(9):2827–31. 10.4103/jfmpc.jfmpc_559_19 . Lulie M, Tadesse A, Tsegaye T, Yesuf T, Silamsaw M. Incidence of peripheral intravenous catheter phlebitis and its associated factors among patients admitted to University of Gondar hospital, Northwest Ethiopia: a prospective, observational study. Thromb J. 2021;19:1–8. 10.1186/s12959-021-00301-x . Simões AM, Vendramim P, Pedreira ML. Risk factors for peripheral intravenous catheter-related phlebitis in adult patients. Revista da Escola de Enfermagem da USP. 2022;56:e20210398. 10.1590/1980 . Keleekai NL, Schuster CA, Murray CL, King MA, Stahl BR, Labrozzi LJ, Gallucci S, LeClair MW, Glover KR. Improving nurses' peripheral intravenous catheter insertion knowledge, confidence, and skills using a simulation-based blended learning program: a randomized trial. Simul Healthc. 2016;11(6):376–84. 10.1097/SIH.0000000000000186 . Osti C, Khadka M, Wosti D, Gurung G, Zhao Q. Knowledge and practice towards care and maintenance of peripheral intravenous cannula among nurses in Chitwan Medical College Teaching Hospital, Nepal. Nurs open. 2019;6(3):1006–12. https://doi.org/10.1002/nop2.288 . Hjelmgren H, Ygge BM, Nordlund B, Andersson N. Nurses’ experiences of blood sample collection from children: a qualitative study from Swedish paediatric hospital care. BMC Nurs. 2022;21(1):62. https://doi.org/10.1186/s12912-022-00840-2 . Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. https://doi.org/10.1093/intqhc/mzm042 . Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Sandström L, Forsberg A. Problems associated with performance of peripheral intravenous catheterization in relation to working experience. J Vasc Nurs. 2018;36(4):196–202. https://doi.org/10.1016/j.jvn.2018.06.002 . Shaukat H, Neway B, Breslin K, Watson AR, Poe K, Boniface K, Cohen JS. Utility of the DIVA score for experienced emergency department technicians. Br J Nurs. 2020;29(2):S35–40. https://doi.org/10.12968/bjon.2020.29.2.S35 . Massey D, Cooke M, Ray-Barruel G, Marsh N, Ullman AJ, Craswell A, Wallis M. Nurses’ education, knowledge and perceptions of peripheral intravenous catheter management: A web-based, cross-sectional survey. Collegian. 2023;30(4):578–85. https://doi.org/10.1016/j.colegn.2023.03.001 . Cruz JP, Baigulina B, Shalkenova Z, Tau G, Dossymbayeva E, Kostauletova A. Investigating the Kazakhstani Pediatric Nurses’ intravenous catheter management knowledge and confidence: A cross-sectional study. Nurse Educ Pract. 2023;73:103816. https://doi.org/10.1016/j.nepr.2023.103816 . Suliman M, Saleh W, Al-Shiekh H, Taan W, AlBashtawy M. The incidence of peripheral intravenous catheter phlebitis and risk factors among pediatric patients. J Pediatr Nurs. 2020;50:89–93. 10.1016/j.pedn.2019.11.006 . Centre for Disease Control and Preventions. Infect Control. 2017. https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html Kim YJ, Lee SM, Park HR, Sohng KY, Kim SJ. Development of evidence-based nursing practice guidelines for peripheral intravenous catheter management in hospitalized children and adult. Int J Stud Nurs. 2017;3(1):82–105. 10.20849/IJSN.V311.309 . Horsfield C. A personal experience of care and the lack of it. J Infect Prev. 2013;15(3):82. 10.1177/1757177413502245 . Ben Abdelaziz R, Hafsi H, Hajji H, Boudabous H, Ben Chehida A, Mrabet A, Boussetta K, Barsaoui S, Sammoud A, Hamzaoui M, Azzouz H. Full title: peripheral venous catheter complications in children: predisposing factors in a multicenter prospective cohort study. BMC Pediatr. 2017;17:1–1. 10.1186/s12887-017-0965-y . Noshy MK, Mohamed MM, El-Reheem A, Abd El HA. Peripheral Intravenous Catheter-Related Phlebitis, Infiltration, and Its Contributing Factors among Patients at Port Said Hospitals. Port Said Sci J Nurs. 2023;10(3):284–308. Santos LM, Figueredo IB, Silva CS, Catapano UO, Silva BS, Avelar AF. Risk factors for infiltration in children and adolescents with peripheral intravenous catheters. Revista Brasileira de Enfermagem. 2022;75(04):e20210176. https://doi.org/10.1590/0034-7167-2021-0176 . van Rens MF, Hugill K, Mahmah MA, Bayoumi M, Francia AL, Garcia KL, van Loon FH. Evaluation of unmodifiable and potentially modifiable factors affecting peripheral intravenous device-related complications in neonates: a retrospective observational study. BMJ open. 2021;11(9):e047788. 10.1136/bmjopen-2020-047788 . Özalp Gerçeker G, Kahraman A, Yardimci F, Bilsin E, Binay Ş, Çevik Özdemir HN, Karakul A, Zengin D, Ardahan Sevgili S, Gümüş M, Başbakkal Z. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7264006","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":514923316,"identity":"2cb93ca5-2239-4014-b442-2c2d01abdc14","order_by":0,"name":"Ratna Shila Banstola","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYBACAzBZAOV9AGI2dsJaGBvAGtmArBkgmpkULcw8ICFCWszZjz9/8MHALp9/fu/Bzza/tsnzMTMwfviYg1uLZU+OYeMMg2TLGcf4kqVz+24btjEzMEvO3IbHYQdyGJt5DJgNGI7xGEjn9txmBGphY+bFp+X884dALfUG8sd4jH9b9ty2J6zlRoIhUMthA4NjPGbSDD9uJxLUYjnjjeHMGQbHDQyP5ZhZ9jbcTm5jZmzG6xdz/vQHHz5UVBvIHT5jfOPHn9u289ubD374iEcLKmBsA5MNxKoHgT+kKB4Fo2AUjIKRAgBO/k20qh2/jgAAAABJRU5ErkJggg==","orcid":"","institution":"Tribhuvan University","correspondingAuthor":true,"prefix":"","firstName":"Ratna","middleName":"Shila","lastName":"Banstola","suffix":""},{"id":514923317,"identity":"7e647da4-eb4b-4698-95c4-00685803514d","order_by":1,"name":"Ramchandra Bastola","email":"","orcid":"","institution":"Pokhara Academy of Health Sciences, Western Regional Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ramchandra","middleName":"","lastName":"Bastola","suffix":""},{"id":514923318,"identity":"9abad253-5eb9-4d2e-b591-b27c9e163d38","order_by":2,"name":"Sachiko Inoue","email":"","orcid":"","institution":"Okayama Prefectural University","correspondingAuthor":false,"prefix":"","firstName":"Sachiko","middleName":"","lastName":"Inoue","suffix":""}],"badges":[],"createdAt":"2025-07-31 15:53:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7264006/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7264006/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91369927,"identity":"64464819-1951-4e14-a584-facbc65efb08","added_by":"auto","created_at":"2025-09-15 18:36:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":717630,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7264006/v1/35237b13-8feb-4858-acb1-8e60a10a67f2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nurses' Experience on Peripheral Intravenous Catheter Insertion, Care and Complications in Pediatric Patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePeripheral intravenous catheter (PIVC) is one of the most frequently performed invasive procedure in health care settings all over the world [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite the necessity and proved benefits of PIVC in treatment and recovery, it is painful and threatening procedure for children [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Compared to adults it is more complex in children because of their smaller and delicate veins that easily collapsed or get swells up, their unpredictable movements, and difficulty in communication (health care provider's difficulty to make children understand or children cannot express their level of discomfort to the provider) [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Mostly the nurses being responsible in carrying out this procedure daily in pediatrics are to deal with anxiety, painful experiences and distress of both the parents and children [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe PIVC failure, frequent occurrence of complications and need for repeated cannulation adds to the negative experience of children, parents and nurses [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A study from Bhutan has reported that 46% of PIVC in children was not successful at first attempt [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. An Australian study reported difficult vein access and multiple attempts not only increases distress in young child and parents but most often lead to avoidance and delayed treatment [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Even the successful cannulation at first attempt get complicated earlier in children than in adults [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The mostly reported complication of PIVC in children are phlebitis and infiltration followed by extravasation, occlusion and infections [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These complications lead to pain, anxiety, extended hospital stay, and increased healthcare costs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In the demanding healthcare system today, healthcare professionals are expected not only to master the insertion, care, and management of vascular access devices and decisions but also the field introduce multiple unexpected challenges [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNurses are on the front lines of patient care and play a crucial role from initiation to ongoing care and maintenance, management, and prevention of complications of PIVCs [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. For quality care, the nurses require not only knowledge and technical proficiency but also the ability to deal with and manage the challenges such as distress, anger, and frustrations of parents and children [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The emotional stress of managing their workload along with challenges in interacting with anxious parents, families, and children is the most demanding care environment for nurses and healthcare teams [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Given that pediatric nurses face unique challenges it is more important to understand the nurses\u0026rsquo; perspectives and experience [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile most of the previous studies have assessed the complications related to PIVC and its associated factors in patients, still less among pediatric patients and very scarce previous work from developing countries [\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Though some studies examined the knowledge and practice of nurses on PIVC care [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], the gap is realized in addressing pediatric nurses' firsthand experiences and insights related to PIVC care and management in patients. Two studies were found in our search and that is Taşdelen et al. explored the thoughts, anxiety factors, and experiences of pediatric nurses on the success and failure of first-time PIVC insertion [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Hjelmgren et al. explored nurses' experience in pediatric blood sampling and revealed that nurses in pediatric hospital care face a big challenge and often feel frustrated due to unsuccessful blood samples in children [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The lived experience and perspective of pediatric nurses on factors that lead to PIVC failures, the challenges they encounter, approaches to managing and preventing PIVC complications, and the overall emotional and professional impact of these experiences are important to explore. Hence to fill the gap, this study explored pediatric nurses\u0026rsquo; perspectives on PIVC insertion and management, the difficulties they encounter, and their strategies for preventing and managing complications. Nurses' experience can provide a valuable base in planning targeted training and support for nurses and health care teams in pediatric settings of a resource-constrained country. Ultimately can lead to improvements in the clinical protocol, education, and support system for nurses, and can enhance patient outcomes and health care quality.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design and participants\u003c/h2\u003e\u003cp\u003eAn exploratory qualitative study was conducted with nurses working in paediatric in-patient unit of a government teaching hospital in Nepal. The Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guidelines for qualitative study were followed [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The pediatric unit has 40 beds including 6 bedded PICU, and 14 registered nurses working in pediatric ward were recruited via purposive sampling technique. The nurses who had at least 6 months of work experience in pediatrics were included in the study. The age range of the nurses was 25 years to 46 years. All the 14 nurses' had the academic qualification of baccalaureate in nursing and work experience in pediatric ward was 9 months to 10 years. Their participation was voluntary and informed written consent was obtained for the participation in this study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eThe data was collected through focus group discussion (FGD) between September and November 2023. Formal permission for data collection was obtained from the hospital authority, then the coordination with the ward in charge was done by the researcher (RSB). With the help of the ward in charge, the initial meetings with the nursing staffs were done to explain the purpose of the research. The researcher (RSB and RB) were familiar with the staff, therefore it was easier to obtain their agreement in participation. The participants were assured that their identity would not be disclosed and the data would be used for research purposes only. The FGD was carried out in the ward (nurses\u0026rsquo; room) at their convenient time. Three FGDs were conducted, Group One included 6 staffs, Group Two included 5, and Group Third included 3 staffs. The audio recording was done with the consent of the participants. And field note was taken during FGD. One FGD took 50 to 60 minutes and subsequent FGD was done until data saturation was met i.e., until no new information was obtained. The FGD guideline included 8 main questions and their probing; such as, who carry out PIVCs in your ward? How is your experience related to PIVC insertion?; Can you please discuss the difficulties experienced related to PIVC initiation and management in children?; Can we discuss here about practice of PIVC care in this department and your perspective?; What are the PIVC-related complications you have witnessed or experienced in pediatric patients?; In your opinion, what are/might be the possible causes of complications related to PIVC in children?; How have you managed the IV complications in pediatric patients?; What can nurses do to prevent or reduce the complications of PIVC in pediatric patients?\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e Ethical principles outlined in the Declaration of Helsinki for the study included human participants were taken into account in all conduct of this study. Written informed written consent was obtained. Confidentiality and privacy of the participants was assured and maintained. Ethical approval was obtained from the Institutional Review Committee of Pokhara Academy of Health Sciences (183/079, 2nd June 2023).\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThematic analysis of the data was done following six phases of thematic analysis according to Braun and Clarke [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. The researchers transcribed the information obtained from FGDs. Then it was read and reread to gain an understanding of the participants' perspectives. Most relevant information was highlighted and coded, again recoding was done by synthesizing and grouping the similar. It was a rigorous process that was done by each of the researchers simultaneously as well as independently. We worked together to find the most appropriate themes from those codes keeping in mind that the data obtained from the participants exactly matches the themes and no information was overrepresented or overlooked. The themes were reviewed finalized, and agreed upon by all the researchers. The result was communicated and discussed with the participants for their approval, which enhanced the trustworthiness and credibility.\u003c/p\u003e\u003c/div\u003e"},{"header":"Findings","content":"\u003cp\u003eStudy explored nurses\u0026rsquo; experience with peripheral intravenous cannulation, complications, and care practice in children. A summarized breakdown of the qualitative data revealed three main themes: 1) responsibility and challenges in initiating and maintaining PIVC in children; 2) Complications of PIVC in children and possible risk factors perceived; and 3) PIVC care practice, realization of gap and hindrances experienced.\u003c/p\u003e\u003cp\u003eNurses feel PIVC insertion and care as their crucial responsibility in pediatric care. Nurses encounter multiple challenges that are linked to emotional responses and patient outcomes. Difficult vein access, dislodgement, pressure from parents, and mixed experiences of success and failure are mostly reported. Various causes of difficulties were expressed, such as, nurse-patient ratio, 2\u0026ndash;3 nurses in a shift for 40-bed units that also include PICU. Therefore, the workload and time hinder the nurses\u0026rsquo; ability and wish for care and counseling to parents before and during PIVC. Lack of counseling is felt to cause parents getting angry, verbalizing negativism, and dissatisfaction with the nurses\u0026rsquo; care. Need for special devices/technology for vein visualization was also raised. Staff shortage also affecting on nurses' feeling of success and satisfaction with the procedure. The difficulty is also linked to communication and the child's level of understanding. Nurses also emphasized nursing graduate preparation, and need for mentoring new staff, and problem of staff turnover (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTheme 1: Responsibility and challenges in initiating and maintaining PIVC\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSub themes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCodes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTranscripts\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResponsible\u003c/p\u003e\u003cp\u003eMix experience of own and parents' emotional response\u003c/p\u003e\u003cp\u003eDifficulty in initiating\u003c/p\u003e\u003cp\u003eFacing multiple challenges\u003c/p\u003e\u003cp\u003erelated to human resource, turnover of trained staff and need of technology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFeeling Responsibility\u003c/p\u003e\u003cp\u003eSuccess and failure\u003c/p\u003e\u003cp\u003eStress, worry, anxiety\u003c/p\u003e\u003cp\u003eAnger, frustration, quarrel\u003c/p\u003e\u003cp\u003eUpset, facial expression\u003c/p\u003e\u003cp\u003eFeel happy when success\u003c/p\u003e\u003cp\u003eAffect subsequent procedure\u003c/p\u003e\u003cp\u003eWish cooperative work environment\u003c/p\u003e\u003cp\u003eCooperative, quiet environment\u003c/p\u003e\u003cp\u003eDifficult vein access\u003c/p\u003e\u003cp\u003eCounseling to parents\u003c/p\u003e\u003cp\u003eChild's characteristics\u003c/p\u003e\u003cp\u003ePressure from parents and others\u003c/p\u003e\u003cp\u003eWant to work without pressure\u003c/p\u003e\u003cp\u003eSpecial devices, Vein visualization technique\u003c/p\u003e\u003cp\u003eStaff shortage, Lack of trained person/staff, Staff turnover,\u003c/p\u003e\u003cp\u003eNurse graduates' preparation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Most specifically nurses do and nurses are responsible. If sometimes no vein is accessed, we inform resident doctors, and doctors put in scalp\u0026rdquo; (N5, N6, N7, N8, N9, N10, N11, N14).\u003c/p\u003e\u003cp\u003e\"When vein is not visible the visitors make facial expression and sound, the child cries. In such we get upset and it affects subsequent success\u0026rdquo; (N7, N11, N13).\u003c/p\u003e\u003cp\u003e\u0026ldquo;If more than one prick needed then they become angry, we wish to work in quiet cooperative environment\u0026rdquo; N10, N11, N12\u003c/p\u003e\u003cp\u003e\u0026ldquo;Those come for chemotherapy, or the child with thalassemia come monthly for blood transfusion and we feel difficulties and feel sorry\u0026rdquo; (N4, N12).\u003c/p\u003e\u003cp\u003e\u0026ldquo;We usually do cannulation in treatment room keeping the parent/guardian inside. Most of the time we have to ask the parent to hold the child and keep still from moving the extremity where we are going to place cannula. And it is difficult to keep parent and tell them to hold because they are already anxious with their child\u0026rsquo;s illness, they fear and worry with procedure, on the other how they hold is not as we wish, the child moves and it is very difficult\u0026rdquo; (N4, N7)\u003c/p\u003e\u003cp\u003e\u0026ldquo;It is more difficult in toddlers compared to infant, and also school age child do not listen to us, they refuse and they are bigger/grown up to control to hold\u0026rdquo; (N2, N8, N9)\u003c/p\u003e\u003cp\u003e\"Critical child, obese or child with immune condition and prolong hospitalization is difficult\" (N1, N5)\u003c/p\u003e\u003cp\u003e\"Nephrotic child already swollen, or if child is dehydrated and high fever the veins get bulge after prick\" (N5, N11, N14)\u003c/p\u003e\u003cp\u003e\u0026ldquo;We heard there are devices to better visualization but we do not have such new technology in our practice. We wish if we have, it would be very better for us and for our children\" (N9).\u003c/p\u003e\u003cp\u003e\"The important issue is trained human resource and it is best if staffs or trained person hold and support the child during cannulation\u0026rdquo; (N8, N13).\u003c/p\u003e\u003cp\u003e\u0026ldquo;During study period, students do cannulation mostly in adult patients. So we should teach new nurses and assist them to cannulate in not critical and cooperative child with well visualized vein in initial period. We need to build their confidence\" (N9, N5, N11).\u003c/p\u003e\u003cp\u003e\"It is better if there is no turnover of nurses, if experienced staff leave we have problem\" (N9, N12).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTheme 2: Experience of complications of PIVC in children and possible risk factors\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubthemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCodes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTranscripts\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications in children\u003c/p\u003e\u003cp\u003ePossible risk factors experienced\u003c/p\u003e\u003cp\u003eParental involvement\u003c/p\u003e\u003cp\u003eImportance of timely recognition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommon complications\u003c/p\u003e\u003cp\u003eRisk factors\u003c/p\u003e\u003cp\u003eDifferent medicines\u003c/p\u003e\u003cp\u003ePeriod of medication\u003c/p\u003e\u003cp\u003eFluid infusion plus IV push\u003c/p\u003e\u003cp\u003eMedicine administration\u003c/p\u003e\u003cp\u003eMobility of child, playful\u003c/p\u003e\u003cp\u003eAnatomical site and vein\u003c/p\u003e\u003cp\u003eDuration of hospitalization\u003c/p\u003e\u003cp\u003eCritical care unit\u003c/p\u003e\u003cp\u003eRealization of asepsis\u003c/p\u003e\u003cp\u003eNeed to change practice\u003c/p\u003e\u003cp\u003eHygiene, parental care and involvement\u003c/p\u003e\u003cp\u003eMissed to recognize pain\u003c/p\u003e\u003cp\u003eTimely recognition\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;We find the problems such as, redness, swelling, pain and fever and common complication is phlebitis and infiltration here. Those getting IV medicine such as, vancomycin has more incidence of phlebitis and those getting both IV fluid infusion and IV medicine have developed infiltration more\u0026rdquo; (N7, N8, N9).\u003c/p\u003e\u003cp\u003e\u0026ldquo;Extravasation also occurred, once the dobutamine was, I saw patient developed blister. It can occur in chemo also, but thank fully not happened to us yet\u0026rdquo; (N10, N12).\u003c/p\u003e\u003cp\u003e\u0026ldquo;Those getting vancomycin, ceftriaxone, amikacin, phenytoin, tazobactum, KCL in infusion, and those getting medicine for long time are developing problem\u0026rdquo; (N1, N2, N3, N7, N8, N9, N13).\u003c/p\u003e\u003cp\u003e'We found more problem in children who are hospitalized for longer duration more than week or those who are very sick and in critical care\u0026rdquo; (N2, N3, N4, N5, N9, N10, N11, N12).\u003c/p\u003e\u003cp\u003e\u0026ldquo;We can do flush, give medicine in beuro or infusion set if quantity of medicine is more and we should dilute medicines properly, because we found vein damages early with higher concentration IV push\" (N5, N7, N8, N9).\u003c/p\u003e\u003cp\u003e\u0026ldquo;Children are playful, they move excessive and do not understand. Therefore, kinking and displacement occurs\u0026rdquo; (N1, N7, N9, N11)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Usually large veins are good, how it is fixed also determines, I feel brachial and saphenous is good and goes for longer. Cannula in the wrist and in small veins are not good, while, we are careful in scalp vein\u0026rdquo;(N1, N3, N4, N5, N11).\u003c/p\u003e\u003cp\u003e\u0026ldquo;We also felt that repeated hospital admission, and repeated and longtime cannulation interfere healing of veins and caused failure at cannulation and more complication\u0026rdquo; (N12, N14).\u003c/p\u003e\u003cp\u003e\u0026ldquo;Infection is also a cause of phlebitis which can be due to contamination with child\u0026rsquo;s urine and stool. Our practice should be changed, once the vein is visualized and confirmed we swab the site for insertion, then the area that should not be touched after swab, or if so it is better to wear gloves\u0026rdquo; (N7, N9, N5)\u003c/p\u003e\u003cp\u003e\u0026ldquo;We are using sterile cotton to swab, we try to do minimal prick as far as possible. We try good fixing can be done\u0026rdquo; (N5, N11, N14).\u003c/p\u003e\u003cp\u003e\u0026ldquo;It is important to follow sterile technique, we should not put cannula in unsterile surface after we open the packet, instead we can put it in the packet of that cannula\u0026rdquo; (N5, N9, N10)\u003c/p\u003e\u003cp\u003e\u0026ldquo;We can wear surgical gloves, and we should not and we do not do double prick\u0026rdquo; (N6) \u0026ldquo;but it is difficult with gloved hand to apply tape\u0026rdquo; (N1)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I saw 2 days back one child came from other hospital and the bandaging in his PIVC site was too tight and the finger was blue due to compromised circulation. Therefore, I always keep fingers out of bandage and I also show the parents fingers are out\u0026rdquo; (N1, N4, N5).\u003c/p\u003e\u003cp\u003e\"While in the part of patient, many of the times cannula in lower extremities is found soaked with urine, some with stool. Parents do not keep bed and surroundings clean. Even the cannula\u0026rsquo;s cap is kept open\u0026rdquo; (N2, N3, N5, N10).\u003c/p\u003e\u003cp\u003e'Children are sensitive, they just cry and always it may not be the pain, so we also miss to recognize either actual pain in IV site or it was the child\u0026rsquo;s fear\u0026rdquo; (N6). \u0026ldquo;It is better to apply tape only, bandage covers the inflammation and redness, therefore, it may miss to timely identification\u0026rdquo; (N9).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eNurses reported the most common complications of PIVC in children is phlebitis and infiltration. The displacement and self-removal also causing need for re-cannulation. Impact of these complications on patient comfort, efficacy of treatment, health care resources, stress and worry to parents, and the economic cost for family were noted from nurses' expression. The nurses also expressed that sometimes they miss to recognize actual pain. Further risk factors they have experienced are insertion technique, movement of child, type of medicine, repeated hospitalization, disease condition and immunity, infection, hygiene and cleanliness, how the parents take care of child, and anatomical site and vein. They emphasized that asepsis is important, however, partial lack is also realized (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNurses expressed their realization of the need for IV site care including adequate dressing, securement, regular monitoring and documentation to ensure early detection of problem. However, there is no routine practice and they do observe when go for medication. They also ask to child and listen to parents for any complain of pain/problem. Despite their realization of importance of IV care, nurse-patient ratio, difficulty in children gaining cooperation were raised as problem. There was mixed responses on knowledge and practice for duration of PIVC. Good to report was their literature search in confirming the duration and make decision on when to change the cannula in children. Nurses reported their inability to adhere to standard practice (for example, changing IV set) for most of their patients linked to supply issue, patient affordability, and resource/financial limitations. The effective of practice they found in managing the complications of PIVC are, immediate removal of cannula, applying ice pack, thrombophob ointment if swelling, and phlebitis. In infiltration or extravasation, before removal of cannula they withdraw the infiltrated fluid as much as possible. They also discussed the importance of timely identification and intervention to prevent worsening complications. The prevention strategies they feel to be followed are maintaining infection prevention through hand washing and maintaining sterile technique before IV cannulation or giving IV medicine/infusion, regular monitoring and documentation of problem, giving more concern to critical children, and education to parents. Nurses expressed their awareness about possible complications of chemotherapeutic drugs and feeling happy for not having such incidences (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTheme 3: PIVC care practice, realization of gap and hindrances experienced\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge and practice gap\u003c/p\u003e\u003cp\u003eEvidence-based practice\u003c/p\u003e\u003cp\u003eStaff-patient ratio\u003c/p\u003e\u003cp\u003eSocioeconomic status of Patient\u003c/p\u003e\u003cp\u003eSupply and economic barrier to health care\u003c/p\u003e\u003cp\u003eManagement practice\u003c/p\u003e\u003cp\u003eManagement of complications\u003c/p\u003e\u003cp\u003ePossible preventive ways\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRealization of gap\u003c/p\u003e\u003cp\u003eNo routine practice\u003c/p\u003e\u003cp\u003eParents responsibility and inform\u003c/p\u003e\u003cp\u003eChild's fear, Patient cooperation\u003c/p\u003e\u003cp\u003eRealization of gap\u003c/p\u003e\u003cp\u003eStaff-patient ratio and workload\u003c/p\u003e\u003cp\u003eMedication and observation\u003c/p\u003e\u003cp\u003eLiterature based practice\u003c/p\u003e\u003cp\u003eInfection prevention\u003c/p\u003e\u003cp\u003ePractice to prevent complication\u003c/p\u003e\u003cp\u003eChanging IV sets\u003c/p\u003e\u003cp\u003eEconomic condition\u003c/p\u003e\u003cp\u003eSupply and support issue\u003c/p\u003e\u003cp\u003eAffordability, feel sorry\u003c/p\u003e\u003cp\u003eManagement of complication\u003c/p\u003e\u003cp\u003eApplication of ointment\u003c/p\u003e\u003cp\u003eElevation, withdraw, removal\u003c/p\u003e\u003cp\u003eConscious on complication\u003c/p\u003e\u003cp\u003eChemotherapy\u003c/p\u003e\u003cp\u003eAware on complication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;We do not practice IV care as routine but if there is cannula swelling, or if child removes, then we do change\u0026hellip;\u0026hellip;plus children are not co-operative\u0026rdquo; (N1).\u003c/p\u003e\u003cp\u003e\u0026ldquo;We tell parents to inform if there is problem or we see blood in dressing, we change the tape and bandage\u0026rdquo; (N1, N3, N6).\u003c/p\u003e\u003cp\u003e\u0026ldquo;We do not change tape or do anything to cannula because the child fear with us looking white dress approaching near, they move and if we try to change new dressing/tape it may dislodge. Therefore, we do not do unnecessarily\u0026rdquo; (N7, N11).\u003c/p\u003e\u003cp\u003e\"There is no condition to one to one care, there are 40 beds and we nurse are 2\u0026ndash;3 in a shift plus we have PICU here, so it is busy and we have challenges. If there are student nurses, we get time to observe\u0026rdquo; (N10).\u003c/p\u003e\u003cp\u003e\u0026ldquo;It is better to care, however, nurses are very few for each shift, plus child do not co-operate but we see when we do medication. We have to do medication TID or QID therefore, at least one medication at a shift make sure that we observe once in each shift\u0026rdquo; (N1, N5, N6, N7, N13, N14)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Previously, there was a discussion in the ward if we should change cannula in 72 hours but after literature searches we confirmed that until the cannula is working and no problem, then not needed to change. We keep how long it works\u0026rdquo; (N5, N6).\u003c/p\u003e\u003cp\u003e\"Our practice should be changed should not touch after swab and if so it is better to wear gloves either\"(N7, N8, N9).\u003c/p\u003e\u003cp\u003e\u0026ldquo;We use syringe for 24 hours and then discard, similarly IV set and Beuro set need to be changed 48\u0026ndash;72 hours but this is not always possible\u0026rdquo; (N1, N5, N7, N9).\u003c/p\u003e\u003cp\u003e\u0026ldquo;This is the government hospital and many patients are poor. If affording family, we change IV set in 3 days otherwise difficult to follow even if we know. How we can\u0026hellip;.if there is support and supply we can follow the practice\u0026rdquo; (N5, N9, N10).\u003c/p\u003e\u003cp\u003e\u0026ldquo;In phlebitis we immediately remove the cannula, swab the area with antiseptic solution, apply ice pack and thrombophob ointment\u0026rdquo; (N1, N2, N3, N5, N8, N11).\u003c/p\u003e\u003cp\u003e\u0026ldquo;Sometimes we feel sorry to ask them to purchase thrombophob, if we have in stock we apply or we just apply ice pack, ice pack also works\u0026rdquo; (N3, N5).\u003c/p\u003e\u003cp\u003e\u0026ldquo;In care of infiltration, we withdraw the infiltrate and remove the cannula, then we elevate the part\" (N7, N8, N9, N3, N4, N10).\u003c/p\u003e\u003cp\u003e\u0026ldquo;In some we put xylocaine gel in a gauze piece and then apply that gauge over the inflamed and painful area\u0026rdquo; (N4).\u003c/p\u003e\u003cp\u003e\u0026ldquo;We are giving chemo drug mostly the vincristine in our ward for last 1 year and luckily we did not have infiltration or extravasation of chemotherapeutic drugs yet, we are conscious for that\u0026rdquo; (N2, N5, N9).\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eResponsibility and challenges in initiating and maintaining PIVC in children\u003c/h2\u003e\u003cp\u003ePeripheral Intravenous Catheter (PIVC) insertion and its care are vital responsibilities for nurses in pediatric settings. A previous study conducted across 47 countries, including the USA, Europe, Africa, and Australia, also found that nurses inserted most PIVCs in children (71%) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Similarly, a qualitative study in Spain revealed that although nurses feel responsible for PIVC care, they do not view themselves as the primary decision-maker about PIVC insertion and removal [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In our study, nurses reported encountering several challenges in PIVC insertion and maintenance in children. One key challenge identified was difficulty of cannulation in a children compared to adults, which is linked to the factors such as the child's understanding level, communication difficulties, and their physical build, particularly in sick and critical children. A study among 200 Bhutanese children found that 36% of PIVC insertion failed on the first attempt [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Additionally, Ullman et al. reported more frequent insertion failures, higher pain and distress, and greater number of insertion attempts; and a higher complication rate in children compared to adults [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Staffing and resource limitations also emerged as significant challenges as discussed by the nurses in this study. Nurses also mentioned hearing about advanced technologies for vein visualization, but they lacked access to such devices in their practice. A previous review highlighted the benefits of technologies that assist in locating veins, determining vessel size and depth, and achieving higher success rates of PIVC insertion, reducing procedure time, and alleviating stress for both parents and children [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A Bhutanese study also reported that 82.7% PIVCs were successfully placed after using a trans-illuminator [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In addition, parents' desire of PIVC insertion to be done with proper visualization, such as, with the use of visualizing light or ultrasound, and by an experienced healthcare provider was revealed by the study [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Hence, providing technological assistance and mentorship could support nurses in improving PIVC insertion success rates.\u003c/p\u003e\u003cp\u003eAs stated earlier, the experience of nurses is a critical factor in ensuring patient safety and satisfaction. However, nurses also raised concerns regarding staff turnover and associated problems. Novice nurses in pediatric settings often rely on senior nurses for guidance and training, but when experienced staff leave, the burden of training new staff increases. Past studies have corroborated this finding, showing that nurses with less than 3 years of experience often lacked the ability to perform successful PIVC insertions [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. In contrast, professionals with five years or more experience in pediatric emergency showed significantly higher success rates and faster PIVC insertions on the first attempt [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The need for preparing the nursing graduate to work confidently in pediatric-settings was also raised in our study. This is particularly important because students often practice cannulation in adult wards, but rare or never perform in children. Similarly, a qualitative study among Australian undergraduate nurses also revealed that while universities provide foundational knowledge about PIVC assessment, the practical application of this knowledge and skill development during clinical placement is inconsistent, which can negatively impact patient safety [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The importance of training and competence in PIVC management was further emphasized by parents, who expressed concern about inadequate competencies of healthcare staff, which threatened their children's comfort and safety [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A study conducted among pediatric nurses in Kazakhstan revealed that a lack of knowledge about patient assessment, PIVC insertion, maintenance, and removal was prevalent. Nurses' education, experience, and recent training were significant predictors of their knowledge and directly influenced their confidence in performing PIVC procedures [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Therefore, preparing competent graduates, mentoring new nurses, and preventing staff turnover are important to high-quality care.\u003c/p\u003e\u003cp\u003eNurses also identified a lack of counseling as a challenge, which they attributed to understaffing and heavy workload. As a result, parents voiced dissatisfaction, verbalize anger, and expressed negative emotions towards the nurses\u0026rsquo; care. Similarly, Spanish pediatric nurses also expressed while patient education is relatively simple and important, it is difficult to implement during PIVC care [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The desire for a cooperative and calm environment without unnecessary pressure was expressed repeatedly by nurses. Parents too have their concerns. For instances, an Australian study reported that some parents had to stop the procedure themselves, noticing that their child was too distressed. Parents expressed the need of clear communication, so they could better prepare their children, however, nurses are often overwhelmed with lack of time and workload [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. A qualitative study in Southern Australia also concluded that multiple PIVC insertion attempts caused distress to children and parents, leading to treatment avoidance. Effective interpersonal skills, offering choices, avoiding frightening language, and referring children with a history of difficult venous access to experienced nurses or specialist would help alleviate distress [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. For some solution, a study in Turkey reported that nurses used distraction techniques during the procedure, such as, allowing child to play with a toy, sitting on mother's lap, watching cartoons, and administering oral sucrose [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Though the parents are kept with the child during the procedure, other distraction techniques were not expressed in the present study. We believe that incorporating such methods could make the procedure less threatening and painful for the child, and reduce parents' distress. Hospital authorities can provide regular training and mentorship to staff, ensuring retention of the experienced nurses and creating pleasant work environment to enhance both the nurses' and patient satisfaction.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eExperience of complications of PIVC in children and possible risk factors\u003c/h3\u003e\n\u003cp\u003eNurses reported encountering various complications of PIVC in children, including redness, pain, swelling, obstructions, displacement, and self-removal all of which require re-cannulation. The most common complications were phlebitis and infiltration, which have been similarly documented in several quantitative studies in different parts of the world [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Nurses also noted the impact of these complications on patient comfort, the effectiveness of treatment, health care resources, parental stress and worry, and the economic burden on families. Other studies have similarly highlighted the negative impact of complications on patient outcomes and cost implications [e.g., 8], as well as the resulting delay in treatment and increased stress to children, parents, and to the healthcare professionals [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA major concern for nurses was the failure to recognize pain in children due to their tendency to cry when a stranger or healthcare provider approached. Additionally, parents sometimes don\u0026rsquo;t want to make next prick if it works for now. Past study also indicated that healthcare provider's competence, infection prevention, and pain management were the key determinants of patient satisfaction [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This presents challenging situation, as nurses struggle to recognize actual pain, while parents may feel nurses are not concerned about them. A study among parents revealed that parents were frustrated by lack of attention to their child's pain, and nurses sometimes did not believe and it feels that not being heard, i.e., staff don\u0026rsquo;t believe when they tell them it is painful, or if asked to give antibiotics slowly to reduce the pain [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCentre for Disease Control and Prevention recommends using antiseptic like 70% alcohol, tincture of iodine, povidone, or chlorhexidine gluconate before PIVC insertion, and emphasized the need for maintaining aseptic techniques [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Wearing at least clean gloves and using of mixture of 70% alcohol and 2% chlorhexidine is also recommended [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Although the nurses expressed that maintenance of asepsis and medication procedures determine the longevity of cannula, they expressed challenges in maintaining it, particularly in emergencies and staff shortages. They got training on maintaining asepsis in cannulation however, due to the color of povidone iodine nurses are feeling inconvenience in proper visualization of the vein and using only 70% alcohol. Nurses also expressed difficulty to apply tape with a gloved hand when they are doing cannulation alone. Past studies also mentioned poor infection prevention practices, such as inadequate hand hygiene, disinfection of insertion sites, improper use of PIVC dressings [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. At this point, healthcare professionals need to have a clear understanding and the commitment to infection prevention practices. Healthcare professionals need to be encouraged and supported to follow infection prevention protocols. Furthermore, parents in our study did not seem concerned about infection prevention, which indicate a lack of awareness of infection prevention. Educating parents and families could help in preventing infections and complications [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNurses also identified the potential impact of concentrated medications, such as, vancomycin, ceftriaxone, amikacin, phenytoin, tazobactum, and potassium chloride on PIVC complications. Several studies also showed the effect of medicines like vancomycin and ceftriaxone [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], piperacillin/tazobactan [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and irritating/vesicant drugs and electrolytes [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] for PIVC complications. Future studies could explore the effect of amikacin, potassium chloride, dobutamine, and phenytoin to add the current understanding. Additionally, risk factors for difficult cannulation, failure, and complications includes the duration of hospitalization, repeated hospitalization, long-term cannulation, infections, immunocompromised condition, malnutrition/obesity, dehydration, and hygiene. Previous studies have confirmed that chronic health problems, immunocompromised status, and long-term hospitalization increase the risk of complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Nurses also expressed that PIVCs in the lower limbs, in small veins and joints tended to develop problems earlier, which is consistent with past studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Thus the findings from this qualitative study of nurses' clinical experience have added to our understanding and supplemented previous findings.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003ePIVC care practice, realization of gap and hindrances experienced\u003c/h2\u003e\u003cp\u003eDespite nurse's realization of the importance of PIVC care and documentation, there was a common expression that PIVC care is not integrated into their routine nursing process. Nurses primarily observe and manage the PIVC during the medication administration or change the dressing if there is blood. A study among Australian nurses found a similar gap in the application of theoretical knowledge on PIVC care and management [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. A Spanish study identified that PIVC care was often seen as task rather than an integral part of nursing care process, which led to disjointed and suboptimal care [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Understaffing and workloads were recurring themes in nurses' experiences. A Jordanian study reported primary care model was protective for phlebitis compared to the functional care model adopted by nurses [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. While, a Spanish study among nurses working in the geriatric ward reported lack of time and workload hindered them from offering the best care and they are not able to devote as much time as they would like to PIVC care [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Some studies have recommended increasing nurse-patient ratio and ensuring sufficient infusion pumps are available to prevent complications [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In our study, nurses expressed that although they have infusion pumps, they still feel insufficient to meet the needs in maintaining drop rates of fluids in children, especially for viscous or irritant medicines that require slow infusion. Therefore, supplies and equipment support could motivate nurses to adhere to the standard practice.\u003c/p\u003e\u003cp\u003eNurses also involve parents during PIVC care process by providing advice and answering questions, and nurses experienced it as convenient approach where one-to-one primary care is not always possible. The CDC also recommended regular monitoring of the catheter sites visually when changing the dressing or by palpation through an intact dressing, and it is also beneficial that the healthcare personnel should encourage patients to report any changes or discomfort in their catheter site [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In an Australian study also the parents expressed that they wanted to be involved, provide them with direction on how to assist, to feel empowered because they know their child best [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Therefore, the involvement of parents can reduce the risk of PIVC complications in children through the identification of the problem earlier. However, routine assessment and care of PIVC by the nurses using a standard guideline in the ward will be the best approach to prevent complications in children. A Turkish study also revealed that despite a high prevalence of infiltration and extravasation, the interventions to address them were inadequate, therefore the need for training and implementation strategies for pediatric nurses was recommended [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. We explored that there is no fixed protocol for PIVC assessment or care followed in the ward. Although it is emphasized on evidence-based guidelines (Massey et al., 2023), and it would be better that hospitals establish algorithms to prevent and manage PIVC insertions and complications [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Therefore, the department or hospital authority can work on this and the effectiveness of using a guideline can be studied in the future and the staffs can be supported and motivated to adherence to a set practice in the department.\u003c/p\u003e\u003cp\u003eThe knowledge-practice gap was evident in IV and burette set changes, a crucial measure of infection prevention. Non adherence was linked to supply shortage, parental affordability and financial limitations. It is also worth mentioning that nurses in our study searching literature for the duration of the cannula and keeping as long as there is no problem, which is a standard recommendation for children as well [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. We revealed that nurses were aware of complications of chemotherapeutic drugs, as they received training on the safe handling and administration of chemotherapy. They were happy to share the experience of no adverse incidents and complications happened yet to their children. Nurses also discussed their experience in effective management of complications. In case of phlebitis, they remove the cannula, clean with 70% alcohol, apply an ice pack and thrombophob ointment, and elevate the area. For infiltration, they first withdraw the infiltrated fluid and do as in phlebitis. They also found beneficial effect of applying xylocaine gel on a gauze piece in reducing pain at PIVC site. Future studies could validate these experiences for cost-effective PIVC management. In partial support lidocaine application before catheterization for pain management was identified by a previous study [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This study added that its application post-removal also reduces pain. A Nepalese study found glycerin magnesium sulfate and heparin benzyl nicotinate effective for paediatric phlebitis [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Additionally, ice pack or cold compress have been shown to alleviate pain during infusion [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. A Turkish study supports interventions like cold application, alcohol swabs, and elevation for infiltration [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Overall, the nurses emphasized the need for human and material resources, training and guidance, and a standard protocol to be followed in pediatric PIVC management. The combination of technical challenges, emotional stress, and resource limitations highlights the necessity for support and innovation in pediatric care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eStudy explored the pediatric nurses' experience on PIVC management in children, and to our knowledge, it is the first study. This added to our understanding and supplemented the quantitative findings of past studies. Despite these strengths, study has some limitations. Although study was conducted in a tertiary-level government hospital, findings of a single setting may not be generalized to other hospitals. Future studies can consider nurses from multiple centers. The study did not include the experience of nurses working in the neonatal unit. Different approaches to care and management of PIVC complications identified in this study can be validated with future studies.\u003c/p\u003e\u003cp\u003eStudy brought the issues and challenges related to PIVC insertion, care, and management in children. The findings can be utilized in practice by nurses and pediatric healthcare team to prevent or reduce complications of PIVC. Findings can be implied by hospital authority to plan interventions and support the nurses and clinicians in establishing routine PIVC care and improving quality care for children. Infection prevention practice and a standard protocol for assessment and care of PIVC in pediatric settings are important. Hence, the nursing supervisors, nurse administrators, and hospital authority can support and motivate the nurses and health care team in pediatric inpatient units by supporting staffing and supplies issues, continuous mentorship, establishing a care protocol, and preventing turnover or retaining experienced staff. The effectiveness of the management of PIVC complications practiced by nurses can be studied to validate and utilize as evidence-based cost-effective clinical practice in the future.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e The experience and perspectives of pediatric nurses from a developing country on PIVC initiation and care in hospitalized children has been explored. The findings revealed that nurses are responsible for PIVC initiation and care, while facing multiple difficulties, challenges, and emotional experiences impacting PIVC maintenance in children. The gap in PIVC care practice, infection prevention, routine assessment, and care was realized. Staffing, staff turnover, equipment, and supplies were the hindering factors. Nurses' experience with complications of PIVC in children, possible risk factors, nurses' practice in the management of complications, and possible preventive ways were revealed. The need for routine PIVC care, infection prevention, and prevention of complications of PIVC in children is identified. To enhance staff satisfaction and quality care to their patient, hospital can focus on the support, supplies, mentorship, and retention of experienced staffs. Nurses' expressions also provided an area for future researches as well.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the hospital authority for the permission to study, and the paediatric nurses for their invaluable participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRSB: conceptualization; methodology; data collection and curation; writing original draft. RB: methodology, writing-review and editing. SI: methodology; writing- review and editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was obtained from Institutional Review Committee of Pokhara Academy of Health Sciences (183/079, 2nd June 2023).\u0026nbsp; Formal permission for data collection was also received from the hospital authority. The study was conducted in accordance to the Declaration of Helsinki. Detail information sheet about the study was provided to the participants and then informed written consent was obtained before data collection. Participation in the study was voluntary. Privacy and confidentiality was assured and maintained. Data was used for research purpose only.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere is no conflict of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted with support of faculty research grant (FRG-79/80-HS-05), University Grants Commission, Nepal. There is no funding for the publication.\u0026nbsp;There was no role of the funding body in the design of the study, including the collection, analysis, and interpretation of data and in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGorski LA, Hadaway L, Hagle ME, Broadhurst D, Clare S, Kleidon T, Meyer BM, Nickel B, Rowley S, Sharpe E, Alexander M. Infusion therapy standards of practice. 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Pain Manage Nurs. 2015;16(1):33\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1016/j.pmn.2014.03.003\u003c/span\u003e\u003cspan address=\"10.1016/j.pmn.2014.03.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Nurses' experience, peripheral intravenous catheter, hospitalized children, pediatric nurses","lastPublishedDoi":"10.21203/rs.3.rs-7264006/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7264006/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePeripheral intravenous catheter (PIVC) is a common invasive procedure carried out by nurses which is more challenging in children. Given the lack of exploration of nurses' experiences related to PIVC initiation, care and management of complications in children, this study aimed to explore paediatric nurses' experience on PIVC initiation, care and management.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eExploratory qualitative study was conducted in Nepal. Three focus group discussions were carried out among 14 nurses working in paediatric in-patient unit of a government teaching hospital between November and December 2023, and thematic analysis was done. The Consolidated Criteria for Reporting Qualitative Research guideline was used.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eNurses face difficulties in initiating PIVC in children which is increased by parental pressure and emotional response; staff turnover and shortage; the wish for vein visualization technology was explored. Significant number of children develop complications and timely recognition, parental involvement and infection prevention are important to reduce possible risk factors. We identified three interrelated themes: 1) Responsibility and challenges in initiating and maintaining PIVC in children. This theme explains four sub-themes; responsible, mix experience of own and parents' emotional response, difficulty in initiating, and facing multiple challenges. 2) Complications of PIVC and possible risk factors: this theme contains four sub-themes; complications in children, possible risk factors experiences, need of parental involvement, and importance of timely recognition. 3) PIVC care practice, realization of gap and hindrances experienced: it includes knowledge and practice gap, evidence-based practice need, staff-patient ratio, patients' socio-economic status, supply and economic barrier to health care and management practice, and complication management and possible preventive ways.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eNurses feel responsible to PIVC maintenance. Nurses has realization of lack of routine care and standard practice including infection prevention, which is linked to resource limitations, staff shortage, turnover, and patient affordability. Findings have practical implications for nurses, healthcare-team, and hospital for quality care of pediatric-patients.\u003c/p\u003e","manuscriptTitle":"Nurses' Experience on Peripheral Intravenous Catheter Insertion, Care and Complications in Pediatric Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 18:20:48","doi":"10.21203/rs.3.rs-7264006/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-30T20:48:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-27T05:25:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175287562374156322949677988140029653003","date":"2025-09-19T13:38:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-18T20:33:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"260770036560043767347707200764190490239","date":"2025-09-17T23:50:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183910217395233431651380835367038178710","date":"2025-09-08T18:43:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-08T18:30:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-08T06:45:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-08T06:36:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-07T15:34:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-08-07T15:06:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4299db54-39dd-470b-8a29-54945966cf43","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-15T18:20:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-15 18:20:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7264006","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7264006","identity":"rs-7264006","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}