INS 2011 S6-S30

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1. Anatomic characteristics and their effect on physical assessment, vascular and nonvascular access device site selection, insertion procedures, site rotation, and use of specialized infusion-related equipment, including care and mainte-nance practices during infusion therapy.3-5_(V) 2. Physiologic characteristics and their effect on drug

and nutrient selection; administration set selection (eg, free of Di[2-ethylhexyl] phthalate); dosage and volume limitations with reference to age, height, weight, or body surface area; pharmacologic actions, interactions, and side effects; monitoring parameters; and response to infusion therapy.3-11 _(V) 3. Growth and developmental stages, including implications related to promoting comfort and reducing pain and fears associated with infu-sion therapy procedures.3,4,9,12-14_(V)

4. Interaction with parents, other family members, or legally authorized representative as members of the patient’s health care team, including patient education that is provided with attention to age, developmental level, health literacy, cul-ture, and language preferences (see Standard 11,

Patient Education).2,4,15_(V)

5. Safe and appropriate setting (eg, acute care, ambulatory, school, or home care) for patients receiving infusion therapy.2,16_(V)

6. Obtaining assent from the school-age or adoles-cent patient as appropriate (see Standard 12,

Informed Consent).2,17-19_(V) REFERENCES

1. American Nurses Association. Neonatal Nursing: Scope and Standards

of Practice. Silver Spring, MD: ANA; 2004.

2. American Nurses Association. Pediatric Nursing: Scope and Standards

of Practice. Silver Spring, MD: ANA; 2008.

3. Frey AM, Pettit J. Infusion therapy in children. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:

An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/

Elsevier; 2010:550-570.

1. PRACTICE SETTING

Standard

1.1 The Infusion Nursing Standards of Practice shall be applied and met in all practice settings where infusion therapy is administered.

1.2 Administration of infusion therapy shall be estab-lished in organizational policies, procedures, and/or practice guidelines.

1.3 Administration of infusion therapy shall be in accor-dance with rules and regulations promulgated by the state’s Board of Nursing and federal and state regulatory and accrediting agencies in all practice settings.

2. NEONATAL AND PEDIATRIC

PATIENTS

Standard

2.1 The nurse providing infusion therapy for neonatal and pediatric patients shall have clinical knowledge and technical expertise with respect to this population. 2.2 Clinical management of neonatal and pediatric patients shall be established in organizational policies, procedures, and/or practice guidelines and in accor-dance with applicable standards of practice.

2.3 The nurse shall verify that informed consent for treatment for neonatal and pediatric patients, as well as those patients who are deemed emancipated minors or mature minors, is documented.

Practice Criteria

A. The nurse should provide care to neonatal and pediatric patients that is individualized, collabo-rative, and age appropriate.1-4_(V)

B. The nurse providing infusion therapy to neonatal and pediatric patients should have knowledge and demonstrated skill competency in the areas of:

Nursing Practice

The Art and Science of Infusion Nursing

Standards of Practice

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4. Pediatric intravenous therapy. In: Weinstein S, ed. Plumer’s Principles

& Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:

Lippincott Williams & Wilkins; 2007:613-685.

5. De Jonge R, Polderman K, Gemke R. Central venous catheter use in the pediatric patient: mechanical and infectious complications.

Pediatr Crit Care Med. 2005;6(3):329-339.

6. Hughes RG, Edgerton EA. Reducing pediatric mediation errors: children are especially at risk for medication errors. Am J Nurs. 2005;105(5):79-84.

7. Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenter-al nutrition. J Parenter Enterparenter-al Nutr. 2004;28(suppl):S39-S70. 8. Phillips SK. Pediatric parenteral nutrition: differences in practice

from adult care. J Infus Nurs. 2004;27(3):166-170.

9. Loff S, Subotic U, Reinick F, et al. Extraction of di-ethylhexyl-phtha-late by home total parenteral nutrition from polyvinyl chloride infu-sion lines commonly used in the home. J Pediatr Gastroenterol Nutr. 2008;47(1):81-86.

10. Pak VM, Nailon RE, McCauley LA. Controversy: neonatal expo-sure to plasticizers in the NICU. MCN Am J Matern Child Nurs. 2007;32(4):244-249.

11. Kambia K, Gressier B, Bah S, et al. Evaluation of childhood exposure to di(2-ethylhexyl) phthalate from perfusion kits during long-term parenteral nutrition. Int J Pharm. 2003;262(1-2):83-91.

12. Zempsky WT. Optimizing the management of peripheral venous access pain in children: evidence, impact, and implementation.

Pediatrics. 2008;122:S121-S124.

13. Cohen LL. Behavioral approaches to anxiety and pain manage-ment for pediatric venous access. Pediatrics. 2008;122:S134-S139.

14. Sparks LA, Setlik J, Luhman J. Parental holding and positioning to decrease IV distress in young children: a randomized controlled trial. J Pediatr Nurs. 2007;22(6):440-447.

15. Czaplewski L. Clinician and patient education. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:

Elsevier; 2010:71-94.

16. Tice AD. Handbook of Outpatient Parenteral Antimicrobial Therapy

for Infectious Diseases. Tarrytown, NY: CRG Publishing; 2006.

17. Unguru Y, Coppes MJ, Kamani N. Rethinking pediatric assent: from requirement to ideal. Pediatr Clin N Am. 2008;55:211-222.

18. Sinclair SJ. Involvement of adolescents in decision making for heart transplants. MCN. 2009;34(5):276-281.

19. Jolly K, Weiss JA, Liehr P. Understanding adolescent voice as a guide for nursing practice and research. Issues Compr Pediatr Nurs. 2007; 30:3-13.

3. OLDER ADULT PATIENTS

Standard

3.1 The nurse providing infusion therapy for older adult patients shall have clinical knowledge and technical expertise with respect to this population.

3.2 Clinical management of older adult patients shall be established in organizational policies, procedures, and/or practice guidelines and shall be according to applicable standards of practice.

Practice Criteria

A. The nurse should provide individualized, collabo-rative, and age-appropriate care to older adults— those people who are 65 years and older.1-8_(V) B. The nurse providing infusion therapy to older

adults should have knowledge and demonstrated skill competency in the areas of:

1. Anatomic changes related to older adults and their effect on physical assessment, vascular and nonvascular access device site selection, inser-tion procedures, and use of specialized infusion-related equipment, including care and mainte-nance practices during infusion therapy.9-11_(V) 2. Physiologic changes related to older adults and

their effect on drug dosage and volume limita-tions, pharmacologic aclimita-tions, interaclimita-tions, side effects, monitoring parameters, and response to infusion therapy.4,9,12-14_(V)

3. Changes in cognitive abilities and dexterity; communication methods, including vision, hear-ing, and verbal changes; as well as psychosocial and socioeconomic considerations.4,9,15_(V) 4. Interaction with family members, caregivers, or

legally authorized representative as members of the patient’s health care team, with consent of the patient or as necessary due to mental status.9,15_(V) 5. Potential for adverse events and drug interac-tions in older adults who may be prescribed multiple medications.4,9,13,16_(V)

6. Safety and environmental considerations related to older adults receiving infusion therapy and effective management of those considerations.9,13,16,17_(V) REFERENCES

1. American Nurses Association. Nursing: Scope and Standards of

Practice. 2nd ed. Silver Spring, MD: ANA; 2010.

2. American Nurses Association. Scope and Standards of Gerontological

Nursing Practice. 2nd ed. Silver Spring, MD: ANA; 2001.

3. Mezey M, Stierle L, Huba GJ, Esterson J. Ensuring competence of specialty nurses in care of older adults. Geriatr Nurs. 2007;28(6) (suppl 1):9-14.

4. Zwicker D, Fulmer T. Reducing adverse drug events. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. Evidence-Based Geriatric Nursing

Protocols for Best Practice. New York, NY: Springer; 2008:257-308.

5. National Gerontological Nursing Association. Definitions of older adults and gerontological nursing. https://www.ngna.org/ about-items/definitions-of-older-adults-and-gerontological-nursing. html. Published September 2, 2008. Accessed February 23, 2010. 6. Steel K. The old-old-old. J Am Geriatr Soc. 2005;53:S314-S316. 7. Woodhouse KW, Wynne H, Baillie S, et al. Who are the frail

elderly? Q J Med. 1988;68(255):505-506.

8. World Health Organization. Definition of an older or elderly person. http://www.who.int/healthinfo/survey/ageingdefnolder/en/. Published 2010. Accessed August 10, 2010.

9. Fabian B. Infusion therapy in the older adult. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:

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Elsevier; 2010:571-582.

10. Schelper R. The aging venous system. J Assoc Vasc Access. 2003; 8(3):8-10.

11. Walsh G. Hypodermoclysis. J Infus Nurs. 2005;28(2):123-129. 12. Aubrun F. Management of postoperative analgesia in elderly

patients. Reg Anesth Pain Med. 2005;30:363-379.

13. Francis DC. Iatrogenesis: the nurse’s role in preventing patient harm. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds.

Evidence-Based Geriatric Nursing Protocols for Best Practice. New York, NY:

Springer; 2008:223-255.

14. Goldstein PC. Assessment and treatment of hypoglycemia in elders: cautions and recommendations. Medsurg Nurs. 2009;18:215-241. 15. Lueckenotte A. Older adult. In: Potter P, Perry A, eds. Fundamentals

of Nursing. 7th ed. St Louis, MO: Mosby Elsevier; 2009:

191-214.

16. Thornlow DK. Increased risk for patient safety incidents in hos-pitalized older adults. Medsurg Nurs. 2009;18:291.

17. Toth L. Monitoring infusion therapy in patients residing in long-term care facilities. J Assoc Vasc Access. 2002;7(1):34-38.

4. ETHICS

Standard

4.1 Ethical principles shall be the foundation for deci-sion making and patient advocacy.

4.2 Guidelines and resources for ethical issues shall be outlined in organizational policies, procedures, and/or practice guidelines.

4.3 The nurse shall act as a patient advocate; maintain patient confidentiality, safety, and security; and respect, promote, and preserve human autonomy, dignity, rights, and diversity.

4.4 Principles of beneficence, nonmaleficence, fidelity, protection of patient autonomy, justice, and veracity shall dictate nursing action.

Practice Criteria

A. Ethical principles should be integrated in all areas of nursing practice.1-4_(V)

B. The nurse should use professional ethical resources, including the Guide to the Code of Ethics for Nurses:

Interpretation and Application by the American

Nurses Association and the Infusion Nursing Code of

Ethics.1-4_(V)

C. The nurse should assess for and raise issues relat-ed to potential ethical problems, act as a role model for ethical care, and contribute to resolving ethical issues related to patients, colleagues, or the health care system.1-4_(V)

D. The nurse should use organizational ethics resources, such as ethics committees, and support nursing participation when dealing with ethical issues.1-4_(V)

REFERENCES

1. Fowler MDM, ed. Guide to the Code of Ethics for Nurses:

Interpretation and Application. Silver Spring, MD: American Nurses

Association; 2008.

2. Infusion Nurses Society. Infusion nursing code of ethics. J Infus

Nurs. 2001;24(4):242-243.

4. Schroeter K. Ethics. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based

Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:60-70.

5. SCOPE OF PRACTICE

Standard

5.1 The scope of practice for each type of personnel involved with the delivery of infusion therapy shall be organized to support patient safety and protection and shall clearly define the roles, responsibilities, tasks, range of services, and accountability for all levels of per-sonnel involved with the delivery of infusion therapy. 5.2 All licensed nursing personnel with responsibility for infusion therapy shall possess a license in good standing with the state’s Board of Nursing.

5.3 All personnel involved with the delivery of infusion therapy shall practice within the legal boundaries of the individual license or scope of practice.

5.4 All personnel involved with the delivery of infusion therapy shall possess the ability to communicate effec-tively with patients, supervisors, peers, and other mem-bers of the health care team.

5.5 The role of nursing assistive personnel (NAP) involved with infusion therapy shall be limited to non-invasive and administrative tasks.

5.6 Delegation of infusion therapy tasks shall be in accordance with rules and regulations promulgated by the state’s Board of Nursing. The registered nurse (RN) shall be responsible and accountable for all tasks delegated to NAP and licensed practical/vocational nurses (LPN/LVN).

5.7 The RN shall be accountable for patient safety in the delivery of infusion therapy.

Practice Criteria

A. The legal scope of practice for all licensed health care professions is defined in the state statutes governing each profession. The changing health care system mandates overlap between profes-sional groups, with no single group claiming exclusive ownership of any skill, activity, or task. Interdisciplinary education and collaboration is known to produce quality patient care.1-3 _(IV, Regulatory)

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B. The method for making scope of practice deci-sions is different for each state’s Board of Nursing and includes a decision-tree model, declaratory rulings, and advisory opinions. The expansion of infusion therapies and technologies requires the nurse to be knowledgeable of the method used in the state(s) where one practices.4,5_{(V, Regulatory)} C. Decisions about the scope of practice for each type of personnel involved with infusion therapy should focus on the following:

I. Nursing Assistive Personnel (NAP)

a. NAP function in assistive roles to perform supportive patient care tasks that are nonin-vasive. Job titles may include many combi-nations of the terms aides, assistants, or

technicians. Training is provided in many

different settings, and requirements vary among states. NAP working in some facili-ties and agencies receiving federal funding are required to have a minimum amount of training and pass a state competency evalu-ation. Some states do require a license.6-8_(V) b. Infusion-related tasks assigned to NAP include managing equipment and supplies, gathering statistics, and assisting licensed personnel with invasive procedures.6,7_(V) c. NAP should not have the responsibility to

perform invasive infusion therapy proce-dures such as catheter insertion, catheter maintenance procedures, or the administra-tion of any fluid, nutriadministra-tion, blood, or med-ication. A practice analysis for NAP identi-fied 119 activity statements; however, there were no infusion-related tasks, activities, or procedures identified.6,9_(IV)

d. State Boards of Nursing may have statements affirming that initiation, administration, and monitoring of infusion therapy may not be delegated to unlicensed personnel.6,7_(V) e. Personnel (eg, infusion team technicians)

performing catheter insertions have been identified as a predictor of complications such as phlebitis and infiltration.10_(IV) II. Medical Assistant (MA)

a. MAs function in assistive roles to physicians and other health care practitioners by per-forming administrative and clinical tasks. Their primary place of employment is the medical office.8,11_(V)

b. Due to the increasing frequency and types of infusion therapy provided in non–acute care settings, MAs should have basic knowledge of infusion therapy as it applies to their role.11_(V) c. MAs should complete a course of infusion therapy training, including supervised clinical practice.11_(V)

III. Licensed Practical/Vocational Nurse (LPN/LVN) a. Successful completion of an organized educa-tional program, including supervised clinical practice on infusion therapy, is required for LPN/LVNs in many states. In states without such requirements, completion of a similar educational program is recommended prior to performing infusion therapy procedures. These educational programs should apply the

Infusion Nursing Standards of Practice.12-14 (V, Regulatory)

b. An LPN/LVN practice analysis identified 13 of 159 activity statements as being infusion tasks, activities, and procedures. The frequen-cy of performance of each activity varies by work practice setting, age and type of patients, and years of experience.9_(IV) c. All infusion-related tasks should be

per-formed under the supervision of a registered nurse with appropriate infusion therapy knowledge and skills.13_{(V, Regulatory)} IV. Registered Nurse (RN)

a. The RN performing infusion therapy should have the requisite knowledge and skills derived from application of the Infusion

Nursing Standards of Practice.15,16 _(V) b. Due to the lack and/or inconsistency of

infu-sion therapy in basic nursing curricula, the RN should successfully complete an organized edu-cational program on infusion therapy.15,17_(V) c. The RN should participate in the

develop-ment of policies and procedures and in qual-ity improvement activities related to infu-sion therapy.18,19_(V)

d. When the RN has received a delegated assignment from another health care profes-sional and concludes that she or he is inade-quately prepared to perform this function, the RN must refuse this assignment and seek other means for providing the patient care required.20_(V)

e. Tasks delegated by the RN to other nurses or assistive personnel are required to be within the legal boundaries for those personnel. Tasks delegated to assistive personnel should not require professional judgment, require little or no modification for each patient, and can be performed with a predictable outcome.20,21_(V) V. Infusion Nurse Specialist (CRNI®₎

a. Infusion nurse specialists are RNs who have attained certification in infusion nursing from the Infusion Nurses Certification Corporation (INCC) and use the designation CRNI® (Certified Registered Nurse Infusion). This credential signifies specialized knowledge and experience in infusion nursing. All RNs

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specializing in infusion nursing should seek to earn this credential.22-24_(V)

b. Nurses earning a certification credential from a professional organization report benefits of per-sonal and professional growth, career advance-ment, financial rewards, and empowerment.25-27 (IV)

c. In addition to the practice criteria for the RN, the CRNI®_{serves as direct care provider, care} coordinator, advocate, patient and staff educa-tor, manager, and consultant on all issues relat-ed to infusion therapy.28_(V)

d. The CRNI® _{is recognized as expert in this} specialty and should organize and coordi-nate quality improvement activities in infu-sion therapy and be the primary resource to guide policy and procedure development derived from best evidence.28_(V)

e. The CRNI®_{should be involved with} imple-mentation of clinical decision support sys-tems (CDSS) to ensure the needs of nursing are addressed. CDSS designed for nursing may have the potential for guiding clinical decisions within the nurse’s scope of practice; however, the available studies have many limitations. Management of catheter- and infusion-related complications could benefit from such systems.29_(V)

VI. Advanced Practice Nurse (APN)

a. Nurse practitioners, clinical nurse specialists, nurse midwives, and nurse anesthetists com-pose the group of advanced practice nurses. APNs may be licensed independent practi-tioners (LIPs) and function under a facility’s guidelines and procedures for medical staff. APNs may have the legal authority to pre-scribe infusion therapy and perform surgical procedures for insertion and removal of vas-cular access devices.30,31_{(IV, Regulatory)} b. APNs should be involved with education,

con-sulting, and research in infusion therapy.21,30_(IV) REFERENCES

1. American Nurses Association; National Council of State Boards of Nursing. Joint statement on delegation. http//www.ncsbn.org/ Joint_statement.pdf. Accessed October 15, 2009.

2. McPherson K, Headrick L, Moss F. Working and learning togeth-er: good quality care depends on it, but how can we achieve it?

Qual Health Care. 2001;10(suppl 2):ii46-ii53.

3. Lindeke L, Sieckert A. Nurse-physician workplace collaboration.

Online J Issues Nurs. 2005;10(1):5. http://www.nursingworld.

org/mainmenucategories/anamarketplace/anaperiodicals/ojin/table ofcontents/volume102005/no1jan05/tpc26_416011.aspx. Accessed January 23, 2010.

4. Markovich MB. The expanding role of the infusion nurse in radi-ographic interpretation for peripherally inserted central catheter tip placement. J Infus Nurs. 2008;31(2):96-103.

5. Sutherland BM. Nursing practice: the regulatory arena. J Infus

Nurs. 1995;18(6):292-296.

6. Infusion Nurses Society [position paper]. The use of nursing assis-tive personnel in the provision of infusion therapy. J Infus Nurs. 2009;32(1):21-22.

7. American Academy of Pediatrics [policy statement]. Guidelines for care of children in the emergency department. Ann Emerg

Med. 2009;54(4):543-552.

8. US Department of Labor. Occupational Outlook Handbook,

2008-09. Washington, DC:Bureau of Labor Statistics; 2008.

9. Wendt A. Report of Findings From the 2005 LPN/VN Post

Entry-Level Practice Analysis. Chicago, IL: National Council of State

Boards of Nursing; 2006.

10. Catney M, Hillis S, Wakefield B, et al. Relationship between peripheral intravenous catheter dwell time and the development of phlebitis and infiltration. J Infus Nurs. 2001;24(5):332-341. 11. Bonewit-West K. Clinical Procedures for Medical Assistants. 7th

ed. St Louis, MO: Saunders/Elsevier; 2008.

12. Weinstein S, ed. Plumer’s Principles & Practice of Intravenous Therapy. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. 13. Corrigan A. Infusion nursing as a specialty. In: Alexander M,

Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:

Elsevier; 2010:1-9.

14. Seago J, Spetz J, Chapman S, Dyer W. Can the use of LPNs alle-viate the nursing shortage? Yes, the authors say, but the issues— involving recruitment, education, and scope of practice—are complex. Am J Nurs. 2006;106(7):40.

Elsevier; 2010:71-94.

16. Diehl-Svrjcek BC, Dawson B, Duncan LL. Infusion nursing: aspects of practice liability. J Infus Nurs. 2007;30(5):274-279. 17. Chippendale M, Gardner H. Review: a model for implementing the

“Scope of Professional Practice.” J Child Health Care. 2001;5(3): 105-110.

18. ECRI Institute. Failure mode and effects analysis: a hands-on guide for healthcare facilities. Health Devices. 2004;33(7):233-243. 19. Montalvo I. The National Database of Nursing Quality

IndicatorsTM_{(NDNQI®). Online J Issues Nurs. 2007;12(3).}

20. American Nurses Association. Principles of Delegation. Silver Spring, MD: ANA; 2005.

21. Kelly-Heidenthal P, Marthaler M. Delegation of Nursing Care. Clifton Park, NY: Thomson Delmar Learning; 2005.

22. American Board of Nursing Specialties [position statement]. The value of specialty nursing certification. Aurora, OH: ABNS; 2005. 23. Infusion Nurses Certification Corporation. Certification vs certifi-cate: do you know the difference? INCC Chronicle. Norwood, MA: INCC; 2009.

24. Infusion Nurses Society; Infusion Nurses Certification Corporation [joint position paper]. The value of certification in infusion nursing.

J Infus Nurs. 2009;32(5):248-250.

25. Piazza I, Donahue M, Dykes P, Griffin M, Fitzpatrick J. Differences in perceptions of empowerment among nationally certified and noncertified nurses. J Nurs Admin. 2006;36(5):277.

26. Briggs L, Brown H, Kesten K, Heath J. Certification a benchmark for critical care nursing excellence. Crit Care Nurse. 2006;26(6):47. 27. Wade C. Perceived effects of specialty nurse certification: a review

of the literature. AORN J. 2009;89(1):183-192.

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Elsevier; 2010:391-436.

29. Staggers N, Weir C, Phansalkar S. Patient safety and health informa-tion technology: role of electronic health record. In: Hughes R, ed.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

Rockville, MD: Agency for Healthcare Research and Quality; 2008. 30. Kleinpell R. Acute care nurse practitioner practice: results of a

5-year longitudinal study. Am J Crit Care. 2005;14(3):211. 31. Klein T. Credentialing the nurse practitioner in your workplace:

evaluating scope for safe practice. Nurs Admin Q. 2008;32(4): 273.

6. COMPETENCE AND

COMPETENCY VALIDATION

Standard

6.1 As a method of public protection, the nurse shall be competent in the safe delivery of infusion therapy with-in her or his scope of practice.

6.2 The nurse shall be responsible and accountable for attaining and maintaining competence with infusion therapy within her or his scope of practice.

6.3 Competency validation shall be performed initially and on an ongoing basis.

6.4 Competency validation shall be documented in accor-dance with organizational policies, procedures, and/or practice guidelines.

Practice Criteria

A. The nurse bears responsibility for becoming compe-tent to enter nursing practice and maintaining contin-ued competence throughout her or his career. Competence goes beyond psychomotor skills to include application of knowledge, critical thinking skills, and decision-making abilities. Competency requires a commitment to lifelong learning, self-reflec-tion, and professional ethics. Completion of continu-ing education programs is the most common method for continuing competence; however, this method does not prove or guarantee competence.1-10_(IV) B. Employers should use competency validation

processes to document that the nurse has the knowl-edge, skills, behaviors, and ability to perform the assigned job. Competence should initially be validat-ed at the time of employment, after orientation to the organization, on an ongoing periodic basis, when scope of practice changes, and with the introduction of new equipment or technology. Frequency of ongo-ing competence validation and performance evalua-tion is determined by the organizaevalua-tion. Frequency for validation of specific skills or tasks should be based on the associated risk and may be considered a com-ponent of the quality improvement process.11,12_(V) C. Multiple infusion-related tasks are identified as core

competencies for all registered nurses.

Infusion-related tasks performed by licensed practical/ vocational nurses (LPN/LVNs) are determined by the state’s Board of Nursing and vary greatly among states.13,14_{(V, Regulatory)}

D. Core competencies for the infusion nurse specialist should be established in the written job descrip-tion and should be based on the infusion nursing core curriculum, including:

1. Technology and clinical application 2. Fluid and electrolyte balance 3. Pharmacology

4. Infection prevention

5. Neonate and pediatric patients 6. Transfusion therapy

7. Antineoplastic and biologic therapy 8. Parenteral nutrition

9. Quality improvement15,16_(V)

E. Nurses working as contracted staff (eg, peripher-ally inserted central catheter [PICC] insertion) are required to document competency with the tasks being performed and to comply with the organi-zation’s requirements for staff qualifications and personnel practices.11_(V)

F. Competency validation is a dynamic process that changes based on organizational needs. Skills or tasks for ongoing competency validation are identi-fied through use of clinical outcome data, problems documented through Unusual Occurrence and Sentinel Event Reports, changing patient popula-tions, and patient satisfaction data. Prioritizing the specific tasks for competency validation is deter-mined by the frequency of performing those tasks and the risks associated with the tasks. Low-fre-quency tasks are performed rarely (eg, less than weekly). High-risk tasks include invasive procedures with the potential to be harmful or even life-threat-ening to the patient. Problem-prone tasks include those that are documented to produce issues for the patient, staff, or organization.11,12,17_(V)

G. A variety of different methods should be used for competency validation including, but not limited to, written tests for evaluating knowledge, use of clinical scenarios, and assessment of critical think-ing skills; observation in a skills laboratory; and observing performance of the skill in the work environment, which is the preferred method for invasive infusion therapy procedures.11,18_(V) H. A skills laboratory setting involves use of

simula-tion with anatomical models and computer-based virtual reality. Performance of invasive proce-dures (eg, venipuncture) on peers is discouraged due to health risk for the peer-volunteer.19-21_(V) I. Documentation of observed performance requires

a well-designed form or checklist that focuses on objective, measurable assessment of the actual performance; however, data on the validity and

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reliability of specific forms are not available. The form includes the competency statement, specific performance criteria statements, or critical behav-iors; the method of demonstrating performance; the criteria for achieving success; and the signa-ture of the validator.11_(V)

J. Initial competency validation for specialized skills not expected of all nurses (eg, PICC insertion, chemotherapy administration) requires attention to prior clinical experience, educating the nurse for these advanced skills, and completion of a procedure demonstration and return demonstra-tion. This is followed by performance of an iden-tified number of successful procedures under supervision in the clinical setting.17,22_(V)

K. The person validating the specific skill should be competent with the skill. When no one in the organization has the specific competency, arrangements for a skill validator from outside the organization may be necessary.11,18,23_(V) L. Competency validation should include

competen-cy for specific patient populations based on age. Age-based competency will address needs by chronological, functional, or life-stage groups, including physical and psychological development needs and patient educational requirements.11_(V) M. Competency validation should facilitate culturally competent health care by identifying and address-ing the needs of ethnically diverse patient popula-tions. Cultural competence includes health care-related beliefs and values, prevalent diseases in pop-ulations served, religious practices, language and literacy issues, and family-based needs.11,24,25_(V) REFERENCES

1. Vanaki Z, Memarian R. Professional ethics: beyond the clinical competency. J Professional Nurs. 2009;25(5):285-291. 2. Tilley D. Competency in nursing: a concept analysis. J Continuing

Educ Nurs. 2008;39(2):58.

3. Burns B. Continuing competency: what’s ahead? J Perinat Neonatal

Nurs. 2009;23(3):218.

4. Allen P, Lauchner K, Bridges R, Francis-Johnson P, McBride S, Olivarez A. Evaluating continuing competency: a challenge for nurs-ing. J Continuing Educ Nurs. 2008;39(2):81-85.

5. Lazarus J, Lee N. Factoring consumers’ perspectives into policy deci-sions for nursing competence. Policy Polit Nurs Pract. 2006;7(3):195. 6. Milton C. Accountability in nursing: reflecting on ethical codes and professional standards of nursing practice from a global perspective.

Nurs Sci Q. 2008;21(4):300.

7. Centers for Disease Control and Prevention (CDC). Progress toward strengthening blood transfusion services: 14 countries, 2003-2007.

MMWR Morb Mortal Wkly Rep. 2008;57(47):1273-1277.

8. Minarik P. Issue: competence assessment and competency assurance of healthcare professionals. Clin Nurse Specialist. 2005;19(4):180. 9. Cowan D, Norman I, Coopamah V. Competence in nursing

prac-tice: a controversial concept: a focused review of the literature.

Nurse Educ Today. 2005;25(5):355-362.

11. Joint Commission Resources. Assessing Hospital Staff Competence. 2nd ed. Oakbrook Terrace, IL: JCR; 2007.

12. McAdams C, Montgomery K. Narrowing the possibilities: using quality improvement tools to decrease competence assessment over-load. J Nurs Staff Dev. 2003;19(1):40.

13. Wendt A, Alexander M. Toward a standardized and evidence-based continued competence assessment for registered nurses. JONA’s

Healthc Law Ethics Regul. 2007;9(3):74.

14. Gorski L, Miller C, Mortlock N. Infusion therapy across the contin-uum. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:109-126.

15. Hadaway L. Infusion therapy equipment. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:

Elsevier; 2010:391-436.

Elsevier; 2010:71-94

17. Rusche J, Besuner P, Partusch S, Berning P. Competency program development across a merged healthcare network. J Nurs Staff Dev. 2001;17(5):234.

18. O’Hearne Rebholz M. A review of methods to assess competen-cy. J Nurs Staff Dev. 2006;22(5):241.

19. Hilton P, Barrett D. An investigation into students’ performance of invasive and non-invasive procedures on each other in class-room settings. Nurse Educ Pract. 2009;9(1):45-52.

20. Landry M, Oberleitner M, Landry H, Borazjani J. Education and practice collaboration: using simulation and virtual reality technology to assess continuing nurse competency in the long-term acute care setting. J Nurs Staff Dev. 2006;22(4):163.

21. Beyea S, von Reyn L, Slattery M. A nurse residency program for competency development using human patient simulation. J Nurs

Staff Dev. 2007;23(2):77-82.

22. Andam R, Silva M. A journey to pediatric chemotherapy compe-tence. J Pediatr Nurs. 2008;23(4):257-268.

23. Ringerman E, Flint L, Hughes D. An innovative education pro-gram: the peer competency validator model. J Nurs Staff Dev. 2006;22(3):114.

24. Polacek G, Martinez R. Assessing cultural competence at a local hospital system in the United States. Health Care Manager. 2009; 28(2):98.

25. Engebretson J, Mahoney J, Carlson E. Cultural competence in the era of evidence-based practice. J Professional Nurs. 2007;24(3):172-178.

7. QUALITY IMPROVEMENT

Standard

7.1 The nurse shall participate in quality improvement activities that advance patient care, quality, and safety. Practice Criteria

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indicators, benchmarks, and areas for improvement; providing best evidence; recommending and imple-menting changes in structures or processes; analyzing data and outcomes against benchmarks; considering the use of cost analysis; or minimizing and eliminat-ing barriers to change and improvement.1-13_(V) B. The quality improvement program should create a

culture that fosters the reporting and analysis of quality and safety indicator outcomes, near-miss-es, errors, and adverse events. The program should focus on systems and processes that promote indi-vidual accountability and a just culture.12,14-22_(V) C. The knowledge gained through this process should

be shared internally and externally with other health care providers and organizations.13,23_(V) REFERENCES

2. Institute of Medicine. Crossing the Quality Chasm: A New

Health System for the 21st Century. Washington, DC: National

Academy Press; 2001:111-144, 231-308.

3. The Joint Commission. Comprehensive Accreditation Manuals. Edition v2.0.0.0. Oakbrook Terrace, IL: TJC; 2010.

4. Sierchio GP. Quality management. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R. Infusion Nursing: An

Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;

2010:22-48.

5. Agency for Healthcare Quality and Research. NQF-Endorsed

Measures. In: National Quality Measures Clearinghouse™. http://

www.qualitymeasures.ahrq.gov/browse/endorsed.aspx. Accessed January 30, 2010.

6. Curtis JR, Cook DJ, Wall RJ, et al. Intensive care unit quality improvement: a “how-to” guide for the interdisciplinary team.

Crit Care Med. 2006;34:211-218.

7. Danello SH, Maddox RR, Schaack GJ. Intravenous infusion safety tech-nology: return on investment. Hosp Pharm. 2009;44:680-687,696. 8. Dunton N, Montalvo I. Sustained Improvement in Nursing

Quality: Hospital Performance on NDNQI Indicators, 2007-2008. Silver Spring, MD: American Nurses Association; 2009.

9. Farquhar M. AHRQ quality indicators. In: Hughes RG, ed.

Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ Publication No. 08-0043. Rockville, MD: Agency

for Healthcare Research and Quality. http://www.ahrq.gov/qual/ nurseshdbk/docs/FarquharM_IS.pdf. Published March 2008. Accessed July 6, 2010.

10. Galloway M. Using benchmarking data to determine vascular access device selection. J Infus Nurs. 2002;25(5):320-325. 11. Institute of Medicine. The State of Quality Improvement and

Implementation Research: Expert Views. Washington, DC: National

Academy Press. 2007;53-56, 29-43.

12. Rudy EB, Lucke JF, Whitman GR, Davidson LJ. Benchmarking patient outcomes. J Nurs Scholarship. 2001;33(2):185-189. 13. Sierchio GP. A multidisciplinary approach for improving outcomes.

J Infus Nurs. 2003;26(1):34-43.

14. Alexander M, Webster H. Legal issues of infusion nursing. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds.

Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis,

MO: Elsevier/Saunders; 2010:49-59.

15. Barnhill S. Clinician and patient safety. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R. Infusion Nursing: An Evidence-Based

Approach. 3rd ed. St Louis, MO: Elsevier/Saunders; 2010:95-108.

16. Hughes RG. Tools and strategies for quality improvement and patient safety. In: Hughes RG, ed. Patient Safety and Quality: An

Evidence-Based Handbook for Nurses. AHRQ Publication No.

08-0043. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/qual/nurseshdbk/docs/HughesR_ QMBMP.pdf. Published March 2008. Accessed July 6, 2010. 17. Institute of Medicine. Patient Safety: Achieving a New Standard for

Care. Washington, DC: National Academy Press. 2004;226-249,

200-225, 279-316.

18. Mitchell PH. Defining patient safety and quality care. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook

for Nurses. AHRQ Publication No. 08-0043. Rockville, MD:

Agency for Healthcare Research and Quality. http://www.ahrq. gov/qual/nurseshdbk/docs/MitchellP_DPSQ.pdf. Published March 2008. Accessed July 6, 2010.

19. Shearburn P, Kratz M. Utilization of error analysis data in chemother-apy order preparation for development of a comprehensive electronic chemotherapy plan of care. Oncol Nurs Forum. 2009;36(3):76. 20. Wachter RM, Pronovost PJ. Balancing “no blame” with

account-ability in patient safety. New Engl J Med. 2009;361(14):1401-1406. 21. Minimizing risk and improving performance. In: Weinstein S, ed.

Plumer’s Principles & Practice of Intravenous Therapy. 8th ed.

Philadelphia, PA: Lippincott Williams & Wilkins; 2007:10-23. 22. Gorski LA. Central venous access device outcomes in a homecare

agency: a 7-year study. J Infus Nurs. 2004;27(2):104-111. 23. Stokowski G, Steele D, Wilson D. The use of ultrasound to improve

practice and reduce complication rates in peripherally inserted central catheter insertions. J Infus Nurs. 2009;32(3):145-155.

8. RESEARCH AND

EVIDENCE-BASED PRACTICE

Standard

8.1 The nurse shall use research findings and current best evidence to expand nursing knowledge in infusion therapy, to validate and improve practice, to advance professional accountability, and to enhance evidence-based decision making.

8.2 The nurse shall obtain approval for research and research-related activities in accordance with federal regulations, professional standards, and criteria set forth by accrediting agencies and organizational poli-cies, procedures, and/or practice guidelines.

8.3 The nurse shall develop and revise organizational policies, procedures, and/or practice guidelines based on research findings and current best evidence.

8.4 The nurse shall integrate evidence-based nursing knowledge with clinical expertise and the patient’s pref-erences and values in the current context when provid-ing infusion therapy.

Practice Criteria

A. The nurse should actively participate in infusion therapy research activities that advance nursing

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knowledge, such as participating on a research team or journal club, or conducting systematic literature reviews, in relation to the individual’s education and experience.1-5_(V)

B. The nurse should actively participate in critically evaluating, interpreting, and implementing research findings and/or current best evidence into nursing practice. This includes, but is not limited to, policy and procedure development and review; product technology selection; practice guideline implemen-tation; or abstraction of data from published papers, in relation to the individual’s education and experience.6-10_(V)

C. The nurse should be competent in using evi-dence-based nursing knowledge and identifying patients’ preferences and values to provide effective and safe infusion therapy practice.7,11-14 (V)

REFERENCES

2. Infusion Nurses Society. Mission. http://www.ins1.org. Accessed August 2, 2010.

3. Infusion Nurses Society; Infusion Nurses Certification Corporation [position paper]. The value of certification in infusion nursing. J

Infus Nurs. 2009;32(5):248-250.

4. Polit DF, Beck CT. Essentials of Nursing Research: Appraising

Evidence for Nursing Practice. 7th ed. New York, NY: Lippincott

Williams & Wilkins; 2009.

Association; 2008.

6. Dos Reis PE, Silveira RC, Vasques CI, Carvalho EC. Pharmacological interventions to treat phlebitis: systematic review. J Infus Nurs. 2009; 32:75-79.

7. Hagle ME, Senk P. Evidence-based practice. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R. Infusion Nursing: An

Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;

2010:10-21.

8. Hertzel C, Sousa VD. The use of smart pumps for preventing medication errors. J Infus Nurs. 2009;32(5):257-267.

9. Titler MG. The evidence for evidence-based practice implementa-tion. In: Hughes RG, ed. Patient Safety and Quality: An

Evidence-Based Handbook for Nurses. AHRQ Publication No. 08-0043.

Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/qual/nurseshdbk/docs/TitlerM_EEBPI. pdf. Published March 2008. Accessed August 2, 2010. 10. Adams J. Utilizing evidence-based practice to support the infusion

alliance. J Infus Nurs. 2010; 33(5):273-277.

11. Bays CL, Hermann CP. An evidence-based practice primer for infusion nurses. J Infus Nurs. 2010;33(4):220-225.

12. Cox JA, Westbrook LJ. Home infusion therapy: essential character-istics of a successful education process—a grounded theory study.

J Infus Nurs. 2005;28(2):99-107.

13. Infusion Nurses Society. Infusion nursing code of ethics. J Infus

Nurs. 2001;24(4):242-243.

14. Evidence-based infusion practice. In: Weinstein S, ed. Plumer’s

Principles & Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:

Lippincott Williams & Wilkins. 2007;188-200.

9. POLICIES, PROCEDURES,

AND/OR PRACTICE GUIDELINES

Standard

9.1 Infusion policies, procedures, and/or practice guide-lines shall describe the acceptable course of action, including performance and accountability, and provide a basis for clinical decision making.

9.2 Infusion policies, procedures, and/or practice guide-lines shall be compliant with state and federal laws and professional standards.

9.3 Infusion policies, procedures, and/or practice guide-lines shall be written, reviewed at established intervals, and revised as needed based on best evidence, and approved within a formal organizational process. 9.4 Infusion policies, procedures, and/or practice guide-lines shall be readily available and accessible to health care team members.

Practice Criteria

A. Infusion policies, procedures, and/or practice guidelines should encompass all applicable areas of infusion therapy and should ensure patient safety, as well as minimize or mitigate patient harm.1-3_(V) B. Infusion policies, procedures, and/or practice guide-lines should be developed in accordance with criteria set forth in this document, in collaboration with other health care disciplines, patients, industry rec-ommendations, and in keeping with specific needs of the organization and criteria set forth by regulatory and nonregulatory agencies (see Standard 8,

Research and Evidence-Based Practice).1,2_(V) C. The organization should have a process to develop

policies, procedures, and/or practice guidelines that are evidence based, maintains the same standard of care throughout the organization, and includes all stakeholders.1,2,4_(V)

D. Procedural checklist(s) should be incorporated into policies, procedures, and/or practice guidelines to pro-mote patient safety and desired patient outcomes.5_(III) REFERENCES

1. Sierchio G. Quality management. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R., eds. Infusion Nursing An Evidence-Based

Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:22-48.

2. Institute of Medicine. Crossing the Quality Chasm: A New Health System

for the 21st Century. Washington, DC: National Academy Press; 2001.

4. Agency for Healthcare Research and Quality: Charting Nursing’s Future, July 2009, Part II—Addressing the Quality and Safety Gap— Part II: How Nurses Are Shaping, and Being Shaped by, Health Information Technologies. http://www.rwjf.org/files/research/20090709 chartingissue11.pdf. Accessed February 26, 2010.

5. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl

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VOLUME 34 | NUMBER 1S | JANUARY/FEBRUARY 2011 S15 Introduction of information technology should incorporate the principles of patient safety and involve all stakeholders in implementing the tech-nology and required processes.2-7_(III)

C. Adherence to prescribing guidelines, such as appropriate dose ranges, population-specific dose reductions, and biochemical and microbio-logical test values, may result from the integra-tion of CDSS with CPOEs, thus facilitating nurs-ing assessment of order appropriateness.5,8_(IV) D. The nurse should advocate for organizational

proto-cols and standard order sets for patient safety.7,9-11 (IV)

E. The nurse should accept verbal orders from LIPs only when medically necessary.11,12_(IV)

F. The nurse should adhere to a standard “read-back” process when accepting verbal or telephone orders from an LIP.6,12_(V)

REFERENCES

1. Tully MP, Ashcroft DM, Dornan T, Lewis PJ, Taylor D, Wass V. The causes of and factors associated with prescribing errors in hospital inpatients: a systematic review. Drug Saf. 2009;32(10): 819-836.

2. Reckmann MH, Westbrook JI, Koh Y, Lo C, Day RO. Does com-puterized provider order entry reduce prescribing errors for hospi-tal inpatients? A systematic review. J Am Med Inform Assoc. 2009; 16(5):613-623.

3. Shamliyan T, Duval S, Du J, Kane R. Just what the doctor ordered: review of the evidence of the impact of computerized physician order entry system on medication errors. Health Serv Res. 2008; 43(1):32-53.

4. van Rosse F, Maat B, Rademaker C, van Vught A, Egberts A, Bollen C. The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review. Pediatrics. 2009;123(4):1184-1190. 5. Yu F, Menachemi N, Berner E, Allison J, Weissman N, Houston

T. Full implementation of computerized physician order entry and medication-related quality outcomes: a study of 3364 hospi-tals. Am J Med Qual. 2009;24(4):278-286.

6. National Quality Forum. Safe Practices for Better Healthcare,

2009. Update: A Consensus Report. Washington, DC: NQF; 2009.

10. ORDERS FOR THE INITIATION

AND MANAGEMENT OF

INFUSION THERAPY

Standard

10.1 Infusion therapy shall be initiated, changed, or discontinued upon the order of a licensed independent practitioner (LIP).

10.2 The nurse shall verify that the LIP’s order is com-plete by inclusion of patient identification; fluid type, volume, and a specific infusion rate; specific medica-tion(s), dosage(s), route, and frequency of administra-tion; and any special considerations.

10.3 The nurse shall verify that the LIP’s order is clear, concise, legible, and complete prior to initiation, change, or discontinuation of infusion therapy. 10.4 Use of verbal and telephone orders shall be estab-lished in organizational policies, procedures, and/or practice guidelines.

10.5 The nurse shall accept only those abbreviations approved by the organization.

10.6 Appropriateness and accuracy of the prescribed ther-apy shall be assessed and documented using the nursing process.

10.7 All patient medications shall be reconciled at the time of admission, transfer within or between health care systems, and discharge.

Practice Criteria

A. The nurse should be aware that processes of pre-scribing and tranpre-scribing medication orders are responsible for the greatest number of adverse drug events. The nurse should advocate for a sys-tems approach for improvement.1-3_(III)

B. Technology for enhancing the process of prescrib-ing, changprescrib-ing, and discontinuing infusion orders includes computerized provider order entry (CPOE) and clinical decision support systems (CDSS).

Patient Care

The Art and Science of Infusion Nursing

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7. Migita D, Postetter L, Heath S, Hagan P, Del Beccaro M. Governing peripherally inserted central venous catheters by com-bining continuous performance improvement and computerized physician order entry. Pediatrics. 2009;123(4):1155-1161. 8. Mack E, Wheeler D, Embi P. Clinical decision support systems in the

pediatric intensive care unit. Pediatr Crit Care Med. 2009;10(1):23-28. 9. Mickle J, Reinke D. A review of anemia management in the oncology setting: a focus on implementing standing orders. Clin J

Oncol Nurs. 2007;11(4):534-539.

10. Weber LM, Ghafoor VL, Phelps P. Implementation of standard order sets for patient-controlled analgesia. Am J Health Syst Pharm. 2008;65(12):1184-1191.

11. Wakefield DS, Brokel J, Ward MM, et al. An exploratory study measuring verbal order content and context. Qual Saf Health

Care. 2009;18(3):169-173.

12. Wakefield D, Wakefield B. Are verbal orders a threat to patient safety? Qual Saf Health Care. 2009;18(3):165-168.

11. PATIENT EDUCATION

Standard

11.1 The nurse shall educate the patient, caregiver, and/or legally authorized representative about the pre-scribed infusion therapy and plan of care, including, but not limited to, purpose and expected outcome(s) and/or goals of treatment, infusion therapy administration, infusion device-related care, potential complications, or adverse effects associated with treatment or therapy, and risks and benefits, according to organizational poli-cies, procedures, and/or practice guidelines.

11.2 The nurse shall document the teaching content pro-vided; to whom it was propro-vided; and the patient, caregiv-er, or legally authorized representative’s response in the patient’s permanent medical record according to organi-zational policies, procedures, and/or practice guidelines. Practice Criteria

A. Teaching methods should be developed and based upon an assessment of age, developmental and cogni-tive level, health literacy, cultural influences, and lan-guage preference; additional factors affecting readi-ness to learn such as current stressors, sensory deficits, and functional limitations should also be assessed.1-4_(V)

B. Health literacy is a critical component of communi-cation and patient educommuni-cation. Written educommuni-cational materials and verbal presentation of teaching should be made as simple as possible for all patients. Use of materials such as pictures, dia-grams, and audio/video instructional aids should be considered for patients with low or limited literacy and/or for those who speak English as a second lan-guage. Medical jargon and abbreviations should be avoided, and simple terminology should be used.1-8 (V)

C. Education should include, but not be limited to: 1. Proper care of the access device.

2. Precautions for preventing infection and other complications, including aseptic technique and hand hygiene.

3. Signs and symptoms to report, including those that may occur after infusion device removal and after the patient leaves the health care set-ting (eg, signs of postinfusion phlebitis, fever) and how/where to report them.

4. Ensuring that health care providers are employing proper infection prevention meth-ods, such as hand hygiene, when providing care.

5. For outpatients and those receiving home infusion therapy, additional education should include: a. Safe storage, maintenance, and disposal of

solutions, supplies, and equipment. b. Infusion administration as appropriate. c. Information on how to live with an access

device, including activity limitations and protecting the device while performing activ-ities of daily living.3,8-14_(V)

D. Patient or caregiver comprehension and perfor-mance should be initially evaluated and periodi-cally reevaluated at established intervals.1-4,11,12 (V)

E. Effective education is critical to the safe provision of infusion therapy and in reducing the risk for infusion-related complications. Goals of infusion therapy and the patient/caregiver role related to performance of specific aspects of infusion care should be mutually developed with the patient or caregiver. 1,3,4,11,15 _(IV)

REFERENCES

1. Czaplewski L. Clinician and patient education. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion

Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:

Saunders/Elsevier; 2010:71-94.

2. Bass L. Health literacy: implications for teaching the adult patient. J Infus Nurs. 2005;28(1):15-22.

3. Gorski LA. Pocket Guide to Home Infusion Therapy. Sudbury, MA: Jones & Bartlett; 2005.

5. Walker J, Gerard PS. Assessing the health literacy levels of patients using selected hospital services. Clin Nurse Specialist. 2010;24(1):31-37.

6. US Department of Health and Human Services. Healthy People

2010: Understanding and Improving Health. 2nd ed. Washington,

DC: DHHS; 2010.

7. National Network of Libraries of Medicine. Health literacy. http://nnlm.gov/outreach/consumer/hlthlit.html. Accessed December 30, 2009.

8. Denham CR. SBAR for patients. J Patient Safety. 2008;4(1):38-48.

S16 Journal of Infusion Nursing

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9. National Quality Forum. Safe practice 21: central line associated bloodstream infection prevention. In: Safe Practices for Better

Healthcare, 2009. Update: A Consensus Report. Washington,

DC: NQF; 2009:225-229.

10. Registered Nurses Association of Ontario. Nursing best practice guideline: care and maintenance to reduce vascular access compli-cations. http://www.rnao.org/Storage/39/3379_Assessment_and_ Device_Selection_for_Vascular_Access._with_2008_Supplement. pdf. Revised 2008. Accessed December 30, 2009.

11. Gorski LA, Czaplewski LM. PICC and midline catheters for the home care nurse. J Infus Nurs. 2004;27(6):399-409.

12. Tice AD. Handbook of Outpatient Parenteral Antimicrobial

Therapy. Tarrytown, NY: CRG Publishing; 2006.

13. US Centers for Disease Control and Prevention (CDC). Frequently asked questions about “catheter associated bloodstream infec-tions.” http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/BSI_tagged. pdf. Accessed December 30, 2009.

14. Perucca R. Peripheral venous access devices. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion

15. Moller T, Borregaard N, Tvede M, Adamsen L. Patient education: a strategy for prevention of infections caused by permanent cen-tral venous catheters in patients with hematological malignancies: a randomized clinical trial. J Hosp Infect. 2005;61(4):330-341.

12. INFORMED CONSENT

Standard

12.1 The nurse shall confirm that the patient’s informed consent was obtained for the defined proce-dure as identified in organizational policies, proceproce-dures, and/or practice guidelines and in accordance with local, state, and federal regulations.

12.2 Consent shall be obtained by the health care provider who will perform the procedure and shall include full details of the procedure, risks and benefits, alternatives, and complications associated with the treatment or therapy, in a language that the patient or legally authorized representative can understand. 12.3 The nurse shall advocate for the patient’s or legally authorized representative’s right to accept or refuse treat-ment.

Practice Criteria

A. The nurse should be knowledgeable of the proto-col for obtaining informed consent from the patient or legally authorized representative, both verbally and written, and ensure that the informa-tion given to the patient or legally authorized rep-resentative has included discussion of risks, bene-fits, alternatives, and complications associated with the treatment or therapy. This should be done in a method such as asking the patient to recount or “teach back” the proposed treatment or procedure.1-7_(V)

B. The nurse should verify that informed consent was obtained for the treatment for neonatal, pediatric, and adolescent patients from the patient’s parent or legal guardian, and should document the infor-mation given to the legally authorized representa-tive(s) and the response in the patient’s permanent medical record.4,8-10_(V)

C. The nurse should obtain and document the child’s (age 7 or older) or teenager’s assent to the proce-dure, tailoring the information with consideration for knowledge and developmental level.11-13_(V) D. As elements of informed consent, the nurse should

ensure that the patient, parent, or legally authorized representative, at a minimum, should be able to explain in everyday words the diagnosis or health problem; the name, type, and general nature of the treatment, service, or procedure; and the primary risks, benefits, and alternatives.5,11_(V)

E. The nurse should ensure that informed consent includes the following elements:

1. Documents written at or below the 5th-grade reading level and provided in the primary lan-guage of the patient.

2. Provision of a qualified medical interpreter or reader to assist patients with limited language proficiency, limited health literacy, and visual or hearing impairments.

3. Patient-centered information that is adequate and meaningful to the individual.

4. A dialogue with the patient and, as appropriate, the family and other decision makers, about the nature and scope of the procedure.6-8,14 (V)

F. The nurse should ensure that if the patient’s con-dition does not allow for such interaction, appro-priate documentation is provided in the patient’s permanent medical record.11_(V)

REFERENCES

1. Alexander M, Webster HK. Legal issues of infusion nursing. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds.

Infusion Nursing: An Evidence-Based Approach. 3rd ed. St

Louis, MO: Saunders/Elsevier; 2010:49-59.

2. Nettina SM, ed. The Lippincott Manual of Nursing Practice. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006: 16.

3. Smith SF, Duell DJ, Martin BC. Clinical Nursing Skills: Basic to

Advanced Skills. 6th ed. Upper Saddle River, NJ: Pearson

Education; 2004:7-8, 54-55.

4. Cheung, W Pond G, Geslegrave, R, Enright K, Potanina L, Siu L. The contents and readability of informed consent forms for oncolo-gy clinical trials. Am J Clin Oncol. 2010;33(4):387-392.

5. Sims, JM. Your role in informed consent. Dimens Crit Care Nurs. 2008;7(3):118-121.

6. Holmes-Rovner M, Wills C. Improving informed consent: insights from behavioral decision research. Med Care. 2002;40(9) (suppl):V30-V38.

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7. National Quality Forum. Safe Practices for Better Healthcare—

2009 Update: A Consensus Report. Washington, DC: NQF;

2009.

8. Paasche-Orlow MK, Taylor HA, Brancati FL. Readability stan-dards for informed consent forms as compared with actual read-ability. N Engl J Med. 2003;348(8):721-726.

9. Simon CM, Siminoff LA, Kodish ED, Burant C. Comparison of the informed consent process for randomized clinical trials in pediatric and adult oncology. J Clin Oncol. 2004;22(13):2708-2729.

10. Committee on Bioethics, American Academy of Pediatrics. AAP publications retired or reaffirmed, October, 2006. Informed con-sent, parental permission and assent in pediatric practice.

Pediatrics. 2007;119:405. doi: 10.1542/peds.2006-3222.

11. Joint Commission on Accreditation of Healthcare Organizations.

Comprehensive Accreditation Manual for Hospitals: The Official Handbook (CAMH). Oakbrook Terrace, IL: JCAHO; 2009.

12. Rossi WC, Reynolds W, Nelson RM. Child assent and parental permission in pediatric research. Theor Med Bioeth. 2003;24(2):131-148.

13. Szalados JE. Legal issues in the practice of critical care medicine: a practical approach. Crit Care Med. 2007;35(suppl 2):S44-S58. 14. Agre P, Rapkin B. Improving informed consent: a comparison of

four consent tools. IRB. 2003;25(6):1-7.

13. PLAN OF CARE

Standard

13.1 The nurse shall collect comprehensive data perti-nent to the patient’s health care needs.

13.2 The nurse shall analyze assessment data and deter-mine nursing diagnosis (problem).

13.3 The nurse shall identify outcome criteria based on nursing diagnoses.

13.4 The nurse shall develop a plan of care that describes nursing actions to achieve expected outcomes. 13.5 The nurse shall implement nursing actions identi-fied in the plan of care.

13.6 The nurse shall evaluate the patient’s progress toward expected outcomes, revising the plan of care as appropriate and at established intervals.

13.7 The use of care plans shall be established in organi-zational policies, procedures, and/or practice guidelines. Practice Criteria

A. Nursing assessment should be systematic and pri-oritized by patient needs, based on organizational policies, procedures, and/or practice guidelines using best evidence and nursing judgment.1,2_(V) B. The nurse should develop nursing diagnoses

(actu-al or potenti(actu-al bio-psychosoci(actu-al patient problems) based on pertinent and accurate assessments.1-4 _(V) C. The nurse should develop interventions consistent with the established plan of care, achievable in the cur-rent patient context, and based on best evidence.1,3,5 (V)

D. The nurse should determine the type and frequen-cy of patient monitoring based on the prescribed therapy, access device, patient’s condition and age, and care setting.1,6-8_(V)

E. The nurse should develop outcome criteria in relation to the patient’s capabilities, availability, and accessibility to resources, and should include a time frame for achievement.1_(V)

F. The nurse should conduct an ongoing evaluation of the plan of care and revise diagnoses, interven-tions, and outcome criteria as needed.1,2_(V) G. The nurse should develop a plan of care that is

minimally composed of assessment, diagnoses, interventions, and outcome criteria; uses nursing judgment and critical thinking; is individualized for the patient, spanning the care continuum as need-ed; and includes, but is not limited to, age, cultur-al and linguistic appropriateness, environmentcultur-al sensitivity, and socioeconomic factors.1,3,6-11_(IV) H. The nurse should involve the patient, caregiver, or

legally authorized representative in the develop-ment, evaluation, and revision of the plan of care to achieve expected outcomes.1,12,13_(V)

I. The nurse should collaborate with other members of the health care team in the development, eval-uation, and revision of the plan of care and com-municate the plan to the team.1,6,14_(V)

J. The documented plan of care should be in a stan-dardized language or terminology, in a retrievable format, and contained within the patient’s perma-nent medical record.1,10,11,15-17_(V)

REFERENCES

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accurately completing other diagnoses and orders for discipline and treatments. Home Healthc Nurse. 2005;23(4):210-212. 4. Herdman TH, ed. Nursing Diagnoses: Definitions and

Classification, 2009-2011. Ames, IA: Wiley-Blackwell; 2009.

5. Hagle M, Senk P. Evidence-based practice. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion

6. Adams-Wendling L, Piamjariyakul U, Bott M, Taunton R. Strategies for translating the resident care plan into daily practice.

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8. American Nurses Association. Nursing’s Social Policy Statement. 2nd ed. Silver Spring, MD: ANA; 2003.

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