A peripheral intravenous catheter (PIVC) is used to administer medications and fluids or parenteral nutrition. PIVC is a practice that is frequently used in patients who are receiving infusion care, and its use by healthcare professionals who are not properly trained may lead to negative outcomes such as phlebitis, thrombosis, and anxiety in many patients in a short time [1, 2]. Several studies suggest that the incidence of phlebitis development is 30.7% [3]. The causes of phlebitis could be mechanical, chemical, and/or bacterial [4]. As a nursing practice, PIVC is frequently used in healthcare services and requires nurses to have relevant knowledge, skills, self-confidence, self-efficacy, and decision-making and problem-solving skills [5, 6].

Self-efficacy is a cognitive-perceptual factor that influences a person's behavior [7]. Individuals with poor self-efficacy not only display poor performance or effort to overcome a challenging case but also have a poor perspective about solving a problem in the best way possible. In other words, their problem-solving skills, which require creative thinking, are poor [8, 9]. Personal characteristics, self-efficacy, problem-solving skills, practice skills, and academic achievement are interrelated concepts [5, 10].

Problem-solving is a concept that requires an individual to receive and process information and put this information into practice. Student nurses and student midwives should be able to deal not only with their own problems but also the problems of others. This requires complex and rapid interventions at the hospital where people are vulnerable to stress and acute situations at all times [11]. Problem-solving is also important for nurses because it is a sub-step of critical thinking. Several studies have demonstrated that students are aware of the problems encountered while they are providing care by comparing the knowledge they have obtained during education with the knowledge they have obtained in clinical settings, but they are inadequate in finding solutions [12]. However, what distinguish an autonomous nurse (a nurse who is able to make decisions independently within the framework of tasks) from a non-autonomous nurse (a nurse who is not able to do so), or an experienced nurse from an inexperienced nurse, are critical thinking and problem-solving skills [13]. Although some studies were conducted to try and explain the skills of nurses or students in terms of evidence-based practices focusing on factors such as critical thinking and problem-solving skills, there are no studies in which two important components of PIVC application, namely problem-solving skills and self-efficacy, are investigated together [5, 8, 9, 11, 14, 15].

Therefore, this study aimed to find out whether several variables such as students' self-efficacy and problem-solving skills may predict their knowledge of and responsibility for performing intravenous practices and monitoring phlebitis and infiltration. The researcher believes that the study contributes to developing strategies to facilitate learning.

The sociodemographic characteristics of the students who participated in the study are given in Table 1. The mean age of the participants was 21.6±1.38. Among the participants, 64.8% were students in the nursing department, 53.4% were third-year students, 84.6% were female, 41.6% had graduated from Anatolian High Schools (high schools where education is provided in English, French, or German), 87.9% were unemployed, 76.0% were satisfied with the profession, 74.4% wanted to improve themselves professionally, the mothers and fathers of 66.9% and 48.4% of the students, respectively, had primary level education (Table 1).

Table 1
Sociodemographic Characteristics of Nursing and Midwifery Students (N=736)

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In this study, the mean scores that the participants obtained from the CCIMQ, SES, and PSI were 9.36±3.56, 85.94±10.26, and 114.43±17.56, respectively. The mean scores that the participants obtained from the subscales of SES were as follows: starting to display the behavior: 32.21±3.79; maintaining the behavior: 27.44±3.34; completing the behavior: 17.07±3.90; and struggling against barriers: 9.21±2.41. The mean scores that the participants obtained from the subscales of PSI were as follows: confidence: 34.66±8.71; approach/avoidance: 52.17±9.86; and personal control: 20.64±3.37. The lowest mean score was obtained from the personal control subscale (20.64±3.37), a significant determinant for effective and successful problem-solving skills in a given situation.

According to the results of the Pearson's correlation analysis, the participants' mean CCIMQ score positively correlated with their mean SES score and year at school on a moderate level (r=.25, p<.001; r=.11, p=.046). However, CCMQ negatively correlated with their mean PSI score and satisfaction with the profession on a moderate level (r=−.21, p <.001; r=−.13, p <.001) (Table 2). In other words, because a low PSI score indicates that the person's problem-solving skill is high, as the problem-solving skill improved, so did the CCIMQ score.

Table 2
Correlation between CCIMQ, SES and PSI (N=736)

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As shown in Table 3, the results of the analysis of variance (F_SES SES_-PSI PSI=21.64) were significant on the level of p<.001. That the results of the variance analysis were significant indicates that the relationship between the dependent and independent variables was linear and statistically significant. The SES, PSI, year at school, and satisfaction with the profession, in combination, predicted the mean score for the CCIMQ by 10.0% (R²=.10).

Table 3
Multiple Regression Analysis between CCIM, SES, PSI (N=736)

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While the SES total score and the “year at school” variable predicted the success of the CCIMQ significantly and positively, the PSI total score and the “satisfaction with the profession” variable predicted it negatively. As the PSI score increased, so did the ability to cope with problems.

Our literature review demonstrated that the literature lacked tools for a validated peripheral intravenous assessment, problem-solving, and self-efficacy specific to nursing students. In this study, 64.2% of the participants had sufficient knowledge about catheter care and infiltration monitoring. The review of the literature related to the issue showed that, although there were not many studies on students, studies on the infiltration knowledge levels of the nurses ranged between 5.0% and 75.9% [5, 24, 25, 26]. Cicolini et al. [6] and Woody and Davis [27] determined that students' possession of good knowledge levels reduced the development of peripheral venous catheter-related infections. In their study conducted with nursing students, Prasanna and Radhika [24] found that 66.7% of the students had sufficient knowledge.

Similar to our study, Simonetti et al.'s study [26] on nursing students showed that the knowledge of one third of the nursing students on PIVC was insufficient. In this study, although the knowledge level of the participants was similar to the average level in the literature, it was higher than the levels in some studies, probably because our study was conducted with third- and fourth-year students. These students are more experienced than are first- and second-year students and they perform PIVC practices more frequently.

Among the participants, the mean SES score was 114.43± 17.56. While the subscale with the highest score was the “starting to display the behavior” subscale which is an important determinant in the development and maintenance of behavior (32.21±3.79), the subscale with the lowest score was the “struggling against barriers” subscale (9.21±2.41). The high self-efficacy score obtained by the participants was regarded as a positive result. It is assumed that a high level of self-efficacy in nursing will provide a high level of thinking efficacy, will contribute to problem-solving skills that enable nurses to find effective solutions, and, thus, will increase the quality of the care that is given [7, 28]. Effective problem-solving strategies and decision-making capability based on strong and accurate knowledge are a process, which is the focus of the nursing practices expected from a professional nurse [29]. Therefore, nurses' problem-solving skills should be evaluated and developed during their professional training. In this study, the mean score that the participants obtained from the PSI (114.43±17.56) was moderate. A high PSI score positively affects an individual's ability to cope with problems. Similarly, in Zhang et al.'s [7] and Kantek et al.'s [11] studies, the participants' PSI scores were moderate. Good and strong problem-solving skills may enable nurses to cope with problems, provide healthy solutions, and, thus, improve the quality of the healthcare they offer. The score obtained from PSI indicates how effective and successful a person is in solving problems. Therefore, the moderate score that the participants obtained from PSI suggested that their problem-solving skills should be improved.

Although a considerable number of studies have focused on PIVC and its complications [4, 30], rather less attention has been paid to the relationship between PIVC and knowledge and skills [5, 7, 31, 32]. In our study, we also investigated the relationship between problem-solving skills and self-efficacy for the first time. The participants' catheter care and infiltration monitoring knowledge scores increased as their PSI scores increased. Similar to this study, the studies by Engström and Forsberg [33], Kantek and Yeşilbaş [11], Karadağ et al. [12], and Kim and Kim [28], found that as the participants' self-efficacy levels increased, so did their success levels. Similarly, as in this study, literature previous studies found that students' catheter care and infiltration knowledge increased parallel to the increase in their self-efficacy scores and experience [5, 8, 25]. The clinical environment provides students with self-confidence, practice skills, and professionalism and it enables them to experience successful clinical learning [8]. Nurses with high levels of self-confidence, self-efficacy, and problem-solving skills were reported to be more successful [7].

This cross-sectional study yielded results on students' PIVC knowledge, the duration of their education, and their satisfaction with the profession. Similarly, in their study, Simonetti et al. [26] found that the duration of education and satisfaction with the profession were related to the participating students' PIVC knowledge. This was probably because the education that the students received increased their knowledge levels, and those who were satisfied with their professions were more interested in issues related to their professions. For example, Günay İsmailoğlu et al. [34] found that students' satisfaction with their profession positively influenced their knowledge levels.

One of the strengths of this study is the large sample size and the multicenter faculty setting. Another strength of the study is that it is one of the first few studies conducted in Turkey in which the relationship between catheter care and infiltration monitoring status and PSI and SES is addressed. The data were collected by equally trained researchers for each structure. However, one limitation of the study was that students at only two faculties participated. Thus, the results of this study cannot be generalized to all students.

The most significant result of our study is its determination that the variables of self-efficacy, problem-solving, liking the profession and year of study predict catheter care and infiltration monitoring levels. The score in the Catheter Care and Infiltration Monitoring Questionnaire increases by the increase in self-efficacy, problem-solving skills, profession increases, years of study. It may be recommended to monitor students in terms of self-efficacy, improve the self-efficacy perceptions of students with low self-efficacy and establish programs for assessing and improving the self-efficacy levels of students who are determined to be excessively stressed in the clinical practice environment. Additionally, it is important to help students participate in planned experiences and decision-making processes where they will apply the steps of problem-solving for the purpose of developing their problem-solving perceptions in the positive direction. In addition to it is recommended for opportunities for students to put their knowledge into practice to be improved. In the study, the participants' knowledge on catheter care and infiltration was above average. The students who had high levels of self-efficacy, practice opportunities and clinical skills also had high knowledge levels. This study provides reliable and valid data for a general understanding of the status of nursing students of being successful in catheter care and infiltration prevention. Discussion for advances in nursing practice and nursing education is strongly recommended. Considering the limitation of this study, there is a need for more comprehensive studies with larger samples in the future.