Invasive procedures such as endotracheal suctioning and peripheral venous catheterization are an important part of nursing care for many patients; however, any invasive procedure performed incorrectly by nurses has the potential to expose patients to serious physical harm. The World Health Organization defines patient safety as the elimination of unnecessary harm to patients and a constant decrease in hazards [1] . High-quality nursing care and avoidance of nursing errors depend on nurses’ adherence to patient safety standards [2] .

Nursing students have fewer opportunities to implement invasive procedures on their patients. Students learn how to conduct invasive procedures using patient simulators and controlled environments in simulation laboratories. Simulation education in schools provides immersive and hands-on learning experiences. Nevertheless, it is difficult for nursing students to acquire complete knowledge and skills in invasive procedures via simulation education alone [3] because of barriers to the use of high-fidelity patient simulators [4] . Despite fewer opportunities for invasive procedures in schools, clinical nurses must conduct invasive treatments accurately from the start of their careers.

There is a substantial gap between actual and expected professional patient care capacity for invasive procedures, particularly among inexperienced nurses [5] . Previous research found discrepancies between guidelines and invasive procedures among nurses [6] . For example, the American Association for Respiratory Care developed guidelines to reduce suction-related adverse effects [7] . A multicenter observational research in France found that nurses did not follow recommendations for suctioning maneuvers (e.g., proper suction catheter size) [6] . Similarly, a cross-sectional study discovered that many critical care nurses do not follow endotracheal suctioning guidelines [8] . According to questionnaire research, many nurses were ignorant of the suggested method of tracheal suctioning [9] . A previous study found that nurses had poor understanding of the guidelines for preventing catheter-related bloodstream infections [10] . A cross-sectional survey was conducted to evaluate the association between adherence to clinical practice guidelines for peripheral venous catheters and work settings (leadership, feedback processes, and organizational characteristics). These findings indicate the need for various strategies to improve nurses [11] . In Japan, the Ministry of Health, Labour, and Welfare (MHLW) developed training guidelines for new nurses and established knowledge, skills, and attitude goals for new nurses [12] . While the MHLW guidelines state that being able to perform invasive procedures (e.g., suctioning) within one year of starting a job is the attainment goal, it has been reported that the achievement levels of invasive procedures are relatively low and that many novice nurses find it difficult to implement invasive procedures [13] . This result indicates that on-the-job training alone may not be sufficient for acquiring invasive techniques. Given the disparities between guidelines (or attainment goals) and practice, it is critical that clinical nurses continue to receive appropriate and effective education programs to build and brush up their knowledge and skills regarding invasive procedures, which will likely result in improved patient outcomes. Many hospitals and other institutions emphasize the importance of continuous education programs to facilitate nurses’ learning activities using various methods and tools to improve their clinical performance. However, it remains unclear how clinical nurses learn and update their knowledge and skills regarding invasive procedures in hospitals and institutions. Therefore, the purpose of this scoping review was to evaluate and map the extant literature relevant to clinical nurse education programs on invasive procedures. There is yet to be a published or registered scoping review or systematic review on this topic.

As technology evolves, educational programs for learning about invasive treatments also evolve. For example, low- and high-fidelity patient simulators are used as teaching tools in nursing education. Numerous studies have demonstrated the efficacy of patient simulations in nursing education [14] [15] [16] [17] . Recently, virtual reality (VR) technology has been offered as a viable educational tool in nursing education [18] [19] [20] . Some studies have created VR systems that enable nurses to perform invasive procedures [21] [22] [23] . For example, the use of VR in nursing student training on intravenous catheterization has been found to be a successful teaching tool [23] . An interventional study revealed that virtual reality (VR) instruction materials with first-person videos improved tracheal suction learning [22] . To perform urinary catheterization, a computer graphic-based VR system with haptic feedback was created [24] . A VR mechanical ventilation nursing program was recently developed [21] . Here, it is predicted that educational approaches with advanced technologies such as VR and augmented reality (AR) will accelerate following the spread of COVID-19 because nursing students have limited clinical practice. Given the remarkable advances in methods for acquiring and improving the knowledge or skills of invasive procedures in nursing schools, it is hypothesized that clinical nurse education programs provided by hospitals and institutions will also change.

This scoping review aimed to provide answers to the following research questions:

In summary, the past researches have shown the significance of continuous education programs for clinical nurses, as nurses’ clinical competence with invasive procedures are insufficient. The research goal of this scoping review is to present vital findings regarding education programs for invasive procedures involving clinical nurses.

In this scoping review, we mapped the existing literature relevant to educational programs on invasive procedures involving clinical nurses. In particular, this study sought to understand the contents of educational programs and the methods for assessing educational effectiveness.

Our first research question was “How are clinical nurses educated to obtain the theoretical knowledge and skills concerning invasive procedures?” Given that professional knowledge and techniques are necessary for clinical nurses to safely administer invasive procedures to patients, it is natural that a combination of didactic lectures (i.e., knowledge) and hands-on training (i.e., skill) was provided most frequently. In the lecture session on the combination, some studies developed online educational materials (e.g., PowerPoint slides and video clips) to enable busy clinical nurses to acquire knowledge without being restricted by place or time. Few studies have investigated the effectiveness of online learning alone [45] . The hands-on training sessions in most studies were performed using high- or low-fidelity patient simulators in the hospital laboratory. In addition to such simulation sessions, an invasive procedure for patients was implemented under the supervision of expert nurses or physicians (i.e., on-the-job training). Despite its rarity, studies using advanced technologies have been conducted. Tsai et al. [32] developed a computer-assisted protocol using VR to conduct Port-a-Cath as a training program for novice nurses. Recently, Huang et al. [87] developed and tested a mobile phone application that included video clips for nurses regarding the use and care of central venous catheters. However, contrary to expectations, clinical studies using VR or information technology are extremely rare. Given the existing VR studies on nursing students [18] - [24] , we inferred that there are some gaps between nursing students’ and clinical nurses’ VR studies. For instance, there might be technical and cost barriers to develop newer education materials using VR in hospitals. Our findings suggest that the effectiveness of training with more advanced technologies, such as VR and AR, in learning invasive procedures by nurses should be investigated in future studies.

The second research question was “How is the effectiveness of the education programs assessed?” Nurses’ theoretical knowledge related to invasive procedures (cognitive domain) was mainly assessed using questionnaires (i.e., knowledge tests). These knowledge tests were administered before and after the interventional education program (i.e., pre- and post-tests), and the differences between the two were evaluated as educational effects. Because clinical nurses require competency in not only cognitive but also psychomotor skills when implementing the nursing process [112] , many studies have used observational methods, in which nurses’ performance of the invasive procedure was evaluated with checklists according to the guidelines. There are two types of observation methods, direct and indirect, using video-recorded images. These observations are advantageous for the step-by-step assessment of the components of the invasive procedure. The results of attempts at invasive procedures were evaluated in approximately one-third of the studies. For instance, the number of successful catheter insertions and the time required to perform them were measured. In addition, because any invasive procedure conducted incorrectly has the potential to expose patients to serious physical harm, some studies have counted the number of procedure-associated complications and infections before and after educational interventions. These measures are useful for objectively assessing the effectiveness of educational programs in clinical settings. Because novice and inexperienced nurses feel uneasy about performing invasive procedures, nurses’ psychological aspects such as confidence, comfort, and self-efficacy were assessed using questionnaires in some studies. In summary, the assessments used in the included studies were largely classified into three categories: cognitive (theoretical knowledge), psychomotor aspect (i.e. skill), and psychological aspects regarding the invasive procedure.

Given the years of publication of the included studies, the number of studies involving educational program development for invasive procedures among nurses is increasing. In addition, the country where most research had been conducted was the United States, meaning that studies relating to the development of education programs on invasive procedures for nurses have increased in the US. This result may involve at least three aspects: working environment, care quality, and cost. For instance, in the working environment, the Accreditation Council for Graduate Medical Education in the United States limited the number of work hours for residents to 80 hours weekly in 2011. This causes task shifting in hospitals, resulting in an increasing need for clinical nurses (or nurse practitioners) to conduct invasive procedures instead of physicians. Regarding care quality, targeting nurses for training in invasive procedures in the acute care setting is advantageous because nurses have direct patient contact 24 hours a day. This may lead to an improved quality of care for patients. Regarding cost, for example, infections related to peripherally inserted central catheters represent a significant proportion of central line-associated bloodstream infections, which are involved in an US$2.68 billion excess cost each year in the United States [113] . Thus, improving the success rate of peripherally inserted central catheters would be linked to reduced medical costs.

While most study designs were one-group pre- and post-test designs (64%), the ratio of RCT designs was relatively low (10.8%). While the purpose of this scoping review was not to clarify the best ways of education, our further interest was in how to learn invasive procedures most efficiently for clinical nurses. In particular, when developing newer educational methods, a comparison between previous and newer methods (control versus experimental groups) would provide insightful findings. Therefore, an RCT design is needed to strengthen the validity of the developed educational programs in future studies, despite some barriers to the introduction of control conditions in the clinical setting.

This scoping review has some limitations. First, we included only studies described in the English language. Therefore, it is possible that relevant studies published in other languages were omitted. Second, unlike systematic reviews, scoping reviews generally do not assess the overall quality of the evidence. However, they are advantageous for summarizing vital evidence. Third, while we searched broadly in four comprehensive databases, it is still possible that relevant research and their findings have been missed out. Despite these limitations, the strength of our study lies in its presentation of vital findings regarding educational programs for invasive procedures involving clinical nurses.

This scoping review mapped the existing literature relevant to educational programs on invasive procedures involving clinical nurses. In this review, we focused on the content of educational programs and evaluation methods for educational effects. We found that a combination of didactic lectures and hands-on training was frequently provided. Education with more advanced technologies was extremely rare, although there have been some VR studies for nursing students. Regarding the assessment of educational effects, nurses’ cognitive, psychomotor, and psychological aspects were evaluated using questionnaires and observations. Future studies should examine the effectiveness of more advanced technologies for learning invasive procedures to facilitate and retain the educational effects more efficiently.

This study was supported by the Japan Society for the Promotion of Science, KAKENHI (Grant No. 20K10698 to H.S.) and Bunkyo Gakuin University.

Conceptualization, H.S., A.S., M.M., N.Y., C.E., and S.S.; Screening, H.S., A.S., M.M., and S.S.; Formal analysis, H.S. and S.S.; Data curation, S.S.; Writing-original draft preparation, H.S. and S.S.; Writing-review and editing, A.S., M.M. and N.Y.; Funding acquisition, H.S. All authors have read and agreed to the published version of the manuscript. H.S and S.S. contributed equally to this work.