Nurse-performed radial arterial access: A scoping review of reported practice, training and evidence gaps

Federico Cucci ¹, Cesario Sergi ², Paolo Caldararo ³, Pierfrancesco Portulano ⁴, Matteo Della Torre ⁴, Luana Conte ^5,6, Elsa Vitale ⁷, Dario Marasciulo ^8,*, Roberto Lupo ⁹

1. Cardiology and Cardiac Intensive Care Unit, Città di Lecce Hospital, Villa Maria Group, 73100 Lecce, Italy.
2. Hemodynamics unit, G. Panico Hospital, 73039 Tricase, Italy.
3. Vascular Surgery Unit, V. Fazzi Hospital, Local Health Authority of Lecce, 73100 Lecce, Italy.
4. Hemodynamics Unit, Casa di Cura “Villa Verde”, 74121 Taranto, Italy.
5. Department of Physics and Chemistry, University of Palermo, 90128 Palermo, Italy.
6. Laboratory of Advanced Data Analysis for Medicine (ADAM) at DReAM, University of Salento and ASL (Local Health Authority), V. Fazzi Hospital, 73100 Lecce, Italy.
7. Directorate of Health and Nursing Professions, Local Health Authority of Bari, 70123 Bari, Italy.
8. Clinical and Experimental Medicine Department, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy.
9. Surgery Unit, San Giuseppe da Copertino Hospital, Local Health Authority of Lecce, 73043 Copertino, Italy.

* Corresponding author: Dario Marasciulo, Clinical and Experimental Medicine Department, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy – ORCID: https://orcid.org/0009-0009-0903-9917 – E-mail: dario.marasciulo@studenti.unicz.it

Cite this article

ABSTRACT

Introduction: Nurse-performed radial arterial access has been described as a potential area of advanced nursing practice in high-acuity settings, although the available evidence remains limited and fragmented.

Objective: To map the extent, range and nature of the literature on nurse-performed radial arterial access, including reported clinical settings, nursing roles, training models, outcomes and evidence gaps.

Materials and Methods: A scoping review was conducted in accordance with Joanna Briggs Institute methodology and PRISMA-ScR guidance. PubMed, Scopus and Web of Science were searched. Original studies involving adult populations and direct nurse involvement in radial arterial puncture, cannulation or device placement were included. Data were synthesized narratively.

Results: Of 325 records identified, 6 studies met the inclusion criteria. Studies were conducted in Australia, Spain, China, Italy and the United Kingdom, mainly in intensive care units, neuro-intensive care units and cardiac catheterization laboratories. Nurse-performed radial arterial access was generally described within structured training or supervision frameworks. Reported outcomes included procedural success, first-attempt success, complications, catheter durability and learning curve. However, studies were heterogeneous and one study reported outcomes aggregated for nurses and intensivists.

Conclusion: Nurse-performed radial arterial access has been described in a small number of selected settings, mainly within structured training, supervision and progressive skill acquisition models. However, the evidence remains limited and heterogeneous and no definitive conclusions can be drawn regarding safety, effectiveness or optimal implementation models. Future studies should use nurse-specific outcome reporting and evaluate training, competency assessment, credentialing, maintenance of competence and organizational impact.

Keywords: Radial artery; Vascular access; Arterial cannulation; Critical care nursing; Scoping review.

INTRODUCTION

Radial arterial access encompasses percutaneous access to the radial artery for monitoring, diagnostic or interventional purposes. In intensive care, perioperative and emergency settings, radial arterial cannulation with an arterial catheter enables continuous hemodynamic monitoring and arterial blood sampling, and the radial artery is one of the preferred sites for arterial cannulation [1]. In critical care settings, catheter durability and functionality are important because they may affect continuity of care and workflow organization [2]. In interventional cardiology, transradial access is widely used for coronary angiography and percutaneous coronary interventions [3–7].

Radial arterial access is a technically defined procedure that requires anatomical knowledge, manual skill, aseptic technique, awareness of potential complications and the ability to recognize procedural indications and risks. These characteristics make it relevant to discussions on advanced nursing competencies, particularly in high-acuity settings where nurses already contribute to vascular access management, hemodynamic monitoring and time-sensitive procedural care. In this context, the direct performance of radial arterial access by nurses may be understood not as an isolated technical act, but as part of a broader competency-based development of specialized nursing roles.

Alongside the increasing adoption of radial access, significant changes have been observed in the roles and responsibilities assigned to nurses in high-acuity care settings. Various healthcare systems have progressively expanded nursing responsibilities through processes of clinical reorganization and models of task-shifting and task-sharing, not only in care management but also in the performance of advanced technical and procedural activities. In Europe, the role of the specialist nurse has received increasing attention in terms of training, regulation and clinical competencies [8]. Recent literature on advanced practice nursing and critical care nursing emphasizes that expanded nursing roles require advanced education, clearly defined competencies, clinical decision-making, interprofessional collaboration, leadership and mechanisms for competency development and maintenance [9–12]. At the same time, international literature suggests that expanded nursing responsibilities may be implemented in selected contexts when supported by structured training, supervision and clear organizational models [13,14].

In this context, nurse-performed radial arterial access may be viewed as part of a broader trajectory of nursing role development in specialized settings. However, because this practice lies at the intersection of advanced competencies, team organization and the redefinition of professional responsibilities, the available literature remains scattered and insufficiently synthesized. International sources emphasize the importance of trained and competent personnel for the insertion and management of intravascular devices [15,16] and reviews of vascular access specialist teams suggest that dedicated teams can improve organizational consistency and procedural outcomes [17].

Despite the growing attention to advanced procedural competencies in nursing, the extent to which nurse-performed radial arterial access has been documented remains unclear. In particular, it is not well established in which clinical settings this practice has been reported, how the nursing role has been defined, what training and supervision models have been described, and which outcomes have been measured. No previous review specifically addressing radial arterial access performed directly by nurses was identified. This gap supports the need for an evidence-mapping approach capable of clarifying the current state of knowledge and identifying areas requiring further research.

Because the available evidence appears limited, heterogeneous and dispersed across different clinical contexts, a scoping review design was considered appropriate to map the extent, range and nature of the literature rather than to estimate effectiveness or generate pooled outcome measures.

Objective

This scoping review aimed to map the extent, range and nature of the available literature on nurse-performed radial arterial access, describing the clinical settings in which this practice has been reported, the nursing roles involved, the training and supervision models described, the outcomes reported and the remaining gaps in evidence.

MATERIALS AND METHODS

Study design and protocol registration

A scoping review was conducted to map the available literature on nurse-performed radial arterial access. This design was selected because the topic is emerging and the evidence base is limited, heterogeneous and dispersed across different clinical contexts. The review was conducted in accordance with the methodological framework proposed by the Joanna Briggs Institute for scoping reviews and the manuscript was prepared following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) reporting guidance [18-20]. The study protocol was registered on the Open Science Framework (OSF) on March 22, 2026 (DOI: 10.17605/OSF.IO/AE2NB).

Sampling and eligibility criteria

The review question and eligibility criteria were defined using the Population, Concept and Context (PCC) framework, which is summarized in Table 1.

PCC element	Definition
Population	Adult patients undergoing diagnostic or therapeutic procedures requiring radial arterial access.
Concept	Radial arterial access performed directly by nurses, including radial arterial puncture, cannulation or arterial device placement at the radial site.
Context	Clinical settings in which nurse-performed radial arterial access has been described in the literature.

Table 1. Population, Concept and Context (PCC) framework.

The Population included adult patients undergoing diagnostic or therapeutic procedures requiring radial arterial access. The Concept of interest was radial arterial access performed directly by nurses, defined as the active involvement of nurses in the technical act of radial arterial puncture, cannulation or arterial device placement. Throughout this review, “radial arterial access” is used as an umbrella term. “Radial arterial cannulation” refers to arterial catheter placement for hemodynamic monitoring and blood sampling, whereas “transradial access” and “distal radial access” refer to vascular access procedures performed in interventional cardiology. Studies focusing exclusively on arterial puncture for blood gas analysis were not considered eligible. The Context included the clinical settings in which nurse-performed radial arterial access has been described in the literature.

Original studies conducted in adult populations were considered eligible if radial arterial access was performed directly by nurses. Eligible studies included quantitative, qualitative and mixed-methods designs as well as observational studies, interventional studies, feasibility studies, pilot studies, implementation studies, before-and-after studies and descriptive studies, provided they contained sufficiently clear information on the nurse’s role in performing the procedure. Studies published in English or Italian were considered, with no restriction on publication year.

Studies were excluded if the nursing role was limited to patient preparation, procedural assistance, post-procedural monitoring, hemostasis management, device removal, or surveillance of complications rather than direct technical performance of radial arterial access. Studies that focused exclusively on arterial puncture for blood gas sampling were also excluded. Pediatric studies, preclinical studies, editorials, commentaries, letters, narrative reviews, systematic reviews, scoping reviews and conference abstracts lacking sufficient information for eligibility assessment were excluded.

Information sources, search strategy and study selection

The literature search was carried out on March 23, 2026 in PubMed, Scopus and Web of Science. These databases were selected because they provide broad biomedical, multidisciplinary and citation-indexed coverage relevant to clinical, interventional and nursing-related literature. The complete search strategies adopted for each database are reported in Table 2.

Database	Search strategy
PubMed	(Nurse[Title/Abstract] OR Nurses[Title/Abstract] OR Nursing[Title/Abstract] OR Nursing staff[Title/Abstract] OR Registered nurse[Title/Abstract] OR Registered nurses[Title/Abstract] OR Advanced practice nurse[Title/Abstract] OR Advanced practice nurses[Title/Abstract] OR Clinical nurse specialist[Title/Abstract] OR Clinical nurse specialists[Title/Abstract] OR Nurse-led[Title/Abstract] OR Nurse performed[Title/Abstract] OR Nurse-performed[Title/Abstract]) AND (Radial access[Title/Abstract] OR Radial arterial access[Title/Abstract] OR Radial artery access[Title/Abstract] OR Radial artery cannulation[Title/Abstract] OR Radial artery puncture[Title/Abstract] OR Radial approach[Title/Abstract] OR Transradial[Title/Abstract] OR Trans-radial[Title/Abstract] OR Transradial access[Title/Abstract] OR Distal radial[Title/Abstract] OR Distal transradial[Title/Abstract] OR Distal trans-radial[Title/Abstract] OR Dorsal radial[Title/Abstract] OR Radial sheath[Title/Abstract] OR Radial catheterization[Title/Abstract] OR Radial catheterisation[Title/Abstract])
Web of Science	(TS=(Nurse OR Nurses OR Nursing OR Nursing staff OR Registered nurse OR Registered nurses OR Advanced practice nurse OR Advanced practice nurses OR Clinical nurse specialist OR Clinical nurse specialists OR Nurse-led OR Nurse performed OR Nurse-performed)) AND (TS=(Radial access OR Radial arterial access OR Radial artery access OR Radial artery cannulation OR Radial artery puncture OR Radial approach OR Transradial OR Trans-radial OR Transradial access OR Distal radial OR Distal transradial OR Distal trans-radial OR Dorsal radial OR Radial sheath OR Radial catheterization OR Radial catheterisation))
Scopus	TITLE-ABS-KEY ((nurs* OR "nursing staff" OR "registered nurse*" OR "advanced practice nurse*" OR "clinical nurse specialist*" OR "nurse-led" OR "nurse performed" OR "nurse-performed") AND ("radial access" OR "radial arterial access" OR "radial artery access" OR "radial artery cannulation" OR "radial artery puncture" OR "radial approach" OR transradial OR "trans-radial" OR "transradial access" OR "distal radial" OR "distal transradial" OR "distal trans-radial" OR "dorsal radial" OR "radial sheath" OR "radial catheterization" OR "radial catheterisation"))

Table 2. Combination of keywords used with the Boolean operators.

The search strategy was built around two main conceptual domains: the nursing profession and radial arterial access. This approach was adopted to maximize search sensitivity and allow broad retrieval of potentially relevant literature.

The PubMed strategy was based on Title/Abstract free-text terms to retrieve records explicitly referring to both nursing roles and radial arterial access. During the preliminary development of the search strategy, combinations of controlled vocabulary terms related to nursing, catheterization and radial artery procedures were explored before the final free-text search approach was selected. However, they were not incorporated into the original search strategy because the review aimed to identify records explicitly describing direct nurse performance of radial arterial access. The potential effect of not including controlled vocabulary terms on search sensitivity is acknowledged in the Limitations section.

CINAHL, Embase and gray literature sources were not searched. CINAHL was not available through the authors’ institutional resources at the time of the original search and revision. Embase and gray literature sources were also not searched because of resource constraints and the need to maintain a reproducible search process. The potential effect of these omissions on the comprehensiveness of the evidence mapping is addressed in the Limitations section.

All records identified through the electronic search were imported into Rayyan [21] for reference management and duplicate removal. Duplicates were identified using combinations of title, authors, year of publication and DOI.

The study selection process occurred in two stages: titles and abstracts screening followed by a full-text assessment of potentially eligible records. Two reviewers, C.S. and P.C., performed the title and abstract screening independently. Records judged to be clearly irrelevant were excluded at this stage. Studies considered potentially eligible, or those for which the available information was insufficient to make a definitive decision, were retained for full-text review. Any disagreement between the two reviewers was resolved through discussion. If consensus could not be reached, a third reviewer, F.C., was consulted. Reasons for exclusion were recorded systematically.

Data charting and synthesis

A standardized data charting form was developed specifically for this review to collect the main characteristics of the included studies. For each included article, the following information was extracted: authors, year of publication, country, study design, setting, description of the nurse’s role, training or supervision model, reported outcomes, results and conclusions. Data charting was performed independently by two reviewers using a standardized extraction form developed for this review. Extracted data were compared and any discrepancies were resolved through discussion. If consensus could not be reached, a third reviewer was consulted. Particular attention was paid to the procedural role attributed to nurses in order to distinguish studies in which nurses directly performed radial arterial access from those in which the nursing contribution was limited to supportive or post-procedural activities. When outcome data were not reported separately for nurses, this was recorded as a limitation in nurse-specific attribution. The extracted data were organized into summary tables and synthesized narratively. The synthesis aimed to describe how nurse-performed radial arterial access has been reported across clinical settings and to map recurring themes related to nursing role, training, supervision, competency development, procedural outcomes and evidence gaps.

Consistent with scoping review methodology, formal critical appraisal was not undertaken because the purpose of the review was to map the extent and nature of the evidence rather than to determine the effectiveness of an intervention. However, study design and key methodological features were extracted to support contextual interpretation of the findings.

RESULTS

Study selection

A total of 325 records were identified through database searches, including 75 from PubMed, 113 from Scopus and 137 from Web of Science.

Prior to screening, 129 duplicate records were removed, resulting in 196 unique records for screening. Titles and abstracts of the 196 records were screened, resulting in the exclusion of 190 records for the following reasons: non-relevant population (n = 73), topic not focused on radial arterial access or referring to a non-relevant access site (n = 7), radial arterial access not performed directly by nurses (n = 37), study focused exclusively on post-procedural care, hemostasis, monitoring or complications (n = 45) and non-eligible publication type (e.g., review, poster, abstract) (n = 28). Six reports were sought for retrieval, all were retrieved and assessed for eligibility and all six met the inclusion criteria.

The selection process is reported in the PRISMA 2020 flow diagram (Figure 1).

Figure 1. PRISMA 2020 flow diagram of the study selection process

Characteristics of included studies

This scoping review includes six original studies reporting radial arterial access performed directly by nurses or involving nurses in the direct performance of the procedure. The articles were published between 2011 and 2025. The represented countries were Australia, Spain, China, Italy and the United Kingdom. The described clinical settings were mainly adult intensive care units (ICUs), neuro-intensive care units and cardiac catheterization laboratories.

Two broad clinical contexts were identified. In intensive care settings, radial arterial cannulation was mainly related to hemodynamic monitoring and arterial blood sampling. In cardiac catheterization laboratories, radial or distal radial access was described as part of interventional cardiology pathways. Although these studies shared the radial artery as the anatomical access site, they differed in clinical indication, technical pathway, procedural endpoints and organizational context.

Mapped outcome domains

The outcomes reported in the included studies were grouped into five domains: procedural performance, complications and procedure-related events, catheter durability and functionality, training and competency development and implementation-related indicators. Definitions and reporting methods varied across studies. Table 3 summarizes the operational meaning of each domain, the studies reporting it and the main limitations identified across the evidence.

Outcome domain	Operational meaning in included studies	Studies reporting the domain	Main limitation
Procedural performance	Procedural success, first-attempt success or technical feasibility	[22-27]	Definitions varied across settings, procedures and clinical contexts
Complications and procedure-related events	Adverse events, immediate procedural complications, blood exposure or minor local events	[22-24,26,27]	Reporting was heterogeneous and definitions were not always explicit
Catheter durability and functionality	Catheter duration, catheter function over time or need for catheter replacement	[23,25]	Reported mainly in ICU-focused studies and with variable definitions
Training and competency development	Supervised attempts, competency achievement, learning curve or progression to independent practice	[22,24,26,27]	Limited detail on formal competency assessment and maintenance of competence
Implementation-related indicators	Training programs, supervised practice, phased autonomy, role definition or organizational arrangements	[22,26,27]	Credentialing, governance, staffing implications, patient experience and organizational impact were poorly reported

Table 3. Mapped outcome domains across included studies

Procedural performance was the most frequently reported domain. It included procedural success, first-attempt success or technical feasibility, depending on the study. Procedural success generally referred to successful radial artery puncture, cannulation or sheath placement. First-attempt success referred to successful completion of the procedure on the first attempt, where reported. Technical feasibility was mainly used in studies conducted in cardiac catheterization laboratories and referred to successful completion of the planned radial or distal radial access procedure.

Complications and procedure-related events were reported heterogeneously. Some studies reported no adverse events or no significant complications, whereas others reported immediate procedural complications, blood exposure or minor local events. Definitions of complications were not consistent across studies and were not always reported in sufficient detail.

Catheter durability and functionality were reported only in studies focused on arterial cannulation in intensive care settings. These outcomes referred to catheter performance over time, duration of catheter function or the need for catheter replacement.

Training and competency development were reported through supervised attempts, achievement of competency, changes in success rates across sequential procedures or comparison between supervised and independent practice phases. However, details on formal competency assessment, minimum procedural volume, credentialing and maintenance of competence were limited.

Implementation-related indicators were less consistently described. Some studies reported structured training programs, supervised practice or phased transition to independent practice, but limited information was available on governance arrangements, staffing implications, patient experience or organizational impact. Overall, the mapped domains show that the available literature reports selected procedural and training-related outcomes, but provides limited evidence on broader implementation, transferability and long-term organizational effects.

Mapping of nursing roles and attribution

The role attributed to nurses varied across studies. In most included studies, nurses directly performed radial arterial puncture, cannulation or radial access after specific training or under supervision. In the cardiac catheterization laboratory studies, nurses were involved in radial access as part of structured or nurse-led programs, including supervised and independent practice phases. In intensive care studies, nurses performed arterial cannulation for monitoring purposes, sometimes as novice operators and sometimes after previous clinical experience or dedicated training.

Training and supervision were recurring features of the included studies. However, the level of detail provided was variable. Some studies described formal training programs, supervised procedural attempts or phased progression toward independent practice. Others provided limited information on educational content, minimum procedural volume, competency assessment, credentialing or maintenance of competence. One study reported outcomes jointly for nurses and intensivists, limiting the possibility of attributing procedural outcomes specifically to nurses.

Summary of included studies

The main characteristics and mapped findings of the included studies are summarized in Table 4.

Study and year	Country and design	Clinical setting and procedure	Nurse role and attribution	Training or supervision model	Mapped outcomes	Key reported findings	Main evidence gap
Chee et al. [22]; 2011	Australia; Descriptive explorative study	Adult ICU; radial artery cannulation for monitoring	Nurses directly performed radial arterial cannulation	Training program with supervised practice	Procedural success; competency achievement; adverse events	107 attempts were recorded, with 67 successful cannulations (63%). Eleven nurses achieved competency. No adverse events were reported.	Limited detail on long-term maintenance of competence and broader implementation outcomes
León et al. [23]; 2025	Spain; Prospective cohort study	Medical ICU; arterial catheterization by palpation or ultrasound guidance	Novice nurses directly performed arterial cannulation	Brief training before clinical performance	First-attempt success; complications; catheter duration	First-attempt success was 50.6% with palpation and 58% with ultrasound guidance. Complications and catheter duration were comparable between groups.	Limited information on competency assessment and transferability beyond novice operators in one ICU
Xie et al. [24]; 2025	China; Prospective randomized controlled trial	Neuro-ICU; radial arterial puncture for invasive blood pressure monitoring	Nurses directly performed radial arterial puncture and cannulation	Nurses had previous clinical experience and received study-specific training	First-attempt success; immediate complications; blood exposure	The transmural puncture plus sensor tube technique showed higher first-attempt success, fewer immediate complications and lower blood exposure than direct puncture.	Focus on technique comparison, with limited information on broader training, governance and competency maintenance
Imbriaco et al. [25]; 2021	Italy; Prospective non-randomized cohort study	General/surgical ICU and general/trauma ICU; radial artery cannulation	Cannulation was performed by critical care nurses and intensivists; outcomes were aggregated	Operator training and supervision not fully detailed for nurse-specific performance	First-attempt success; catheter durability; catheter functionality	Ultrasound guidance was associated with higher first-attempt success in hypotensive patients and longer catheter duration when insertion was performed 4–10 cm from the wrist.	Nurse-specific attribution not possible because outcomes were reported jointly for nurses and intensivists
Wojcik et al. [26]; 2024	United Kingdom; Clinical audit	Cardiac catheterization laboratory; radial access program	Nurses directly performed radial access in a nurse-led program	Structured training with supervised, independent and consolidation phases	Procedural success; complications; program implementation	Success rates were reported across supervised, independent and consolidation phases, with no significant complications reported.	Limited generalizability due to local program design and limited detail on credentialing or long-term outcomes
Cereda et al. [27]; 2023	Italy; Single-center observational study	Cardiac catheterization laboratory; distal radial access	Nurse performed puncture, wiring and sheath advancement under cardiologist supervision	Supervised practice with learning curve assessment	Technical feasibility; learning curve; complications	Technical feasibility was 89%. Failures were concentrated in the first 50 cases. No major complications were reported.	Single-center experience, with limited evidence on transferability, governance and maintenance of competence

Table 4. Summary of included studies.

To further illustrate heterogeneity in outcome reporting, Table 5 summarizes how procedural success, complications and competency attainment were defined or operationally reported in each included study. Where no explicit definition or competency threshold was provided, this is indicated accordingly.

As shown in Table 5, outcome definitions were not standardized across studies.

Study	Procedural success	Complications	Competency attainment
Chee et al. [22];	Each skin penetration was considered a cannulation attempt. Failure was defined as inability to obtain arterial blood flashback or failure to advance the cannula into the radial artery. Overall, 67/107 attempts were successful.	Adverse events were assessed clinically and included bleeding, distal tissue ischemia, redness or swelling. No adverse events were reported.	Competency required a minimum of two successful cannulations under supervision before independent performance.
León et al. [23];	First-attempt success was the primary endpoint; overall success, failed attempts and number of attempts were also reported. No additional operational definition was provided.	Immediate complications included hematoma, while late complications included catheter infection or dysfunction.	No formal competency threshold was reported. Nurses completed two 3-hour workshops followed by supervised clinical practice.
Xie et al. [24];	Initial success was calculated as successful initial catheterizations divided by total punctures. Overall success required successful cannulation at the same puncture site within three attempts. Failure was defined as inability to aspirate arterial blood or absence of an arterial pressure waveform after transducer connection.	Study-specific definitions were provided for hematoma/ecchymosis, catheter-associated infection and distal limb ischemia; blood exposure was also assessed.	No formal competency attainment threshold was reported. Nurses had previous clinical experience and received study-specific preparation.
Imbriaco et al. [25];	First-attempt insertion was reported for blind and ultrasound-guided cannulation. Outcomes were aggregated for critical care nurses and intensivists.	Complications were not a primary nurse-specific outcome; local infection signs and dressing requirements were reported.	No formal competency attainment outcome was assessed and nurse-specific attribution was not possible.
Wojcik et al. [26];	Complication-free procedural success was defined as radial access secured within two puncture attempts and without adverse events.	Adverse events and vascular complications were monitored, including vascular trauma or spasm leading to cannulation failure and complications before discharge.	Competency required 50 procedures under direct consultant-led observation, review of a procedural log and formal sign-off. A further 100 independent procedures were then evaluated before sign-off as an independent practitioner.
Cereda et al. [27];	Technical feasibility was reported as 89%. Failures were concentrated in the first 50 cases; a more detailed operational definition of technical feasibility was not reported.	No major complications were reported. Minor complications were described, but detailed operational definitions were not provided.	No formal competency threshold was reported. Competency development was indirectly explored through the learning curve and operator experience.

Table 5. Study-specific definitions and reporting of selected outcomes

Procedural success ranged from successful cannulation or first-attempt success to complication-free access within a predefined number of attempts. Formal criteria for competency attainment were reported only in a minority of studies. This variability limits direct cross-study comparison and reinforces the need for standardized outcome definitions in future research.

Overall, the mapped evidence remains limited and heterogeneous across clinical contexts, procedures and outcome definitions, precluding firm conclusions regarding safety, effectiveness or transferability across settings.

DISCUSSION

From reported procedures to advanced nursing competencies

This scoping review mapped the available literature on radial arterial access performed directly by nurses. The main finding is not that nurse-performed radial arterial access can be considered established, but that it has been reported in a small number of selected clinical settings, usually within structured training or supervision frameworks. This distinction is important. The current evidence does not allow conclusions about effectiveness, safety or broad implementation. Rather, it identifies radial arterial access as an emerging procedural area in which nursing roles, competencies and organizational models are still being defined.

Across the included studies, radial arterial access was not described as a simple technical task transferred from physicians to nurses. In the intensive care studies, nurses performed radial arterial cannulation mainly for monitoring purposes, either after dedicated training or within defined clinical protocols [22–25]. In the cardiac catheterization laboratory studies, nurse-performed radial or distal radial access was described within structured or supervised procedural pathways [26,27]. These findings suggest that nurse-performed radial arterial access should be interpreted as a competency-dependent activity requiring procedural knowledge, manual skill, recognition of complications, supervision and progressive autonomy. This interpretation is consistent with broader literature on advanced practice nursing and critical care nursing competence. International guidance describes advanced practice nursing as requiring advanced education, expert knowledge, complex decision-making skills and clinical competencies shaped by the context in which nurses are authorized to practice [9].

Recent reviews in emergency and critical care settings have similarly emphasized that advanced practice roles require clearly defined competencies, interprofessional collaboration, leadership and mechanisms for competency development [10,11]. Literature on critical care nursing expertise also suggests that competence develops progressively from core critical care competencies toward specialized and advanced levels through clinical experience, postgraduate education and continuing professional development [12]. These external sources were not part of the evidence map on nurse-performed radial arterial access, but they help contextualize why training, supervision, competency assessment and governance emerged as central issues in the present review.

Heterogeneity of clinical contexts and procedures

A key finding of this review is the heterogeneity of the clinical contexts in which nurse-performed radial arterial access was reported. Although all included studies involved the radial artery as the anatomical access site, the clinical meaning of the procedure differed across settings. In intensive care units, radial arterial cannulation was mainly related to hemodynamic monitoring and arterial blood sampling [22–25]. In cardiac catheterization laboratories, radial or distal radial access was part of an interventional cardiology pathway [26,27].

These differences are relevant because the indications, technical pathway, procedural endpoints and organizational requirements are not identical across settings. Chee et al. focused on a training program for ICU nurses performing radial arterial cannulation [22]. León et al. compared palpation and ultrasound guidance among novice nurses in an adult ICU [23]. Xie et al. evaluated two radial puncture techniques for invasive blood pressure monitoring in a neuro-ICU [24]. Imbriaco et al. examined radial arterial cannulation in ICU patients, although outcomes were reported jointly for nurses and intensivists [25]. By contrast, Wojcik et al. described a nurse-led radial access program in a cardiac catheterization laboratory [26], while Cereda et al. focused on nurse-led distal radial access under cardiologist supervision [27]. Therefore, the available evidence should not be interpreted as supporting a single transferable model of nurse-performed radial arterial access. Rather, it suggests that implementation models may need to be setting-specific and adapted to the clinical purpose of the procedure. Radial arterial cannulation for hemodynamic monitoring and transradial access for interventional cardiology should therefore be regarded as distinct procedural and organizational contexts rather than as interchangeable expressions of the same practice. Accordingly, findings related to training, procedural performance or implementation in one setting should not be assumed to be directly transferable to the other.

Training, supervision and competency governance

Training and supervision emerged as the most consistent implementation conditions across the included studies. Chee et al. explicitly evaluated a radial arterial cannulation training program for intensive care nurses and reported competency achievement after supervised practice [22]. Xie et al. involved nurses with previous clinical experience and study-specific preparation before performing radial arterial puncture [24]. Wojcik et al. described a phased program including supervised practice, independent practice and consolidation in a cardiac catheterization laboratory [26]. Cereda et al. reported a learning curve for distal radial access, with failures concentrated in the initial phase of experience [27]. However, the level of detail provided on competency development was variable. The literature offered limited information on educational content, minimum procedural volume, formal competency assessment, credentialing processes and maintenance of competence over time. This is a central issue for nursing practice. If radial arterial access is considered as an advanced procedural nursing competency, implementation cannot rely only on local enthusiasm or informal task delegation. Within the context of this review, procedural competency refers specifically to the knowledge, technical skills and clinical judgment required to perform radial arterial access. Broader professional competence encompasses additional dimensions of advanced nursing practice, including complex decision-making, interprofessional collaboration, leadership and professional accountability [9–12]. The two constructs are therefore related but not interchangeable. Such implementation requires explicit role definition, standardized training pathways, supervised clinical practice, criteria for competence assessment and mechanisms for ongoing evaluation. Governance and accountability were also insufficiently described. Some studies reported supervision or structured implementation [22,26,27], but few described how procedural privileges were granted, how responsibilities were shared within the interprofessional team or how adverse events were monitored from an organizational perspective. In addition, the study by Imbriaco et al. limits nurse-specific interpretation because outcomes were aggregated for nurses and intensivists [25]. These gaps limit the ability to translate the reported experiences into broader practice recommendations.

Regulatory context and transferability

Differences in national regulatory frameworks and professional scope of practice may partly explain why nurse-performed radial arterial access has been reported only in selected countries and clinical environments. The included studies were conducted in Australia [22], Spain [23], China [24], Italy [25,27] and the United Kingdom [26]. These healthcare systems differ in nursing education, recognition of advanced practice roles, local credentialing processes and interprofessional organization. Such contextual factors may influence whether nurses are allowed, prepared or supported to perform advanced procedural activities.

Transferability should therefore be interpreted cautiously. A training model developed for ICU arterial cannulation [22,23] may not be directly transferable to a cardiac catheterization laboratory radial access program [26,27]. Similarly, evidence from neuro-intensive care radial puncture for invasive blood pressure monitoring [24] may not apply directly to distal radial access for interventional cardiology procedures [27]. Before wider implementation is considered, healthcare organizations should evaluate local legislation, professional regulation, educational preparation, supervision capacity, interprofessional agreements and systems for monitoring outcomes. Moreover, findings generated in highly specialized and closely supervised settings should not be assumed to be directly transferable to routine clinical practice unless comparable training, competency assessment, governance and supervision structures are in place.

Implications for nursing practice, education and policy

For nursing practice, this review highlights that nurse-performed radial arterial access should be considered only within structured and well-governed practice models. The available evidence suggests that training and supervision are central to implementation, particularly in studies where nurses progressed through supervised attempts, dedicated preparation or phased autonomy [22,24,26,27]. Therefore, local implementation should be preceded by explicit governance arrangements, role definitions, supervised training and mechanisms for monitoring outcomes. Local protocols should define nurse eligibility, required preparation, supervision arrangements, documentation requirements, escalation criteria and nurse-specific outcome monitoring. However, the current literature does not support unsupervised or broadly generalized adoption, and stronger evidence is required before wider implementation can be recommended.

For nursing education, these findings support the need to define the theoretical and practical components required for advanced procedural competencies. Educational pathways should address anatomy, procedural technique, ultrasound use where relevant, aseptic practice, complication recognition, patient safety, communication within the interprofessional team and post-procedural monitoring. Competency assessment should include both procedural performance and clinical judgment, rather than the number of completed procedures alone.

Evidence gaps

The review identified several evidence gaps. First, few studies provided nurse-specific outcome data. Second, definitions of procedural success, complications and competency attainment varied across studies. Third, limited information was available on credentialing processes, maintenance of competence, staffing implications, patient experience, cost-effectiveness and long-term organizational outcomes. Fourth, the available literature does not provide sufficient evidence to determine whether findings from highly structured or specialist settings can be transferred to other clinical contexts.

These gaps reinforce the value of a scoping review approach. The purpose of this review was not to determine whether nurse-performed radial arterial access is effective or safe, but to map how this practice has been reported, which concepts and outcomes have been used and where evidence remains insufficient. On this basis, the current literature should be considered preliminary and hypothesis-generating. Future research should prioritize multicenter prospective studies with nurse-specific outcome reporting and standardized competency assessment frameworks. Such studies should also evaluate patient-reported outcomes and experience, organizational outcomes including workflow, staffing and implementation sustainability, cost-effectiveness and transferability across healthcare systems.

Notably, none of the included studies systematically assessed patient-reported outcomes or patient experience. This represents an additional gap because procedural implementation should also consider the patient perspective alongside technical and organizational outcomes. Future studies should therefore incorporate patient-centered measures such as perceived comfort, anxiety, satisfaction, acceptability and preferences regarding nurse-performed procedures.

CONCLUSION

This scoping review mapped a small and heterogeneous body of literature on nurse-performed radial arterial access in selected critical care and interventional settings. The available evidence suggests that this practice has mainly been reported within structured training, supervision and progressive skill acquisition models, rather than as routine or broadly standardized nursing practice.

The review also shows that the current literature provides limited nurse-specific outcome reporting and limited information on competency assessment, credentialing, maintenance of competence, governance arrangements and transferability across settings. Therefore, no definitive conclusions can be drawn regarding safety, effectiveness or optimal implementation models.

Future research should use robust designs, clearly define procedural success and complications, report outcomes separately by operator group and describe training, supervision, competency assessment and organizational requirements in detail. These steps are needed to clarify the clinical, educational and organizational implications of this potential area of advanced nursing practice.

Limitations

This review has several limitations. First, the findings should be interpreted as a preliminary mapping of the indexed literature retrieved through the selected databases. The search was limited to PubMed, Scopus and Web of Science. CINAHL was not searched because it was not available through the authors’ institutional resources at the time of the original search and revision. Embase and gray literature sources were also not searched because of resource constraints and the need to maintain a reproducible search process. These omissions may have led to the exclusion of nursing-specific, vascular access-related, practice-based, biomedical or unpublished evidence. More specifically, the absence of CINAHL and Embase may have resulted in underrepresentation of nursing-specific and multidisciplinary clinical studies, while the exclusion of gray literature may have reduced the retrieval of implementation reports, local practice models and other non-indexed evidence. Consequently, the small body of literature identified in this review should not be interpreted as necessarily representing the full extent of existing evidence.

In addition, the PubMed search strategy relied on free-text Title/Abstract terms and did not include controlled vocabulary terms. Although this choice was intended to retrieve records explicitly referring to both nursing roles and radial arterial access, it may have affected search sensitivity. Taken together, the exclusion of nursing-specific databases and the absence of controlled vocabulary terms may have contributed to the small number of eligible studies identified. Therefore, the scarcity of included studies should be interpreted cautiously and may reflect both the emerging nature of the topic and the methodological boundaries of the search strategy.

Second, only studies published in English or Italian were considered. Relevant evidence published in other languages may therefore have been missed.

Third, only six studies met the inclusion criteria and these were heterogeneous in terms of setting, design, technique, operator profile and reported outcomes. This heterogeneity limits the extent to which the findings can be synthesized under a single implementation model. Fourth, one included study reported outcomes in aggregate for nurses and intensivists, limiting nurse-specific interpretation.

Finally, because no formal critical appraisal was conducted, the findings should be interpreted as a mapping of the available literature rather than as evidence of effectiveness or safety.

Ethics statement

Formal approval by the Local Ethics Committee was not required for this study because it was a scoping review of previously published literature and did not involve human participants, human tissue or patient-level data.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Conflict of interest

The authors declare that they have no known financial, institutional, personal or professional conflicts of interest that could have appeared to influence the work reported in this paper.

Authors’ contribution

F.C.: Conceptualization, Methodology, Investigation, Data curation, Formal analysis, Writing – original draft, Writing – review & editing, Project administration. C.S.: Investigation, Data curation, Writing – review & editing. P.C.: Investigation, Data curation, Writing – review & editing. P.P.: Writing – review & editing. M.D.T.: Writing – review & editing. L.C.: Methodology, Formal analysis, Supervision, Writing – review & editing. E.V.: Writing – review & editing. D.M.: Conceptualization, Supervision, Writing – review & editing, Correspondence. R.L.: Conceptualization, Methodology, Formal analysis, Supervision, Writing – review & editing. Dario Marasciulo and Roberto Lupo contributed equally to this work.

Acknowledgements

No specific institutional or individual acknowledgements are declared.

Use of AI tools

During the first phase of this work, the authors used Rayyan, including its AI-assisted features, to support the screening and data management process. During manuscript preparation, the authors used ChatGPT Plus (OpenAI, San Francisco, CA, USA) to assist with text organization and English language refinement. The tool was not used to generate, alter or analyze data, select studies or determine the scientific interpretation of the findings. All AI-assisted text was reviewed, critically assessed and edited by the authors, who take full responsibility for the final content of the manuscript.

REFERENCES

1. Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg. 2009;109:1763-81. https://doi.org/10.1213/ANE.0b013e3181bbd416.
2. Imbrìaco G, Monesi A, Spencer TR. Preventing radial arterial catheter failure in critical care – factoring updated clinical strategies and techniques. Anaesth Crit Care Pain Med. 2022;41:101096. https://doi.org/10.1016/j.accpm.2022.101096.
3. Saugel B, Kouz K, Meidert AS, Schulte-Uentrop L, Romagnoli S. How to measure blood pressure using an arterial catheter: a systematic 5-step approach. Crit Care. 2020;24:172. https://doi.org/10.1186/s13054-020-02859-w.
4. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40:87-165. https://doi.org/10.1093/eurheartj/ehy394.
5. Valgimigli M, Gagnor A, Calabró P, Frigoli E, Leonardi S, Zaro T, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015;385:2465-76. https://doi.org/10.1016/S0140-6736(15)60292-6.
6. Kiemeneij F. Left distal transradial access in the anatomical snuffbox for coronary angiography and interventions. EuroIntervention. 2017;13:851-7. https://doi.org/10.4244/EIJ-D-17-00079.
7. Ferrante G, Condello F, Rao SV, Maurina M, Jolly S, Stefanini GG, et al. Distal vs conventional radial access for coronary angiography and/or intervention. JACC Cardiovasc Interv. 2022;15:2297-311. https://doi.org/10.1016/j.jcin.2022.09.006.
8. Dury C, Hall C, Danan J, Mondoux J, Aguiar Barbieri-Figueiredo MC, Costa MAM, et al. Specialist nurse in Europe: education, regulation and role. Int Nurs Rev. 2014;61:454-62. https://doi.org/10.1111/inr.12123.
9. International Council of Nurses. Guidelines on advanced practice nursing 2020. Geneva: International Council of Nurses; 2020.
10. Yamaguchi Y, Matsunaga-Myoji Y, Fujita K. Advanced practice nurse competencies to practice in emergency and critical care settings: a scoping review. Int J Nurs Pract. 2024;30:e13205. https://doi.org/10.1111/ijn.13205.
11. Jafari Pour F, Watson R, Jafaripour E, Jafarian R. The roles and responsibilities of advanced practice nurses in intensive care units: a scoping review. Enferm Intensiva (Engl Ed). 2024;35:e31-e40. https://doi.org/10.1016/j.enfie.2024.06.002.
12. Kinnunen A, Hagman T, Paakkonen H, Saaranen T. Constructing critical care nursing expertise: an integrative literature review. Nurse Educ Today. 2025;149:106668. https://doi.org/10.1016/j.nedt.2025.106668.
13. Maier CB, Köppen J, Busse R. Task shifting between physicians and nurses in acute care hospitals: cross-sectional study in nine countries. Hum Resour Health. 2018;16:24. https://doi.org/10.1186/s12960-018-0285-9.
14. Paier-Abuzahra M, Posch N, Jeitler K, Semlitsch T, Radl-Karimi C, Spary-Kainz U, et al. Effects of task-shifting from primary care physicians to nurses: an overview of systematic reviews. Hum Resour Health. 2024;22:74. https://doi.org/10.1186/s12960-024-00956-3.
15. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39:S1-34. https://doi.org/10.1016/j.ajic.2011.01.003.
16. Gorski LA, Hadaway L, Hagle ME, Broadhurst D, Clare S, Kleidon T, et al. Infusion therapy standards of practice, 8th edition. J Infus Nurs. 2021;44:S1-224. https://doi.org/10.1097/NAN.0000000000000396.
17. Fernandez-Fernandez I, Parra-García G, Blanco-Mavillard I, Carr P, Santos-Costa P, Rodríguez-Calero MÁ. Vascular access specialist teams versus standard practice for catheter insertion and prevention of failure: a systematic review. BMJ Open. 2024;14:e082631. https://doi.org/10.1136/bmjopen-2023-082631.
18. Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis. Adelaide: JBI; 2024.
19. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169:467-73. https://doi.org/10.7326/M18-0850.
20. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021:n71. https://doi.org/10.1136/bmj.n71.
21. Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan: a web and mobile app for systematic reviews. Syst Rev. 2016;5:210. https://doi.org/10.1186/s13643-016-0384-4
22. Chee BC, Baldwin IC, Shahwan-Akl L, Fealy NG, Heland MJ, Rogan JJ. Evaluation of a radial artery cannulation training program for intensive care nurses: a descriptive, explorative study. Aust Crit Care. 2011;24:117-25. https://doi.org/10.1016/j.aucc.2010.12.003.
23. León M, Marco DN, Cubedo M, González C, Guirao A, Cañueto M del C, et al. Comparing arterial catheterisation by palpation or ultrasound guidance by novice nurses in an adult intensive care unit: a prospective cohort study. Aust Crit Care. 2025;38:101135. https://doi.org/10.1016/j.aucc.2024.101135.
24. Xie F, Yu G, Mei B, Liu Y, Chen F, Feng X, et al. Comparison between transmural puncture combined with sensor tube technique with direct puncture in invasive blood pressure monitoring: a randomized controlled trial. Sci Rep. 2025;15:38978. https://doi.org/10.1038/s41598-025-22883-6.
25. Imbriaco G, Monesi A, Giugni A, Cilloni N. Radial artery cannulation in intensive care unit patients: does distance from wrist joint increase catheter durability and functionality? J Vasc Access. 2021;22:561-7. https://doi.org/10.1177/1129729820953020.
26. Wojcik D, Sindhi RMS, Ahmad M, Lockie T, Rakhit R, Coghlan JG. Devising and delivering the UK’s first nurse-led cardiac catheter laboratory radial access programme. Br J Cardiol. 2024;31(4):047. https://doi.org/10.5837/bjc.2024.047.
27. Cereda A, Allievi L, Busetti L, Koleci R, De Nora V, Vecchia A, et al. Nurse-led distal radial access: efficacy, learning curve, and perspectives of an increasingly popular access. Does learning by doing apply to both the doctor and the nurse? Minerva Cardiol Angiol. 2023;71(1):35-43. https://doi.org/10.23736/S2724-5683.22.05843-4.