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Review ArticleComparing Intravenous Insertion InstructionalMethods with Haptic Simulators
Lenora A. McWilliams1 and Ann Malecha2
1University of Houston, 14000 University Blvd., Sugar Land, TX 77479, USA2Texas Woman’s University, 6700 Fannin Street, Houston, TX 77030-2343, USA
Correspondence should be addressed to Lenora A. McWilliams; lamcwilliams@uh.edu
Received 30 June 2016; Accepted 4 January 2017; Published 29 January 2017
Academic Editor: Maria H. F. Grypdonck
Copyright © 2017 Lenora A. McWilliams and Ann Malecha.This is an open access article distributed under theCreative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.
Objective. The objective of this review was to compare traditional intravenous (IV) insertion instructional methods with the useof haptic IV simulators. Design. An integrative research design was used to analyze the current literature. Data Sources. A searchwas conducted using key words intravenous (IV) insertion or cannulation or venipuncture and simulation from 2000 to 2015 inthe English language. The databases included Academic Search Complete, CINAHL Complete, Education Resource InformationCenter, and Medline. Review Methods. Whittemore and Knafl’s (2005) strategies were used to critique the articles for themes andsimilarities. Results. Comparisons of outcomes between traditional IV instructional methods and the use of haptic IV simulatorscontinue to show various results. Positive results indicate that the use of the haptic IV simulator decreases both band constrictionand total procedure time.While students are satisfied with practicing on the haptic simulators, they still desire faculty involvement.Conclusion. Combining the haptic IV simulator with practical experience on the IV arm may be the best practice for learning IVinsertion. Research employing active learning strategies while using a haptic IV simulator during the learning process may reducecost and faculty time.
1. Introduction
One of the most commonly performed basic nursing skillsis intravenous (IV) catheter insertion. IV catheterization,cannulation, or insertion is a complex [1] and invasiveprocedure [2]. While it is the most common and importantskill performed in the clinical setting, it is also a technicallydifficult procedure [3]. Reinhardt et al. [4] note that learninghow to insert an IV catheter is the most challenging skilltaught in nursing school. Traditional methods of instructionfor IV insertion vary between nursing and medical students.The nursing student IV education typically consists of facultydidactic presentation followed by faculty demonstrating theprocedure on an IV arm task trainer. For this teachingmethod, students practice under faculty supervision followedby a skills competency check off assessment. The traditionalteaching method for medical students varies and may consist
of didactic instruction followed by either practicing on asimulated arm, practicing the actual procedure on students orpatients [5], learning by doing [6], or see-one do-one format[7].
Traditional methods of teaching IV insertion can be timeconsuming and costly [8]. Sotto et al. [7] state that notonly the current methods of teaching IV insertion are costineffective but also opportunities for practicing the procedureare inconsistent, with limited variability, and generally del-egated to ancillary personnel such as lab assistants. Engumet al. [6] discuss the importance of practitioners developingclinical skills for invasive procedures prior to working withpatients. Students need to master high risk skills, such asIV catheter insertion, prior to performance in the clinicalsetting. Proficiency of IV insertion may prevent seriouspatient complications including infiltration, phlebitis, or pain[9].
HindawiNursing Research and PracticeVolume 2017, Article ID 4685157, 11 pageshttps://doi.org/10.1155/2017/4685157
2 Nursing Research and Practice
The use of patient simulators in education allows studentsto learn and experience real world situations, while ensuringthat patients receive safe, competent treatment as well asreducing cost of instruction and practice [8]. The use ofsimulators provides opportunities for students to practiceand perfect skills in a safe nonthreatening environment [10]while making errors without harm or discomfort to a patient[6]. During simulation, students become active learners [10].They construct new knowledge by attaching meaning tocurrent or past experiences, which is then assimilated forfuture encounters [11]. More and more, the skill of IV inser-tion is being taught with a haptic IV simulator. This deviceincludes a catheter/hub assembly and an interface that allowsstudents to palpate a vein, stretch the skin, and feel resistanceduring venipuncture. Additionally, during the simulated veincannulation, a computer screen provides immediate feedbackrelated to bleeding, bruises, and swelling.
Nurse educators must prepare nursing students to becompetent as they transition from student to clinical prac-titioner [12]. Nursing students need opportunities to practiceand learn how to perform safe and competent IV insertion orcannulation as inappropriate cannulation may have harmfuleffects, including infiltrations, phlebitis, and pain [13]. Withthe increasing use of simulation in nursing education, it isunclear if traditional methods of teaching IV insertion orthe use of an IV simulator result in better skill performancecompetency.
2. Aim
An integrated literature review was performed to examineand/or compare traditional IV insertion instructional meth-ods with haptic IV simulators and compare the outcomes ofthe instructional methods.
3. Search Methods and Strategy
A search of the databases Academic Search Complete,CINAHLComplete, Education Resource Information Centerand Medline was conducted in order to locate publishedarticles onmethods and simulators used to teach IV insertionor cannulation. The search was limited to English languagearticles published between the years 2000 to 2015. Searchterms employed were a combination of intravenous (IV)insertion, cannulation, or venipuncture and simulation. Ofthe 51 articles retrieved, 11 met the inclusion criteria forresearch studies utilizing haptic IV simulators for the purposeof teaching IV insertion or cannulation. Whittemore andKnafl’s [14] data analysis strategies were used to providestructure and rigor while employing a constant comparisonapproach to the literature review process. For this integrativereview, these strategies included reducing data into subcat-egories, organizing data using a matrix format, followed bycomparison, analysis, and verification of overarching themesand conclusions of the subcategories. Synthesis of thesesubcategorieswas then integrated to provide a comprehensivesummation of the topic of IV instructional methods using asimulator.
4. Results
4.1. Comparison of Instructional Methods and Performance
4.1.1. Setting and Sample. Table 1 summarizes the IV simu-lators and instructional methods for this review. Of the 11articles reviewed, 6 studies were conducted in the UnitedStates while the other 5 studies were conducted in Greece,HongKong,Korea, Philippines, and Sweden.Theparticipantsvaried from nursing students (n = 5 studies), to medicalstudents (n = 2 studies), to registered nurses (n = 2 stud-ies). One study utilized both nursing and medical studentswhile another one used a combination of medical students,graduate medical doctors, and nurses who were experts in IVcannulation.
4.1.2. Teaching and Practice. Almost every study (n = 10)compared the use of a haptic IV simulator tomore traditionalteaching methods. The haptic IV simulators used in thesestudies included the CathSim Intravenous Training System(CS) from Immersion Medical, Inc., Laerdal’s Virtual IV(VIV) training system, and the virtual reality/haptic IVtraining simulator from the Republic of Korea [3].Themajor-ity of the instructional methods followed a pattern of (a)pretest-lecture-practice-performance testing or (b) lecture-pretest-practice-performance testing. Traditional instructionincluded students practicing on a plastic IV arm (n = 8studies), on each other (n = 1), on a healthy volunteer (n =1), or on a manikin (n = 1).
4.1.3. Skill Performance. In eight of the eleven studies, thestudents’ skill performance was evaluated via actual IVinsertion attempt on a patient [3, 4, 7, 10, 13] or a humanvolunteer [6, 8, 15]. For three studies, skill performance wasevaluated with the use of an IV arm [5], on a haptic IVsimulator [16], or a combination of an IV arm and a hapticsimulator [9].
In six studies, the use of a haptic IV simulator ora combination of an IV arm and a haptic IV simulatorshowed improvement in performance skills. Bowyer et al. [5]indicated that while all groups improved on performance asevaluated by the faculty, the group using the VIV simulatorshowed greater improvement over the IV arm group. Theyconcluded that both haptic IV simulators (VIV and CS)were at least equal to the traditional method of teaching IVinsertion, which is costlier and faculty intensive. Jamison etal. [9] noted that skill performance was moderately related toimproved cognitive posttest scores for the CS group.
In three of the eleven studies, students’ IV cannulationsuccess rates were compared and no differences were notedbetween the traditional training method and training on thehaptic IV simulator [4, 6, 15]. Chang et al. [13] were unableto determine if one training method was superior to anotherdue to confounding factors and unequal group composition,even though both groups had successful cannulation rates.
However, Sotto et al. [7] found that the group usingthe VIV simulator had a greater success rate in startingan IV on a patient and lower band constriction and totalprocedure time than the traditional method of teaching IV
Nursing Research and Practice 3
Table1:IV
simulatorsa
ndinstructionalm
etho
ds.
Author
Year
Sample/setting
Purpose
Varia
bles
Metho
ds/analysis
Find
ings
Instructionalm
etho
ds
Bowyere
tal.
(2005)
[5]
𝑁=34
3rdyear
medical
students,Maryland,
USA
Com
pare
cann
ulation
(skill)
perfo
rmance
INV1
4grou
ps:
Each
other(EO
)VirtualIV(V
IV)
CathSim
(CS)
IVarm
(IVA
)DV2
Skill
perfo
rmance
RCT;
Pretest
Posttest
t-test
ANOVA
Allgrou
psim
proved:
EO:p<.0003
VIV:p<.0003
CS:p<.02
IVA:p<.009
All:p<.000
01VIV
greaterimprovem
entthanIVAgrou
pp<
.026
5-minutetraining
video
Pretest
Rand
omassig
nment
Practic
e:EO
:1ho
ur2stu
dents
perfaculty
VIV:1
hour
alon
eCS
:1ho
uralon
eIVA:1
hour
alon
ePo
sttest
Skill
perfo
rmance
ontheIVA
Changetal.
(2002)
[13]
N=28
commun
itynu
rses,
Hon
gKo
ng
Com
pare
outcom
esbetween2
instructionalm
etho
ds
INV
2grou
ps:
IVArm
(IVA
)Ca
thSim
(CS)
DV
Successrates
Skill
perfo
rmance
Anx
iety
Quasi-experim
ental;
Posttest
t-test
Successrates
oninitialattempt:(%)
IVA:85.71
CS:64.29
Successfu
lcannu
latio
nrate:(%)
IVA:100
CS:92.86
Skill
perfo
rmance:M
(SD)
IVA:23.29
(1.54)
CS:22.86
(1.83)
p=.509
TraitA
nxietyLevel:M
(SD)
IVA:21.4
2(1.69)
CS:21.14(2.82)
p=.418
Statea
nxietylevel:M
(SD)
IVA:29.5
0(5.00)
CS:28(4.64)
p=.74
9
Lecture
Rand
omassig
nment
Practic
e:Supervise
d:2ho
urs
Independ
ently
:1week
Posttests
Skill
perfo
rmance
onpatie
nt
4 Nursing Research and Practice
Table1:Con
tinued.
Author
Year
Sample/setting
Purpose
Varia
bles
Metho
ds/analysis
Find
ings
Instructionalm
etho
ds
Engum
etal.
(2003)
[6]
N=163stu
dents,
Indiana,USA
n=70
BSnu
rsingstu
dents
n=93
3rdyear
medical
students
Com
pare
outcom
esbetween2
instructionalm
etho
ds
INV
2grou
ps:
IVarm
(IVA
)Ca
thSim
(CS)
DV
Cognitiv
egains
Stud
entsatisfactio
nSelf-effi
cacy/reliance
Docum
entatio
nPatie
ntfeedback
Skill
perfo
rmance
Quasi-experim
ental;
pretest,po
sttest
t-test𝜒2
Allstudents
IVAgrou
phigh
erscores:
Cognitiv
egains:p
=.013
Stud
entsatisfactio
n:p<.0001
Self-effi
cacy/reliance:p
=.0146
Docum
entatio
n:p=.014
Instr
uctio
nhelpful:p<.01
Skill
perfo
rmance
notsignificant
Nursingstudent
group
IVAgrou
phigh
erscores:
Cognitiv
egains:p
=.006
4Stud
entsatisfactio
n:p<.0002
Self-effi
cacy/reliance:p
=.0167
Medica
lstudent
group
IVAgrou
phigh
erscores:
Stud
entsatisfactio
n:p=.043
Pretest
Onlycogn
itive
gains
IVAgrou
p:Self-stu
dymod
ule
with
video
90min
faculty
instruction
Practic
eCS
grou
p:Self-stu
dymod
ule
90min
independ
ent
learning
onCS
Practic
ePo
sttest
AllDV
Skill
perfo
rmance
onvolunteer
Jamiso
netal.
(200
6)[9]
N=18
BSnu
rsingstu
dents,
Midwestern
USA
University
Com
pare
outcom
esbetween2
instructionalm
etho
ds
INV
2grou
ps:
IVarm
(IVA
)Ca
thSim
(CS)
DV
Know
ledge
Skill
perfo
rmance
Educationalpractices
Designfeatures
Exploratory;pretest
posttest
t-test
Know
ledge
OnlyCS
grou
pim
proved:p<.05
Skillsp
erform
ance
CSgrou
pkn
owledger
elated
toskill
perfo
rmance:p<.05
CSgroup
Mostimpo
rtantedu
catio
nalpractices
were
feedback
anddiversew
ayso
flearning
Mostimpo
rtantsim
ulationdesig
nfeatures
werefeedb
ackandcues
Lecture
Pretest
Know
ledge
Rand
omassig
nment
Both
grou
ps:
Practic
eSkill
perfo
rmance
onIVAor
CSPo
sttests
Know
ledge
Educationalpractices
Designfeatures
Nursing Research and Practice 5
Table1:Con
tinued.
Author
Year
Sample/setting
Purpose
Varia
bles
Metho
ds/analysis
Find
ings
Instructionalm
etho
ds
Johann
esson
etal.(2010)
[10]
N=24
BSnu
rsingstu
dents,
University
ofLink
oping,
Sweden
Investigates
tudents’
learning
expectations
before
andaft
ertraining
related
toIV
catheterization
3measurementtim
es:
Pretraining
Posttraining
Poste
xam
DV
Learning
expectations
(pretraining
)Fu
lfillm
ento
fexpectations
(posttraining
and
poste
xam)
Curricular
goal
expectations
(pretraining
and
poste
xam)
Skill
exam
ination
Descriptiv
e;pretest
posttest
Wilcoxon
signedrank
test
Open-ended
questio
ns
Pretraininglearning
expectations:
20/21loo
kedforw
ardto
usingCS
19/21loo
kedforw
ardto
usingIVA
Fulfillm
ento
fexp
ectatio
nswas
metaft
ertraining
:Learning
supp
ortfrom
teacher:p=.038
17/22CS
was
valuablelearning
tool
Fulfillm
ento
fexp
ectatio
nsaft
erexam
:4/20
CSwas
valuablelearning
tool
Learning
supp
ortfrom
teacher:p=.038
Curricular
goalexpectations
after
exam
:Decreaseinabilityto
Organizea
ctions:p<.001
Explainmaterials/procedure:p=.008
Interactwith
patie
nt:p
=.003
Besensitive
topatie
nt:p
=.004
8/20
feltprepared
Rand
omization
Lecture
Pretraininglearning
expectations
Training
:Intro
duction
Practic
einpairs
onCS
andthen
IVA
Practic
eonow
nPo
sttraining
Fulfillm
ento
fexpectations
Posttest:
Skillse
xaminations
Curricular
goal
expectations
Skill
exam
inationon
patie
nt
Jung
etal.
(2012)
[8]
N=114
nursingstu
dents,
Korea
Com
pare
outcom
esbetween3
instructionalm
etho
ds
INV:
3grou
ps:
IVarm
(IVA
)IV
Sim
(IVS
)IVA/IV
SDV:
Anx
iety
Skillsp
erform
ance
Satisfaction
Know
ledge
RCT
t-test
Mann–
Whitney
Utest
One-w
ayANOVA
State-anxietydecreased
IVA:p
=.004
IVA/IV
S:p=.002
VAS-anxietydecreased
IVA:p
=.012
IVS:p=.006
IVA/IV
S:p<.001
Skillsp
erform
ance
IVA/IV
Sgrou
p:Scores>than
otherg
roup
s:p=.015
Task
time<
than
IVS:p=.007
Satisfaction
Overallteaching
effectiv
eness:
IVA/IV
SandIVA>IV
S:p=.005
Learning
procedure:
IVA/IV
Sgrou
pmostsatisfi
ed:p
=.014
Rand
omassig
nment
Lecturea
ndvideo
Pretestanx
iety
Dem
onstr
ationon
ahealthyvolunteer
Dem
onstr
ationon
training
aid
Practic
ePo
sttestanx
iety
Skillsp
erform
ance
onvolunteer
6 Nursing Research and Practice
Table1:Con
tinued.
Author
Year
Sample/setting
Purpose
Varia
bles
Metho
ds/analysis
Find
ings
Instructionalm
etho
ds
Louk
asetal.
(2011)[16]
N=53
medicalstu
dents
andnu
rsee
xperts,
Athens,G
reece
Com
pare
outcom
esbetweengrou
psusing
VIV
INV:
3grou
ps:
Novice(N)
Interm
ediate(I)
Experts(E)
DV:
Perfo
rmance
onVIV:
Learning
Curve
ProcedureT
ime
Errors
Efficacy
Con
fidence
Quantitativ
eand
qualitativ
emixed
metho
dFriedm
an,
Kruskal-W
allis,
Kuder-Richardson
tests
Perfo
rmance
Learning
curvep
lateausa
fter
N=23
attempts
I=15
attempts
Proceduretim
edecreased
p<.01
Errorsdecreased:
Critical:p<.01
Non
critical:p<.05
Posttrainingperfo
rmance
N=I=
E:p>.01
Efficacy
Learning
principles:p<.05
Realism
andcontent:p<.05
Confi
dence
Increased:p<.05
Pretest:
3scenarioso
nVIV
Interventio
n:Group
sNandI:
Lecture
Practic
e9different
scenarios
Posttest:
3scenarioso
nVIV
Reinhardtet
al.(2012)[4]
N=94
BSnu
rsingstu
dents,
New
Mexico,USA
Com
pare
outcom
esbetween3
instructionalm
etho
dsandsequ
encing
ofmetho
ds
INV:
3Group
s:IV
arm
only(A
)VIV
then
A(VA)
Athen
VIV
(AV)
DV:
Skill
perfo
rmance
Con
fidence
Clinicalprofi
ciency
RCT
ANOVA
t-test𝜒2 Pearsoncorrelation
Allgrou
psweres
imilaro
nskill
and
confi
dences
cores.
Clinicalprofi
ciency:
A87.5%
VAandAV
84.2%
Rand
omassig
nment
Lecture
Dem
onstr
ationon
APractic
eSkillsp
erform
ance
onpatie
nt
Nursing Research and Practice 7
Table1:Con
tinued.
Author
Year
Sample/setting
Purpose
Varia
bles
Metho
ds/analysis
Find
ings
Instructionalm
etho
ds
Reyese
tal.
(2008)
[15]
N=28
LPNstu
dent
nurses,
Washing
ton,
USA
Com
pare
outcom
esbetween2
instructionalm
etho
ds
INV:
2grou
ps:
VirtualIV(V
IV)
IVarm
(IVA
)DV:
Cognitiv
egain
Skill
perfo
rmance
Stud
entsatisfactio
n
RCT
t-test
Fisher’sEx
act
Cognitiv
egainwith
ingrou
ps:M
(SD)
VIV:14.7(11)
IVA:11.6
(11.2
6)p<.001
Skill
perfo
rmance:successrateon
initial
attempt
(%):
VIV:64
IVA:78
Stud
entsatisfactio
n:Re
commendcontinueduseo
fVIV
(%)
VIV
79IVA66
Rand
omassig
nment
Pretest
Cognitiv
egain
Review
IVcompetency
VIV:
Orie
ntationon
VIV
Practic
eIVA:
Faculty
instr
uctio
nanddemon
stration
Posttest
Skillsp
erform
ance
onvolunteer
IVA:
VIV
training
oppo
rtun
ityIVAandVIV:
Cognitiv
etest
Satisfactionsurvey
Sotto
etal.
(200
9)[7]
N=40
medicalstu
dents,
Manila,P
hilip
pine
Com
pare
outcom
esbetween2
instructionalm
etho
ds
INV:
2grou
ps:
See-1D
o-1(S1D1)
VIV
DV:
Successrate
Skill
perfo
rmance
Band
constrictio
ntim
eProceduretim
e
Rand
omized
posttest
t-test𝜒2
Successrates
(%):
S1D1:15
VIV:40
p<.05
Skill
perfo
rmance
score:M
(SD)
S1D1:44
(15.3)
VIV:56(19
.2)
p<.03
Band
constrictio
ntim
e:M
(SD)
S1D1:240(38)
VIV:159
(31)
p<.05
Proceduretim
e:M
(SD)
S1D1:380(48)
VIV:277
(53)
p<.05
Instructionalvideo
onVIV
Stratifi
edrand
omassig
nment
S1D1:
Dem
onstr
ationon
apatie
ntVIV:
Practic
euntil
successfu
lPo
sttest
Skill
perfo
rmance
onpatie
nt
8 Nursing Research and Practice
Table1:Con
tinued.
Author
Year
Sample/setting
Purpose
Varia
bles
Metho
ds/analysis
Find
ings
Instructionalm
etho
ds
Wilfon
getal.
(2011)[3]
N=46
registe
rednu
rses,
Penn
sylvania,U
SA
Com
pare
outcom
esbetween2
instructionalm
etho
ds
INV:
2grou
ps:
VIV
andpatie
ntmanikin
(VIV
PM)
Each
other(EO
)DV:
Skill
perfo
rmance
SuccessR
ate
Com
plication
RCT
t-test
Mann–
Whitney
Utest
𝜒2
Successrateo
n1statte
mpt:
VIV
PM(m
edian=1.0
0)EO
(median=2.00):U=143;p<.043
Com
plications
oninitialattempt
(%)
VIV
PM:21
EO:33
Rand
omassig
nment
pretest
Self-assessment
VIV
PM:
Presentatio
nRe
view
policiesa
ndprocedures
Practic
ePerfo
rmIV
onsim
ulators
EO:
Presentatio
nRe
view
policiesa
ndprocedures
Practic
eoneach
other
Posttraining
:IV
attemptso
npatie
nts
1IN
V:ind
ependent
varia
ble.
2DV:dependent
varia
ble.
Nursing Research and Practice 9
insertion. Wilfong et al. [3] noted that the VIV simulatorgroup required fewer attempts in order to be successful atinserting an IV on a patient compared to the group whopracticed on each other. Jung et al. [8] noted that students’procedure scores were higher if they trained on both the IVarm and haptic IV simulator and task time was shorter thanthose students using only the haptic IV simulator. Loukasand colleagues [16] compared outcomes between groupsusing the VIV simulator. The groups consisted of novicestudents (no IV experience) or intermediate graduates (lessthan ten IV insertions) and the outcomes measured includedlearning curve, errors, and task time on the VIV simulator.After training on the VIV simulator, both the novice andintermediate groups’ scores for the outcomes measured weresimilar to those of a group of experts who were proficient inIV insertion (p > .1).
4.1.4. Knowledge, Satisfaction, and Students’ Expectations.Engum et al. [6] study results indicated that students’ posttestscores and satisfaction scores were higher for the traditionalmethods group. In addition, both nursing and medical stu-dents preferred the traditional method of one-to-one faculty-student instruction over the CS system. Feedback fromthe traditional group indicated that they enjoyed workingwith faculty and touching the equipment but wanted morepractice time in smaller groups with more instructors pergroup. Feedback from the CS group indicated that whilethe haptic IV simulator was not “real world,” they enjoyedthe simulator’s variety of case scenarios, the instant feedbackfeature, and the ability to self-pace their own learningwithoutharm to a patient. Overall, medical students were moreaccurate with IV placement but were more businesslike andtask drivenwhile the nursing students weremore emotionallyinvolved and concerned for their patients.
Two studies showed that the haptic groups’ posttestknowledge scores improved [9] and assessment tool scoreswere greater [7] compared to the traditional groups. Reyes etal. [15] indicated that both groups (traditional andVIV)madecognitive gains. After posttesting [15], the traditional groupwas given the opportunity to train on the VIV simulator.Student satisfaction with the VIV experience showed that thegroup who initially trained on the VIV felt that the haptic IVsimulator helpedwith clinical training (64% versus 42%), wastimewell spent (57% versus 50%), and helped develop clinicalskills (35% versus 32%) compared to the group who receivedtraining on the VIV after their traditional method training.The traditional method group felt that their VIV experiencehelped test decisionmaking (57% versus 50%) and challengedcritical thinking (41% versus 21%) compared to the originalVIV simulation group. Both groups recommended that VIVsimulation be continued (VIV group 79%; traditional group66%).
Reyes et al. [15] concluded that IV performance wasreinforced by practicing using the VIV simulator. Jung et al.[8] noted that repeated practice reduced students’ anxietywhile Chang et al. [13] found no differences in state anxietylevels between groups. Jung et al. [8] indicated that studentswho used both the IV arm and the haptic IV simulatorwere more satisfied with learning the procedure and that by
combining both methods students were able to learn the skillin a timely manner using fewer consumables.
In the Johannesson et al. [10] study, students using a hap-tic simulator were asked an open-ended question regardingtheir learning expectations before training, after training, andafter skill examination. Pretraining expectations includedlearning the practical technique, gaining confidence andinsight, meeting the patient, and managing the situation.Posttraining findings noted that the simulator was helpfulin building confidence and was a valuable learning tool.However, postskill examination results found the simulatorwas less valued as a learning tool. Overall, students’ learningexpectations were not met. Students felt that the hapticIV simulator did not equate with reality, that it limitedtheir experience from a holistic perspective, and that theexperience did not provide opportunity to practice com-munication skills. However, they expressed appreciation forthe simulators’ realism, variations in case scenarios, valuein giving feedback, and opportunity for repeated practice.Students indicated that their awareness of patients’ conditionsand their effect on the patient’s veins increased and theybecomemore confident in their skills.The authors concludedthat the haptic IV simulator was useful in the learning processwhen combined with the IV arm and that repeated practicebuilt confidence in a safe environment while using active andindependent learning. Loukas et al. [16] also noted that thehaptic IV simulator was useful for learning the principlesof IV cannulation and both Loukas et al. [16] and Wilfonget al. [3] noted that the haptic IV simulator increased self-confidence.
4.2. Cost. Five articles in this review expressed concernregarding the cost of either the haptic IV simulator technol-ogy or the traditional approach (faculty/lab time intensiveplus supplies) when teaching IV insertion. As of July 2015,the approximate cost of one haptic IV simulator rangesbetweenUS$20,000–US$25,000. Jung et al. [8] note thatmoreeconomical training methods are needed in order to preparepractitioners who are skilled using learning methods that areeffective.
Wilfong et al. [3] identified the cost of the haptic IVsimulator as being an issue in developing countries butalso mentioned that the traditional method of teaching IVinsertion requires a high faculty-to-student ratio which isalso costly. Bowyer et al. [5] noted that haptic IV simulatorsare as effective in teaching IV insertion as the traditionalmethod, which consists of didactic instruction followed bypractice on a simulated arm or practicing the procedure onanother student or patient. However, the traditional methodis costlier in terms of supplies, equipment, and faculty time[5]. Reinhardt et al. [4] addressed the cost of the haptic IVsimulator in comparison to the IV training armwhile Engumet al. [6] noted the importance of keeping cost down in orderto gain academic support. Jung et al. [8] stated that haptic IVsimulators are cost effective as students do not need to useconsumables during the learning process and they providerepeated educational opportunities for student practice. Junget al. [8] recommended combining the haptic IV simulatorwith the IV arm to assist students with learning skills in atimely manner.
10 Nursing Research and Practice
5. Discussion
Current use of haptic IV simulators and traditional trainingmethods continue to have different outcomes. For this review,some of the studies indicated a decrease in student anxietylevels and an increase in cognitive gains with practice butthese results were not related to themethod of IV instruction.Other studies indicated performance improvement by adecrease in insertion time and band constriction time withthe use of the haptic IV simulator.
Students’ learning expectations related to the haptic IVsimulator were high. They presumed that the technologywas going to teach all aspects of IV insertion, includingsuccessful cannulation, when in reality the IV simulatorteaches the process. Students continue to need faculty supportand feedback during practice on the IV arm but during thelearning process other options may be more feasible andcost effective. It is interesting to note that, even with theavailability of IV plastic arms and haptic simulators, someeducational programs still have students practicing on eachother as well as on patients.
Intravenous catheter insertion is one of the most chal-lenging skills taught in nursing school. A nurse’s ability toinsert an IV successfully depends on experience, number ofinsertions performed, and patient factors such as veins thatroll or are resistant to venipuncture and color or turgor of theskin [17]. More importantly, the patient’s perceptions of howcaring the nurse is can be linked to his/hers beliefs about thenurse’s skill in performing the procedure [17].
Simulation is an educational strategy that provides oppor-tunities for students to practice skills in a risk-free envi-ronment without fear of harming patients [18]. Haptic IVsimulators are useful in learning the process and skillstraining for IV insertion and cannulation [3, 5, 7, 9, 10, 15, 16].Haptic IV simulators allow students to practice IV proce-dures repeatedly on complex patient scenarios [18] whiledeveloping proficiency and critical learning skills withoutusing costly consumables and faculty time. While there islittle information on the cost of the haptic IV simulators andvirtually no information regarding the cost of consumablesor faculty time needed to teach this skill, a cost comparisonbetween these instructional methods would be beneficial.
Alexandrou et al. [19] concluded in their review of theliterature on the training of vascular access for undergraduateclinicians that no method of training was found to besuperior to another. However, the results of the currentreview lean towards more positive outcomes. The use ofhaptic IV simulators to teach the process of inserting an IVdecreased the number of attempts needed to be successfulwhen inserting an IV on patients [3] and reduced the total IVinsertion procedure time and band constriction time [7, 16].
6. Conclusion
Based on this review and noted by Johannesson et al. [10]and Jung et al. [8] the best IV instructional method wouldcombine the haptic IV simulator followed by practice timeon the IV arm. During the learning process, group workwhile using the haptic IV simulator may be one alternative
to decrease cost while providing support to group members.Only one of the studies in this review [10] trained 2 studentstogether for one hour while using the CS followed by practiceon an IV arm. Further research using cooperative learningor other active learning strategies while using the haptic IVsimulator may be beneficial and could potentially reduce theoverall cost of learning IV insertion.
Competing Interests
The authors declare that they have no competing interests.
References
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