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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; [email protected]

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

https://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


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


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


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


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


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.


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.


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

[1] R. S. Jones, A. Simmons, G. L. Boykin, D. Stamper, and J.C. Thompson, “Measuring intravenous cannulation skills ofpractical nursing students using rubbermannequin intravenoustraining arms,”Military Medicine, vol. 179, no. 11, pp. 1361–1367,2014.

[2] G. A. Da Silva, S. Priebe, and F. N. Dias, “Benefits of establishingan intravenous team and the standardization of peripheralintravenous catheters,” Journal of Infusion Nursing, vol. 33, no.3, pp. 156–160, 2010.

[3] D. N. Wilfong, D. J. Falsetti, J. L. McKinnon, L. H. Daniel,and Q. Wan, “The effects of virtual intravenous and patientsimulator training compared to the traditional approach ofteaching nurses,” Journal of Infusion Nursing, vol. 34, no. 1, pp.55–62, 2011.

[4] A. C. Reinhardt, I. L. Mullins, C. De Blieck, and P. Schultz,“IV insertion simulation: confidence, skill, and performance,”Clinical Simulation in Nursing, vol. 8, no. 5, pp. e157–e167, 2012.

[5] M. Bowyer, E. Pimentel, J. Fellows et al., “Teaching intravenouscannulation to medical students: comparative analysis of twosimulators and two traditional educational approaches,” inEbook: Medicine Meets Virtual Reality 13, vol. 111 of Studies inHealth Technology & Informatics, pp. 57–63, 2005, http://ebooks.iospress.nl/volumearticle/10037.

[6] S. A. Engum, P. Jeffries, and L. Fisher, “Intravenous cathetertraining system: computer-based education versus traditionallearning methods,” The American Journal of Surgery, vol. 186,no. 1, pp. 67–74, 2003.

[7] J. Sotto, E. Ayuste, M. Bowyer et al., “Exporting simulationtechnology to the Philippines: a comparative study of traditionalversus simulated methods for teaching intravenous cannula-tion,” Studies in Health Technology & Informatics, vol. 17, pp.346–351, 2009.

[8] E.-Y. Jung, D. K. Park, Y. H. Lee, H. S. Jo, Y. S. Lim, and R.W. Park, “Evaluation of practical exercises using an intravenoussimulator incorporating virtual reality and haptics device tech-nologies,” Nurse Education Today, vol. 32, no. 4, pp. 458–463,2012.

[9] R. J. Jamison, M. T. Hovancsek, and J. M. Clochesy, “A pilotstudy assessing simulation using two simulation methods forteaching intravenous cannulation,” Clinical Simulation in Nurs-ing, vol. 2, no. 1, pp. e9–e12, 2006.

[10] E. Johannesson, M. Olsson, G. Petersson, and C. Silen, “Learn-ing features in computer simulation skills training,” NurseEducation in Practice, vol. 10, no. 5, pp. 268–273, 2010.

[11] T. Rutherford-Hemming, “Simulation methodology in nursingeducation and adult learning theory,” Adult Learning, vol. 23,no. 3, pp. 129–137, 2012.

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[12] S. Sportsman, “Competency education and validation in theUnited States: what should nurses know?” Nursing forum, vol.45, no. 3, pp. 140–149, 2010.

[13] K. K.-P. Chang, J. W.-Y. Chung, and T. K.-S. Wong, “Learningintravenous cannulation: a comparison of the conventionalmethod and the CathSim Intravenous Training System,” TheJournal of Clinical Nursing, vol. 11, no. 1, pp. 73–78, 2002.

[14] R. Whittemore and K. Knafl, “The integrative review: updatedmethodology,” Journal of Advanced Nursing, vol. 52, no. 5, pp.546–553, 2005.

[15] S. D. Reyes, K. Stillsmoking, and D. Chadwick-Hopkins,“Implementation and evaluation of a virtual simulator system:teaching intravenous skills,” Clinical Simulation in Nursing, vol.4, no. 1, pp. e43–e49, 2008.

[16] C. Loukas, N. Nikiteas, M. Kanakis, and E. Georgiou, “Evalu-ating the effectiveness of virtual reality simulation training inintravenous cannulation,” Simulation in Healthcare, vol. 6, no.4, pp. 213–217, 2011.

[17] A. F. Jacobson and E. H. Winslow, “Variables influencingintravenous catheter insertion difficulty and failure: an analysisof 339 intravenous catheter insertions,”Heart and Lung: Journalof Acute and Critical Care, vol. 34, no. 5, pp. 345–359, 2005.

[18] S.Decker, S. Sportsman, L. Puetz, and L. Billings, “The evolutionof simulation and its contribution to competency,” The Journalof Continuing Education in Nursing, vol. 39, no. 2, pp. 74–80,2008.

[19] E. Alexandrou, L. Ramjan, J. Murphy, L. Hunt, V. Betihavas, andS. A. Frost, “Training of undergraduate clinicians in vascularaccess: an integrative review,” JAVA - Journal of the Associationfor Vascular Access, vol. 17, no. 3, pp. 146–158, 2012.

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