87CHAPTER 9
IV Simulation Curriculum Development
INTRAVENOUS SIMULATION
Intensifying standards and increases in technology demand the transformation of education in colleges and universities worldwide. Nursing education is no exception. In the not-so-distant past, many of the skills and competencies necessary to substantiate a student nurses’ capabilities transpired through practicing on a student nurse peer or other willing nursing program volunteer. These skills encompassed a vast spectrum of learning objectives, including such noninvasive nursing procedures as taking each other’s blood pressures to more invasive procedures such as nasogastric tube and Foley catheter insertion.
Learning how to insert intravenous (IV) catheters is quite possibly the skill student nurses look most forward to acquiring during their nursing education. In the past, this skill was fairly easily taught and performed within nursing labs throughout the United States, with students using each other’s veins for practice. In today’s nursing labs, IV education has fallen on hard times as a result of financial and litigious concerns. IV catheters, which the students use for practice, continue to rise in cost, causing a substantial decrease in most lab coordinators already thinly stretched budgets, placing strict limitations on the number of IV starts allotted to each student. Another concern involves the possibility of a needle-stick injury occurring within the lab setting. Carefully developed policies and procedures must be in place if this predicament occurs, including the necessary follow-up bloodwork required by the involved students. Simulation solves these dilemmas by allowing students the opportunity to learn IV skills while taking away the potential risks to the nursing lab through the use of an IV simulator.
When students begin a simulation or skills lab, they enter into it with the somewhat mistaken expectation that they will perfect every nursing skill or task within this setting, and venture out into the nursing world with the ability to flawlessly perform any skill solicited of them. As much as nursing educators would like to imagine this as an accurate description of what transpires within simulation and skills labs, the realistic probability and actual syllabus objective descriptions state that the students walk away with the knowledge and understanding of how to safely and accurately perform these skills or tasks within the clinical setting. Perfection, or near to it, is what transpires within the actual nursing setting. No other skill needs to be more accurate than IV insertion.
Until approximately 5 years ago, from this author’s experience, any skill learning performed by the nursing students occurred in the Fundamentals Laboratory (lab). This was the only lab available to the nursing students until the construction of the new Simulation Lab. Any instructional methods for implementing IV education transpired within the Fundamentals Lab during the student’s second medical–surgical semester. The IV education was taught by whoever the designated lab instructor was and usually consisted of several different instructors who filled 88the many lab courses necessary to provide instruction to the entire second-level nursing student group.
The first step within the IV education protocol consisted of the students viewing a series of videos within the lab focusing on preparing a patient for an IV line, IV cannulation, care and maintenance of the IV site, and discontinuing an IV catheter. After viewing the videos, the lab instructor provided further instruction through lecturing. Subsequently, the students practiced IV cannulations on mannequin arms preloaded with simulated blood, with the instructor overseeing the attempts. Finally, following the mannequin arm practice, students were required to sign an IV Start Informed Consent form. On signature completion, the students commenced to practicing IV cannulation on each other as the lab instructor said a prayer for anyone who entered the lab that day, that he or she came in well hydrated. Those students who chose not to sign the informed consent observed the other students during their IV cannulation performances. The instructor was required to actively observe each student’s IV cannulation attempt(s).
Several complications existed with the use of this IV program protocol. First, if the students did not sign the informed consent, they did not receive the opportunity to practice IV cannulation in a realistic fashion. Second, because the students were attempting IV cannulation on each other, a standardized method of assessment could not transpire because every student could not attempt IV cannulation on the same vein. Third, because each student’s attempt had to be witnessed by the instructor, it resulted in a slow process with many students stating boredom. Not all of the students could gather around to observe the individual IV cannulation attempt, yet every student had to remain present until the opportunity presented itself for his or her turn under the instructor’s surveillance. Finally, although the students who participated in the IV cannulation performances signed an informed consent releasing the university from any responsibility, the university was still at risk for potential liability from either the student who was performing the procedure or the student on the receiving end of the procedure.
Beside the noted complications with the preexisting IV program protocol and the decree from the university stating students no longer practice IV cannulations on each other, an addition to the simulation lab created the need to change the way IV education transpired. This addition was the purchase of Laerdal’s Virtual IV simulator, that consists of the software, simulator, and the computer that houses the software and to which the simulator is attached. The Virtual IV simulator provides learners with the opportunity to learn and practice IV insertions noninvasively in a safe, controlled environment preparing them for real-world experiences within clinical settings. It would be irrational to purchase this equipment that cost in excess of $18,000 and not use it to its fullest potential.
This series of events created the need to develop and implement a new curriculum and protocol for the IV education within the school of nursing. Although essential to implement a new curriculum, past components of the old curriculum remain crucial. It is still necessary to teach students the proper technique of IV insertion and allow them to familiarize themselves with and learn how to manipulate IV equipment and supplies through the use of videos and mannequin arms. The addition of the simulator creates the need to orientate students on the operation of the Virtual IV simulator, develop the module sequence most appropriate for the students, and determine how competence is measured and achieved (Reyes, Stillsmoking, & Chadwick-Hopkins, 2008).
The Bachelor of Science in Nursing (BSN) students receiving training with the Virtual IV simulator successfully completed their fundamentals of nursing courses and clinical practicum, and mental health nursing courses and clinical practicum. These students are currently within their third semester of the program, which is comprised of level-one medical–surgical nursing courses, including a nutrition didactic course, medical–surgical nursing didactic course, clinical practicum, and simulation lab. Within their 2-hour weekly simulation lab, they experience not only a simulated medical–surgical nursing experience, but also learn a variety of nursing skills. Previous to this grouping of students, IV skills were not taught until the students’ level-two medical–surgical nursing courses. Once the IV skills were taught, they were never revisited within any of the labs or classes remaining within the students’ nursing education. The decision to change when this curriculum is delivered was based on the implementation of simulation within the BSN program education; the students’ desire and eagerness to acquire IV skills; and the addition of 89the Virtual IV simulator, which allows further skill development throughout the remainder of the students’ nursing education. Before learning how to insert an IV line, certain skills are acquired within this lab that is related to IV therapy. These skills include learning how to prime, hang, and administer primary and secondary IV tubing; learning how to calculate IV drip rates and IV push medications; learning how to perform a blood transfusion; understanding and using the various IV infusion pumps available within the hospitals in which clinical transpires; and learning how to dress, assess, and remove an IV site. Subsequently, the students learn how to insert an IV line through lecture, demonstration, and practice using a mannequin arm filled with simulated blood. Although the Virtual IV simulator allows the student repeated IV insertion practice opportunities, it remains important for the students to understand how to manipulate true IV catheters and equipment (Jung et al., 2012). This places the introduction and orientation of the Virtual IV simulator toward the end of the students’ first semester of their sophomore year.
Virtual IV Experience Learning Objectives
• Students verbally state and demonstrate the correct operation of the Virtual IV simulator.
• Students demonstrate the ability to:
Properly select the correct equipment necessary to perform various intravenous cannulations using the Virtual IV simulator, obtaining a 90% or higher within the debriefing for each case scenario.
Follow the correct procedure when performing IV cannulation using the Virtual IV simulator, obtaining a 90% or higher within the debriefing for each case scenario.
Correctly secure and dress the IV catheter and properly dispose of used supplies when finished performing IV cannulation using the Virtual IV simulator, obtaining a 90% or higher within the debriefing for each case scenario.
A variety of practice case scenarios are available within the Virtual Products software and include varying ethnicities; six different levels of complexity; and trauma, medical, surgical, pediatric, obstetric, and geriatric cases (Laerdal, n.d.). The students’ ranges of patient experiences to this point within their education include basic medical–surgical, geriatric, and mental health patient care. Therefore, the practice case scenarios involving medical or geriatric cases are used. The students are also limited to learning within the “S1” level within the Virtual Products software because this is the students’ first introduction to IV insertion (Laerdal, n.d.). The practice case scenarios chosen within the Virtual Products software include the medical gastroenteritis case involving a Hispanic female and the upper respiratory infection case involving a geriatric female (Laerdal, n.d.). Subsequent to the students’ introduction and orientation to the Virtual IV simulator, a sign-up sheet with slots representing 2-hour time blocks for use of the simulator is distributed, allowing the students to sign their name to the block of time that works best for them. Successful completion of a student’s use of the Virtual IV simulator enables the student to begin the insertion of IV lines within the next semester’s clinical setting under his or her instructor’s observation. The student demonstrates successful completion of the Virtual IV simulator experience by achieving a 90% as determined by the Virtual IV software within both of the case scenarios the students are required to perform. The students have a 2-hour time block with unlimited attempts during this time frame to complete the simulation. In addition, feedback and debriefing are built into the IV simulation software and are provided at the end of each student’s IV attempt, with video demonstrations of correct portions of the procedure offered. If a student is unable to accomplish a 90% within the 2-hour time block, additional time with the lab instructor to review IV insertion is scheduled followed by another time block with the Virtual IV simulator.
A complication that exists in learning how to use Laerdal’s Virtual IV simulator is that one-on-one instruction is not provided by Laerdal. Whereas a majority of Laerdal’s other simulation equipment comes with a 1- or 2-day training provided by a Laerdal educator following installation, the Virtual IV simulator does not. A small amount of instruction may accompany the installation of the Virtual IV simulator, but it is not enough to fully understand its use or potential 90within an educational setting. On installation, the educator is given an administrator user name and password that allows for the addition and management of students within the system.
The rational starting point to understanding Laerdal’s Virtual IV simulator is found within the Virtual Products software in the form of the directions-for-use manual. The manual provides information on the installation or tear down of the Virtual IV simulator; Laerdal’s explanation of the benefits, learning objectives and features of the simulator; a quick-start user guide, system overview, training, administration, and frequently asked questions (Laerdal, n.d.). Although the directions for use provide instructors with the basic information on the use of the simulator, it does not provide them with any guidance for curriculum implementation. It may also be perceived as slightly overwhelming to the novice user who has not yet attempted to use the simulator.
The next step to understanding the use of Laerdal’s Virtual IV simulator is to observe the system tutorial found within the Virtual Products software. The system tutorial delivers a visual and verbal monologue on the use of the simulator, provides users with an explanation of the different areas that can be explored within the Virtual Products software, and explains the meaning of many of the symbols within the software (Laerdal, n.d.). A special section for the instructor can also be found within the Virtual Products software system tutorial that provides direction on how to add and manage students within the system (Laerdal, n.d.). Again, although the system tutorial provides directions for use, it does not provide any recommendations for curriculum implementation or provide step-by-step instructions for use, or any helpful hints. The tutorial moves fairly fast and is hard to remember when actually using the Virtual IV simulator.
On further exploration of the Virtual Products software, other features that may assist instructors or IV-skills novice users include the procedure video and the anatomical viewer (Laerdal, n.d.). The procedure video provides users with both verbal and visual education on initiating IV lines within a clinical setting, and displays health care providers starting IV lines on actual patients rather than a simulated arm. The anatomical viewer within the Virtual Products software provides views of a supinated or pronated arm and allows the learner to either add or delete skin, nerves, arteries, bones, veins, muscle, and connective tissue (Laerdal, n.d.). This offers the learners a supplemental approach to understanding where veins likely may be palpated, if not plainly visible.
After perusing the directions for use, system tutorial, procedure video, and anatomical viewer within the Virtual Products software, it is necessary for the instructor to practice using the newly acquired simulator. Within the Virtual Products software, two options, practice case scenarios and competency training, are available for use by the learners (Virtual IV In-Hospital Module, n.d.). Novice users should start with the practice case scenarios because as the name suggests, these scenarios provide opportunities for practice with the Virtual IV simulator. The competency training is more appropriate for advanced learners or assessment purposes because it provides learners with increasing complexity after each successful IV cannulation attempt. The competency training may be perfectly suited for students within their final, practicum semester before graduation to further increase their skill and confidence level.
Some instructors may encounter frustration when learning how to use the system because the only instruction received is that provided through the directions for use and system tutorial within the Virtual Products software (Laerdal, n.d.). Educators who do not have a thorough knowledge of the Virtual IV simulator experience difficulty when working with students that may increase the students’ fear or anxiety related to their IV insertion skills (Walton, Chute, & Ball, 2011). The only feedback received is that given within the debriefing session after an IV cannulation attempt is made. It can be extremely difficult to pinpoint errors in technique when one has no experience with the simulator and does not have an expert on hand to assist in correcting errors. In addition, one error that is easy to make is not recognizing that a scroll bar exists on the side of the debriefing list. It is necessary to scroll to the very end of the document to completely view the debriefing of the attempt. It may take educators several hours before mastery of the simulator transpires. The author of this chapter has received a significant amount of training within simulation, including the Certificate in Simulation offered by Drexel University, and recommends a person experienced with simulation manage the implementation of the Virtual IV simulator to both the students and faculty using the simulator within the lab setting.
91Until students receive the opportunity to initiate an IV line in a human patient, the mere thought of performing the task may instill a sense of terror within them. A large portion of the skill of starting an IV line is having an understanding of the supplies and steps involved. The Virtual IV simulator provides students with the opportunity to practice acquiring the proper supplies and following the correct procedure, providing feedback within the debriefing session that assists in increasing the confidence of the student when faced with performing the skill on a human patient (Johannesson, Olsson, Petersson, & Silén, 2010). The Virtual IV simulator provides an experience that standardizes the learning experience for the students, creating the opportunity for a streamlined process in which all the students learn the skill in the same way. In addition, the learning does not end with the newly acquired, basic medical and geriatric cases; it can be continued and built on within each subsequent semester. The addition of increasingly difficult and challenging IV attempts can be assigned with cases that are extremely relevant to the semester and clinical patients whom the student experiences.
CONCLUSION
It was determined that a 90% can be achieved (vs. 100%) without successfully completing the procedure and that this is acceptable. The rationale for this decision is that within the clinical setting, a nurse may not successfully feed the catheter into the vein every time, but it is still extremely crucial the proper technique for insertion is followed.
It is the responsibility of nursing educators who acquire new equipment to provide an enriching and rewarding learning experience the nursing students whom the equipment is intended to benefit. Implementation of IV simulation curriculum provides students with realistic experiences invoking critical thinking and increases the level of patient care and satisfaction provided by the students within the various health care environments in which they practice.
REFERENCES
Johannesson, E., Olsson, M., Petersson, G., & Silén, C. (2010). Learning features in computer simulation skills training. Nurse Education in Practice, 10(5), 268–273.
Jung, E. Y., Park, D. K., Lee, Y. H., Jo, H. S., Lim, Y. S., & Park, R. W. (2012). Evaluation of practical exercises using an intravenous simulator incorporating virtual reality and haptics device technologies. Nurse Education Today, 32(4), 458–463.
Reyes, S. D., Stillsmoking, K., & Chadwick-Hopkins, D. (2008). Implementation and evaluation of a virtual simulator system: Teaching intravenous skills. Clinical Simulation in Nursing, 4(1), e43–e49. doi:10.1016/j.ecns.2009.05.055
Laerdal [Computer Software]. (n.d.). Virtual IV in-hospital module. Retrieved from http://www.laerdal.com/us/item/280–04201
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