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Educational intervention to improve IV Cannulation skills in
pediatric nurses using low fidelity simulation: Indian experience.
Journal: BMJ Paediatrics Open
Manuscript ID bmjpo-2017-000148
Article Type: Original article
Date Submitted by the Author: 31-May-2017
Complete List of Authors: Morgaonkar, Vallaree; Pramukhswami Medical College, Department of
Pediatrics Shah, Binoy; Pramukhswami Medical College, Department of Pediatrics Nimbalkar, Somashekhar; Pramukhswami Medical College, Department of Pediatrics; Charutar Arogya Mandal, Central Research Services Phatak, Ajay; Pramukhswami Medical College, Central Research Services Patel, Dipen; Pramukhswami Medical College, Department of Pediatrics Nimbalkar, Archana; Pramukhswami Medical College, Department of Physiology
Keywords: Neonatology, Evidence Based Medicine, Nursing
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Title: Educational intervention to improve IV Cannulation skills in pediatric nurses using low
fidelity simulation: Indian experience.
Authors: Vallaree Anant Morgaonkar1, Binoy Viresh Shah
1, Somashekhar Marutirao
Nimbalkar1,2, Ajay Gajanan Phatak
2, Dipen Vasudev Patel
1, Archana Somashekhar
Nimbalkar3.
Affiliation of Authors:
1 - Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat,
India. Pin-388325
2 - Central Research Services, Charutar Arogya Mandal, Karamsad, Anand, Gujarat, India.
Pin - 388325.
3 - Department of Physiology, Pramukhswami Medical College, Karamsad, Anand, Gujarat,
India. Pin-388325
Corresponding Author: Prof. Somashekhar Nimbalkar, Professor of Pediatrics, Department
of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat, India. Pin-
388325. Email: [email protected]
Source of funding: Nil
Financial Disclosure: None of the authors have any financial disclosure to make
Conflict of Interest: None of the authors have any conflict of interests to disclose
Word Count: 2075
Reference Count:
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nlyTitle: Educational intervention to improve IV Cannulation skills in pediatric nurses using low
fidelity simulation: Indian experience.
Abstract:
Objective: Inserting, monitoring, maintaining IV access are essential components of nursing.
We evaluated simulation training on manikin for improvement of cannulation skills.
Methods: Nursing staff managing pediatric patients were asked to cannulate NITA
NewbornTM – 1800 manikin before and after training. Skills were assessed by single
assessor using OSCE checklist. Four steps were identified as critical. Score of 8/10(80%) was
satisfactory. Knowledge was assessed by 10 questions. A training module consisting of
theoretical aspects, PowerPoint presentations, videos and hands on training over a manikin,
was conducted. Post training assessment was done one week later. Ethics and
Dissemination: 75(80.6%) nurses who completed pre-post assessments were assessed for
paired comparisons of knowledge and skill. Majority nurses were females, contractual hires,
early career and from pediatric wards. NICU nurses performed better than the rest. The mean
(SD) income of the nurses was INR17062(9105) [IQR: 10000, 24000]. One nurse had a
graduate degree (B.Sc.) in nursing. The mean (SD) post training knowledge score was greater
vis-a-vis pre-training score [7.52(1.58) vs 5.32(1.57), p<0.001]. Similar result was observed
for total OSCE scores [9.22(0.66) vs 7.91(1.11), p<0.001]. Significant proportion of
participants exhibited IV cannulation satisfactorily after the training vis-a-vis pre-training
assessment [69(92%) vs 36(48%), p<0.001] Conclusion: Training using manikin improves
the skills of IV cannulation in nurses. NICU nurses had good score before training and hence
we need to ensure simulation training for all.
Keywords: Simulation, Cannulation, Nurses, India
What is Known Simulation improves task training in healthcare personnel
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nlyWhat this study adds: NICU nurses were the best and this is expected because they are
skilled at inserting IVs on a regular basis.
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nlyEducational intervention to improve IV Cannulation skills in pediatric nurses using low
fidelity simulation: Indian experience.
Introduction:
Pediatric nurses are often required to place intravenous (IV) lines in neonates and children as
part of the care provided. Cannulation of a vein is one of the most important procedures that
pediatric nurses need to perform with precision and minimal discomfort to children.
Cannulation not only involves placing the IV cannulas in an appropriate location, but also
requires the nurses to monitor and maintain access to the circulatory system [1]. Nurses need
to undergo training (cognitive and psychomotor) and supervised practice to be proficient in
the skill of IV cannulation and thus eligible to place IV lines in children. Skill of
IVcannulation must be practiced regularly to maintain a high level of competency [2]. This is
important to gain quick and efficient IV access in pediatric populations when required.
Children may have small sized and fragile veins, they may not co-operate during cannulation
due to fear making it more difficult than in adults. There have been studies about cannulation
skills of nurses in adults; but very little data is available in pediatric and neonatal patients.
Hence we decided to train our Nurses using an infant manikin and assess its effect. In adult
studies, High success rates of nurses who were evaluated have been attributed to the frequent
performance of cannulation [3].
There are different ways in which IV cannulation skills could be taught and evaluated. In the
Indian setup, the traditional way of training has been by practice on actual patients under
supervision of senior Nurse/doctor, after an initial period of observation and evaluation of
knowledge regarding cannulation. This method though effective, is more opportunistic
learning and uniform attainment of skills cannot be guaranteed. While training methodologies
have remained same over time, there has been rapid advancement in IV cannulation over the
previous decades with the equipment improving from hypodermic needles to scalp veins to
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nlyintravenous cannulas that are currently used across most of India. Widespread dissatisfaction
with the education provided has been reported sometime back in the pre-internet era [4],
while the current era has many websites which do provide guidelines, reports and videos
which can facillitate self learning. However, supervised learning may be more appropriate as
one of the main responsibilities of the nurse is the safety of the patient to whom she is
providing care [5]. This can be achieved by detailed planning of training by experts who have
a profound understanding of the techniques and associated risks involved, while the therapy
itself is empowering to the nurse [6]. Education in evidence-based care followed by routine
practice in wards gives nurses the opportunity to improve their ability to use cognitive
knowledge in clinical problems [7]. In the end, the care of the patient before and after the
procedure and satisfactory maintenance of the IV line rests with the nurse [8]. The nurse has
to be aware of the various complications such as thrombophlebitis, catheter embolism,
bleeding, nerve, tendon or ligament damage, needle stick injuries, sepsis, etc [9].
In our Hospital, the nursing profession has a high turnover rate and new nurses join every
year. The composition of our nursing staff is of variable experience across different
departments. We decided to train our Nurses in pediatric IV cannulation skills using a
manikin. To ensure standardization of the nursing staff for usage of various cannulas; we
trained them on a newborn mannequin to improve psychomotor skill while knowledge was
shared by interactive lectures. This was a training program to improve skills of our nurses.
Materials and Methods
Shree Krishna Hospital, Karamsad is a rural tertiary care hospital affiliated with a medical
college in Gujarat with recruitment of nurses occurring throughout the year due to attrition.
Most nurses are trained as General Nurse Midwifery (GNM) or equivalent diploma, with very
few having graduate degree in Nursing. Nurses from Neonatal Intensive Care unit (NICU),
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nlyPediatric Intensive Care unit (PICU), Pediatric ward, Post Natal Gynecology ward, Special
Bed Unit (SBU) and Privilege gold ward were included in the training sessions.
Nurses were trained in batches of 20-25 with the training session lasting for four hours.
Each session consisted of a pre training assessment of knowledge and skills, and an
interactive lecture for knowledge including hands on training on mannequins for skills. NITA
NewbornTM
– 1800 mannequin was used for training and assessment. The sequence of
training session was-
1. Assessment of knowledge using Multiple Choice Questions (MCQs),
2. Assessment of IV cannulation skills using Objective Structured Clinical Examination
(OSCE) checklist, on mannequin.
3. Actual Training- by investigators by a training module consisting of PowerPoint
presentations, videos and hands on training over a mannequin and discussion with a group of
20-25 nurses on the theoretical aspects of IV cannulation. Discussion contained theoretical
aspects and practical aspects and was active in nature.
4.Post training assessment was done one week later using OSCE for assessment of skillson
mannequin and MCQs for assessment of knowledge.
IV cannulation skills in all nurses were assessed by single assessor using OSCE checklist,
both before and after training Marks were given out of 10 depending on accuracy of step
performed. Four out of twelve steps were identified as critical steps by all investigators after
reviewing similar checklists used in adults. Participants securing 80% or more marks (8 or
more out of 10) and performing all critical steps correctly were considered to possess
satisfactory skill. Knowledge was assessed by using 10 MCQs.
Descriptive statistics was used to portray baseline characteristics of the study population. The
impact of the training was assessed using paired sample t test and test of difference between
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nlyproportions depending on the nature of variables involved. The analysis was done using
STATA 14. The study was approved by the institutional ethics committee.
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Results:
A total of 93 nurses providing care mainly to infants were invited to participate in the
training. The response rate was good with 79(84.9%) appeared for the pre training assessment
followed by training. Four nurses could not attend post training assessment (one nurse went
on maternity leave, one nurse was admitted to the hospital for Typhoid and 2 nurses were
posted in peripheral centers for a month during the post training assessment). Thus 75(80.6%)
completed both the pre and post assessments and only these records were used for paired
comparisons of knowledge and skill.
Majority of the participating nurses were females, contractual workers, in their early career
and from pediatric wards. The mean (SD) income of the nurses was INR17062(9105) [IQR:
10000, 24000]. Only one nurse had a graduate degree (B.Sc.) in nursing [Table 1].
At Baseline, significantly higher proportion of NICU nurses (72.7%) performed IV
Cannulation satisfactorily as compared to other departments (p=0.024, Fisher’s exact test).
The mean (SD) knowledge score was 5.29(1.65). Albeit low, it was similar across
departments except Special Bed Unit nurses with mean (SD) score of 3.44(1.51). Education,
experience and appointment type were not associated with knowledge score or IV
Cannulation skills.
The mean (SD) post training knowledge score was significantly greater as compared to pre-
training score [7.52(1.58) vs 5.32(1.57), p<0.001] [Figure 1][Table 2]. The mean (SD) post
training OSCE score was significantly greater as compared to pre-training score [9.22(0.66)
vs 7.91(1.11), p<0.001]. Significant proportion of participants exhibited IV cannulation
satisfactorily after the training as compared to pre-training assessment [69(92%) vs 36(48%),
p<0.001]. [Table 3] Out of the 6 participants who could not exhibit the skill satisfactorily
after the training, 3 failed in both the criteria of attaining 80% total score and performing all
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nlycritical steps while 3 failed in performing all critical steps despite attaining a passing score. In
the pre-training assessment about one fifth (7 out of 36) participants failed in performing all
critical steps despite attaining a passing score. Surprisingly one participant who exhibited the
skill satisfactorily in the pre-training assessment failed to exhibit the same in the post-training
assessment again due to failure in performing all the critical steps.
Discussion
We report that the training module is effective in improving the skills and knowledge of
nurses in IV cannulation. As it was part of the training process, we have not used a stronger
experimental design such as a randomized control trial to demonstrate this. There has been
evidence from our center where, in a similar setting for a different skill in medical students,
low fidelity simulation was as effective as high fidelity simulation [10]. However, the
strength of our module is that we tested the post-test score a week later in nurses to address
the issue of loss of skills and knowledge over a period of time. A better approach would be
testing the same after six months. However, since IV cannulation is a frequent practice in
most areas, it is likely that the skills will be maintained. As seen with the NICU nurses who
are more likely to use IV cannulation, their pre-training scores were fairly high. Another
aspect that needs further exploration is critical steps in cannulation and what is acceptable.
The mean (SD) scores do provide useful information on measuring change but it does not
provide enough information on attainment of acceptable level. Identifying and incorporating
critical steps is crucial for comprehensive analysis of impact of any educational intervention.
These steps can be given greater attention during training.
It is well known that more experience and high self-rated competence is associated with
better skills in IV cannulation [11]. Nursing education in India has a generalized approach
with lack of specialization at major centers; learning on the job in respective
department/hospital being commonplace. Learning on the job may have variable exposure to
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nlyprocedure and cannot guarantee satisfactory skills for IV cannulation in children. Simulation
technique on high/low fidelity mannequins is proven to be beneficial in case of adult
cannulation. Our study addresses the lack of studies in newborn/pediatrics populations. An
additional factor to be considered in the Indian context is the high turnover of nurses which
may lead to unequal skills in the workforce. Hence using regular low fidelity simulation
training programs will be a good approach for hospitals. A detailed analysis of various
nursing issues has been addressed elsewhere [12].
In children, especially those below five years, IV cannulation is difficult, time consuming and
often requires multiple skin pricks and nursing resources making it a cost intensive process.
The reasons may range from small, poorly visible veins, distressed and fearful children, etc.
Being skilled in various parameters such as proper technique of insertion and fixation,
appropriate cannula selection, adequate monitoring and maintenance has significant impact
beyond the immediate clinical scenario [13]. A study which evaluated the effects of various
equipment used for venepuncture on the antecubital vein of an adult manikin, found that
simulation education was beneficial in improving IV cannulation skills of experienced nurses
[14]. Similarly, in medical students a randomized controlled trial involving under graduate
students revealed that IV cannulation-related skills acquired in a skills laboratory is superior
to bedside teaching, which enabled students to perform IV cannulation more professionally
[15]. In a prospective evaluation of success rates in IV cannulation in children, it was found
that 53% did successful cannulation on the first attempt, 67% within two attempts, and 91%
within four attempts [16]. In a randomized controlled trial compared mannequins with actual
practice on one another in nursing students, there was evidence of equivalence between the
methods with the risk of harm being lesser with mannequins [17]. In current study the
probable cause behind NICU nurses having better skills could be because of low rate of
attrition, teaching protocols being followed for last 7-8 years, policy of not transferring, more
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nlynumber of patient exposure and repeated need to insert iv cannulas in neonates. Though,
patient exposure of PICU and pediatric ward was also fair, with treatment protocols in place.
The current study showed improvement in knowledge as well as skills among Nurses from all
departments irrespective of patient exposure/years of experience.
Hence our study shows that use of manikin is effective in improving skills of IV cannula
insertion in nurses for Neonatal/pediatric population also- which has important implications
for training of nursing students who may not have enough exposure to pediatric patients
during course of their training, especially so in India. The current study does not show actual
improvement of skill on real patients in terms of number of attempts required for successful
cannulation. This can however be addressed in the future.
Conclusion
Training using manikin improves the skills of IV cannulation in nurses. Traditional methods
of on the job training may have varying impact depending on patient load and years of
experience.
Conflict of interest: None
“We have read and understood BMJ policy on declaration of interests and declare that
we have no competing interests.”
Authors’ Contribution:
Binoy Shah contributed to the design and plan of analysis of the study, data analysis,
writing the manuscript, intellectual contribution and final approval of this manuscript. Dipen
Patel contributed to the design of the study, data acquisition, data analysis and writing the
manuscript. Vallaree Morgaonkar contributed to the design of the study, data acquisition,
data analysis and writing the manuscript. Archana Nimbalkar helped in design the planning
strategy, data analysis, wrote the manuscript and approved the final manuscript. Ajay Phatak
contributed to design of study, plan of analysis, data analysis, writing the manuscript and
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nlyfinal approval of the same. Somashekhar Nimbalkar contributed to the design and planning of
the study, data analysis, revision of the manuscript for important intellectual content, and
final approval of this manuscript.
Acknowledgements: Dr Apurva Chawla for assistance in conducting the study. Dr Amee
Amin for language check.
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References
1. J. Pettit, “Assessment of an Infant with a Peripheral Intravenous device,” Journal of
National Association of Neonatal Nurses, vol. 3, no. 5, pp.230-240, 2003.
2. J. Willis, “Intravenous therapy: an expanding role with implications for
education,” Nursing Times, vol.95, no.25, pp.48-49,1999.
3. Frey, “Success rate for Peripheral Intravenous Insertion in a children’s
hospital,” Journal of Intravenous Nursing, vol.21, no.3, pp.160-165, 1998.
4. R. Wilkinson, “Nurses concern about IV therapy and devices,” Nursing
Standards, vol.10, no.35, pp.35-37, 1996.
5. H. Clarke, “Using research to make a difference in clinical nursing practice,”
International Pediatric Conference, pp. 1-4, Canada,1995.
6. D. Keenlyside, “Every little detail counts,” Infection control in IV therapy,”
Professional Nurse , vol.7, no.5, pp.226-232, 1992.
7. Lundgren,K. Wahren, “Effect of education on evidenced- based care and
handling of peripheral intravenous line,” Journal of Clinical Nursing, vol.8, no.5, pp.577-
585, 1999.
8. G. Downie,J. Mackenzie,W.Arthur,“Pharmacology and Medicines
Management for Nurses,” Third Edition, Philadelphia: Elsevier Churchill Livingstone;
2001.
9. L.Hadaway, “ What can you do to decrease catheter related infections? ,”
Nursing, vol.32, no.9, pp.46-48, 2002.
10. A.Nimbalkar, D.Patel D, A.Kungwani, A.Phatak, R.Vasa , S.Nimbalkar
,“Randomized control trial of high fidelity vs low fidelity simulation for training
undergraduate students in neonatal resuscitation,” BMC Res Notes, vol.3, no.8, pp.636,
Page 13 of 18
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http://bmjpaedsopen.bm
j.com/
bmjpo: first published as 10.1136/bm
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nly2015.doi: 10.1186/s13104-015-1623-9.
11. P.Larsen, D.Eldridge, J.Brinkley, D.Newton, D.Goff, T.Hartzog, N.Saad,
R.Perkin, “ Pediatric peripheral intravenous access:does nursing experience and
competence really make a difference?,” J Infus Nurs, vol.33,no.4, pp.226-235,
2010.doi:10.1097/NAN.0b013e3181e3a0a8.
12. R. Tiwari, K.Sharma, S.Zodpey, “Situational analysis of nursing education and
work force in India,” Nurs Outlook, vol.61,no.3, pp.129-136, 2013.doi:
10.1016/j.outlook.2012.07.012. Epub 2012 Sep 10.
13. D.Goff, P.Larsen, J.Brinkley, D.Eldridge, D.Newton, T. Hartzog, J.Reigart, “
Resource utilization and cost of inserting peripheral intravenous catheters in hospitalized
children,” Hosp Pediatr, vol.3,no.3, pp.185-191, 2013.
14. C.Fujii, H.Ishii, A.Takanishi, “A Comparison of the Effects of Different
Equipment used for Venipuncture to Aid in Promoting More Effective Simulation
Education,” J Blood Disorders Transf, vol.5, pp.228, 2014. doi: 10.4172/2155-
9864.1000228
15. F.Lund, J.Schultz, I.Maatouk, M.Krautter, A.Moltner, (2012)“Effectiveness of
IV Cannulation Skills Laboratory Training and Its Transfer into Clinical Practice: A
Randomized, Controlled Trial,”PLoS ONE,vol.7,2012. : e32831.
doi:10.1371/journal.pone.0032831
16. R. Lininger, “Pediatric peripheral i.v. insertion success rates,” Pediatr Nurs,
vol.29,no.5, pp.351-354, 2003.
17. R.Jones, A.Simmons, G.Boykin, D.Stamper, J.Thompson, “Measuring
intravenous cannulation skills of practical nursing students using rubber mannequin
intravenous training arms,” Mil Med, vol.179,no.11, pp. 1361-1367, 2014.doi:
10.7205/MILMED-D-13-00576
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Table 1: Socio-demographic profile of the participants
Characteristics Frequency (%)
N= 79
Gender
Male 5(6%)
Female 74(94%)
Education
General Nursing and Midwifery (GNM) 61(77.2)
Diploma-General Nursing and Midwifery (DGNM) 7(8.9%)
Registered Nurse Registered Midwife (RNRM) 6(7.6%)
Auxiliary Nurse Midwifery (ANM) 4(5.1%)
B.Sc. (Nursing) 1(1.3%)
Appointment Type
Contractual 64(81%)
Permanent 15(19%)
Posting
Pediatric wards:
Neonatal Intensive Care Unit (NICU) 22(27.8%)
Pediatric Intensive Care Unit (PICU) 9(11.4%)
Pediatric Ward 8(10.1%)
Cardiac Intensive Care Unit (CICU) 6(7.6%)
Gynecology ward 17(21.5%)
Privilege Gold 8(10.1%)
Special Bed Unit (SBU) 9(11.4%)
Experience
0 – 5 years 43(54.4%)
6 – 10 years 15(19%)
11 – 15 years 9(11.4%)
16 years or more 12(15.2%)
Mean(SD)[IQR] 7.52(6.86) [2, 13]
Income (per month in Indian Rupees)
Up to 10000 23(29.5%)
11000 – 15000 28(35.4%)
16000 – 25000 12(15.2%)
>25000 16(20.3%)
Mean(SD)[IQR] 17238(9181) [10000, 24000]
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Table 2: Comparison of knowledge scores before and after the training programme.
Questions Pre-Training
(N=79)
n(%) of
correct answers
Post-Training
(N=75)
n(%) of
correct answers
When we use IV therapy in children? 70(88.6) 74(98.7)
When we should not give IV therapy? 19(24.1) 51(68.0)
Check list before administration contains….. 56(70.9) 66(88.0)
Mention toddler age group 50(63.3) 68(90.7)
Ideal solution for flushing 61(77.2) 61(81.3)
IV Cannula for neonates should be without
injection port. (True/False)
30(38.0) 55(73.3)
TPN will be administered via a dedicated lumen
of a central venous catheter. TPN may not be
administered peripherally. (True/False)
27(34.2) 36(48.0)
Tick IV therapy related complications 29(36.7) 43(57.3)
To prevent infiltration ……. 61(77.2) 65(86.7)
Inspection of IV line after every _______ hour 15(19.0) 45(60.0)
Mean(SD) Total Score out of 10* 5.32(1.57) 7.52(1.58)
* Mean(SD) was calculated for 75 participants who completed both the assessments.
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Table 3: Comparison of IV Cannulation skill before and after the training programme.
Steps Pre-Training
(N=79)
n(%) of
correct performance
Post-Training
(N=75)
n(%) of
correct performance Ensures the equipment availability required for the
procedure 53(67.1) 70(93.3)
Assistant applies proximal pressure^ 13(16.5) 29(38.7)
Does hand hygiene.^ 79(100) 75(100)
Cleans area with antiseptic 64(81.0) 71(94.7)
Appropriate IV cannula 30°toskin 43(54.4) 68(90.7)
Proper insertion of catheter in vein (flash back of
blood in cannula seen) ^ 27(34.2) 73(97.3)
Completes successful insertion of cannula in 1-2
attempts (i.e. gets blood on aspiration in syringe)^ 71(89.9) 75(100)
Cleans blood spillage 58(73.4) 73(97.3)
Assistant removes proximal pressure 17(21.5) 37(49.3)
Attaches blocker 77(97.5) 72(96.0)
Removes gloves 76(96.2) 75(100)
Fixes dressing properly. 68(86.1) 69(92.0)
Participants exhibiting satisfactory skill 36(48.0) 69(92.0)
Mean(SD) Total Score out of 10* 7.91(1.11) 9.22(0.66)
* Mean(SD) was calculated for 75 participants who completed both the assessments.
^ Identified as critical steps.
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Figure 1: Box plot depicting improvement in knowledge score.
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Educational intervention to improve IV cannulation skills in
paediatric nurses using low fidelity simulation: Indian experience.
Journal: BMJ Paediatrics Open
Manuscript ID bmjpo-2017-000148.R1
Article Type: Original article
Date Submitted by the Author: 22-Aug-2017
Complete List of Authors: Morgaonkar, Vallaree; Pramukhswami Medical College, Department of
Pediatrics Shah, Binoy; Pramukhswami Medical College, Department of Pediatrics Nimbalkar, Somashekhar; Pramukhswami Medical College, Department of Pediatrics; Charutar Arogya Mandal, Central Research Services Phatak, Ajay; Pramukhswami Medical College, Central Research Services Patel, Dipen; Pramukhswami Medical College, Department of Pediatrics Nimbalkar, Archana; Pramukhswami Medical College, Department of Physiology
Keywords: Neonatology, Evidence Based Medicine, Nursing, Clinical Procedures, Pain
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Category: Original Article
Title: Educational intervention to improve IV Cannulation skills in pediatric nurses using low
fidelity simulation: Indian experience.
Authors: Vallaree Anant Morgaonkar1, Binoy Viresh Shah
1, Somashekhar Marutirao
Nimbalkar1,2, Ajay Gajanan Phatak
2, Dipen Vasudev Patel
1, Archana Somashekhar Nimbalkar
3.
Affiliation of Authors:
1 - Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat, India.
Pin-388325
2 - Central Research Services, Charutar Arogya Mandal, Karamsad, Anand, Gujarat, India. Pin -
388325.
3 - Department of Physiology, Pramukhswami Medical College, Karamsad, Anand, Gujarat,
India. Pin-388325
Corresponding Author: Prof. Somashekhar Nimbalkar, Professor of Pediatrics, Department of
Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat, India. Pin-388325.
Email: [email protected]
Source of funding: Nil
Financial Disclosure: None of the authors have any financial disclosure to make
Conflict of Interest: None of the authors have any conflict of interests to disclose
Word Count: 2684
Reference Count: 20
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Title: Educational intervention to improve IV Cannulation skills in paediatric nurses using low
fidelity simulation: Indian experience.
Abstract:
Introduction: Inserting, monitoring and maintaining IV access are essential components of
nursing. We evaluated simulation training on manikin to improve cannulation skills.
Methods: Nursing staff managing paediatric patients were asked to cannulate NITA
NewbornTM – 1800 manikin before and after appropriate training. Skills were assessed by a
single assessor using OSCE checklist. Four steps were identified as critical. A score of
8/10(80%) was considered satisfactory. Knowledge was assessed by 10 questions. A training
module consisting of theoretical aspects, PowerPoint presentations, videos and hands on training
over a manikin, was conducted. Post training assessment was done one week later.
Results: Seventy-five (80.6%) nurses who completed pre and post-assessments were assessed
for paired comparisons of knowledge and skill. Majority of the nurses were females, had
contractual appointment, were in their early career phase and from the paediatric wards. The
mean (SD) post training knowledge score was greater vis-a-vis pre-training score [7.52(1.58) vs
5.32(1.57), p<0.001]. Similar result was observed for total OSCE scores [9.22(0.66) vs
7.91(1.11), p<0.001]. Significantly higher proportion of participants exhibited IV cannulation
satisfactorily after the training vis-a-vis pre-training assessment [69(92%) vs 36(48%), p<0.001]
Conclusion: Training using manikin improves IV cannulation skills of paediatric nurses. The
module can be refined and tested further to evolve as a standard module to train and evaluate IV
cannulation skills of paediatric nurses at various levels (education, pre-employment,
reinforcement etc.)
Keywords: Simulation, Cannulation, Nurses, India
What is Known: Simulation improves task training in healthcare personnel
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What this study adds: Training using low fidelity simulation improved IV cannulation skills of
paediatric nurses.
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Educational intervention to improve IV Cannulation skills in pediatric nurses using low fidelity
simulation: Indian experience.
Introduction:
Pediatric nurses are often required to place intravenous (IV) lines in neonates and children as
part of the routine care. Cannulation of a vein is one of the most important procedures that
pediatric nurses need to perform with precision and minimal discomfort to the children.
Cannulation not only involves placing the IV cannulas at an appropriate location, but also
requires the nurses to monitor and maintain access to the circulatory system [1]. Nurses need to
undergo training (cognitive and psychomotor) and supervised practice to be proficient in the skill
of IV cannulation. Skill of IV cannulation must be practiced regularly to maintain a high level of
competency [2]. This is important to gain quick and efficient IV access in pediatric populations
when required. Children may have small sized and fragile veins, may not co-operate during
cannulation due to fear - making it more difficult than in adults. There have been studies about
cannulation skills of nurses in adults; but very little data is available in pediatric and neonatal
patients. Assessment of paediatric IV cannulation skills would help highlight the areas for
improvement and plan further training for the nurses that is targeted and focused. We developed
and tested a module to train the nurses in paediatric cannulation using an infant manikin and
subsequently assessed the impact of the training. High success rates of nurses who were
evaluated have been attributed to the frequent performance of IV cannulation in adult population
[3]. There are different ways in which IV cannulation skills could be taught and evaluated. In the
Indian setup, the traditional way of training has been by practice on actual patients under
supervision of a senior Nurse/doctor, after an initial period of observation and evaluation of
knowledge regarding cannulation. This method though effective, is more of an opportunistic
learning and uniform attainment of skills cannot be guaranteed. While training methodologies
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have remained same over time, there has been rapid advancement in IV cannulation over the
previous decades with the equipment improving from hypodermic needles to scalp veins to
intravenous cannulas that are currently being used across India. Widespread dissatisfaction with
the provided education has been reported in the pre-internet era. [4] The current era has many
websites which do provide guidelines, reports and videos which can facilitate self-learning.
However, supervised learning may be more appropriate as one of the main responsibilities of a
nurse is safety of the patient to whom she is providing care [5]. This can be achieved by detailed
planning of training by experts who have profound understanding of the techniques and
associated risks involved, while the therapy itself is empowering to the nurse [6]. Education in
evidence-based care followed by routine practice in wards provides nurses the opportunity to
improve their ability to use cognitive knowledge in the clinical settings [7]. In the end, the care
of the patient before and after the procedure and satisfactory maintenance of the IV line rests
with a nurse [8]. A nurse has to be aware of the various complications such as thrombophlebitis,
catheter embolism, bleeding, nerve, tendon or ligament damage, needle stick injuries, sepsis, etc.
[9].
At the study site, the nursing profession has a high turnover rate with new nurses joining every
year. The composition of the nursing staff is of variable experience across different departments.
A module was developed and tested to train nurses in the paediatric IV cannulation skill.
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Materials and Methods
Study Settings: Shree Krishna Hospital, Karamsad is a tertiary care teaching hospital in rural
Gujarat with recruitment of nurses occurring throughout the year due to a high attrition rate.
Most nurses are trained as General Nurse Midwifery (GNM) or equivalent diploma, with very
few possessing a graduate degree in Nursing. Nurses from Neonatal Intensive Care unit (NICU),
Paediatric Intensive Care unit (PICU), Paediatric ward, Post Natal Gynaecology ward, Special
Bed Unit (SBU) (private sharing rooms) and Privilege gold ward (private single rooms) were
included in the training sessions.
Study design: We conducted an interventional study to assess knowledge and skills of Nurses
regarding IV cannulation before and after training.
Sample size: In absence of any background data, moderate effect size of 0.40 was considered for
sample size calculation. A sample of size 68 was required to detect effect size of 0.4 (related to
skills score) at 5% level of significance with 90% power. However, it was thought unethical to
select some nurses for the training and exclude the others. Hence, all the 93 nurses eligible for
the training were included hoping that we will have about 70-75 nurses completing both pre and
post intervention assessments.
Training Module: The nurses were trained on a newborn manikin to improve psychomotor
skills while knowledge was shared by interactive lectures.
Nurses were trained in batches of 20-25 with each training session lasting four hours.
Each session consisted of a pre training assessment of knowledge and skills, and an interactive
lecture for knowledge followed by hands on training on mannequins for skills in a closed group
(5-6 per group). NITA NewbornTM
– 1800 mannequin was used for training and assessment. The
sequence of training session was-
1. Assessment of knowledge using Multiple Choice Questions (MCQs),
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2. Assessment of IV cannulation skills using Objective Structured Clinical Examination (OSCE)
checklist, on a manikin.
3. Actual Training- by investigators using a training module consisting of PowerPoint
presentations, videos and hands-on training on a manikin and finally a discussion with a group of
20-25 nurses on the theoretical aspects of IV cannulation. The discussion contained theoretical as
well as practical aspects and was active in nature.
4.Post training assessment was done one week later using OSCE and a manikin for assessment of
skills and MCQs for assessment of knowledge.
The knowledge questionnaire(MCQ) was prepared based on the information provided in
Interactive lectures in order to assess the effect of training by comparing the knowledge before
and after the training. It is available as Supplemental File
IV cannulation skills in all nurses were assessed by single assessor using OSCE checklist both
before and after training. Participants were graded on a scale of 0-10 depending on accuracy of
steps performed.
Using the guidelines of Integrated Procedural Performance Instrument (IPPI) [10] and some
other available checklists for IV cannulation in adults [11-12], a checklist was prepared and
consensually validated by a senior anaesthesiologist for its use in our skill lab for undergraduate
students. The checklist was contextually modified and consensually validated among 4
neonatologists and 2 senior nursing in-charge.
Four out of twelve steps were identified as ‘critical’ by all investigators after reviewing similar
checklists used in adults. Participants scoring greater than 80% and performing all critical steps
correctly were considered to possess satisfactory skill.
Statistical analysis: Descriptive statistics were used to describe baseline characteristics of the
study population. The impact of the training was assessed using paired sample t-test and test of
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difference between proportions depending on the nature of variables involved. The analysis was
done using STATA (14.2). The study was approved by the institutional ethics committee.
Results:
A total of 93 nurses providing care mainly to infants were invited to participate in the training.
Seventy nine (84.9%) nurses appeared for the pre training assessment followed by training. Four
nurses could not attend post-training assessment (one nurse went on a maternity leave, one nurse
was admitted to the hospital for Typhoid and 2 nurses were posted in the peripheral centres for a
month during the post-training assessment. Thus, 75(80.6%) nurses completed both the pre and
post assessments and only these records were used for paired comparisons of knowledge and
skill.
Majority of the participating nurses were females, contractual workers, in their early career and
from paediatric wards. The mean(SD) income of the nurses was INR17,062(9,105) [IQR:
10,000, 24,000]. Only one nurse had a graduate degree (B.Sc.) in nursing. [Table 1]
At baseline, significantly higher proportion of NICU nurses (72.7%) performed IV Cannulation
satisfactorily as compared to other departments (p=0.024, Fisher’s exact test). The mean(SD)
knowledge score was 5.29(1.65). Albeit low, it was similar across departments except Special
Bed Unit nurses with mean(SD) score of 3.44(1.51). Education, experience and appointment type
were not significantly associated with knowledge score or IV Cannulation skills. [Table 2]
The mean(SD) post training knowledge score was significantly greater compared to the pre-
training score [7.52(1.58) vs 5.32(1.57), p<0.001]. [Figure 1] [Table 3] The mean(SD) post-
training OSCE score was significantly greater compared to the pre-training score [9.22(0.66) vs
7.91(1.11), p<0.001]. Significant proportion of participants exhibited IV cannulation
satisfactorily after the training compared to pre-training assessment [69(92%) vs 36(48%),
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p<0.001]. [Table 4] Out of the 6 participants who could not exhibit the skill satisfactorily after
the training, 3 failed in both the criteria (attaining 80% total score and performing all critical
steps), while 3 failed in performing all critical steps despite attaining a passing score. In the pre-
training assessment about one fifth (7 out of 36) participants failed in performing all critical steps
despite attaining a passing score. Surprisingly one participant who exhibited the skill
satisfactorily in the pre-training assessment failed to exhibit the same in the post-training
assessment again due to failure in performing all the critical steps.
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Discussion
We report that the training module is effective in improving the skills and knowledge of nurses
in IV cannulation. Further, NICU nurses fared better in almost all aspects of IV cannulation.
To the best of our knowledge, this is the first well documented training module developed and
tested in India for IV cannulation in paediatric nurses. The evidence from same centre revealed
that low fidelity simulation was as effective as high fidelity simulation in training neonatal
resuscitation to undergraduate medical students [13].
It is well known that more experience and high self-rated competence is associated with better
skills in IV cannulation [14]. The study site established a WHO level III NICU after initial
hiccups. There was a fire in the NICU a decade ago and episodes of widespread infection before
efforts of the current NICU was initiated. Currently, the NICU is well equipped and a blame free
culture is instilled amongst the NICU staff. Further, as a policy decision, NICU nurses are not
transferred to the other wards for past 8-9 years and get satisfactory perks resulting in low
attrition rate. The unit also conducts a fellowship program for neonatology and one of the
components for residents is regular training of nurses. They also have more patient exposure and
repeated need to insert iv cannulas in neonates. The nurses have opportunity to participate in
more academic training programs as compared to others in the institute as the physician leaders
of the NICU are involved in many regional and national learning programs. This probably
explains better performance of NICU nurses in this study.
The mean (SD) scores do provide useful information on measuring change but it does not
provide enough information on attainment of acceptable level. Identifying and incorporating
critical steps is crucial for comprehensive analysis of impact of any educational intervention
involving assessment of skills. These steps can be given greater attention during training.
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Nursing education in India has a generalized approach with lack of specialization even at major
centers; learning on the job in respective department/hospital being common. Learning on the job
may have variable exposure to procedure and cannot guarantee satisfactory skills for IV
cannulation in children. Simulation technique on high/low fidelity manikins is proven to be
beneficial in case of adult cannulation. Our study addresses the lack of studies in
newborn/pediatrics populations. An additional factor to be considered in the Indian context is the
high turnover of nurses which may lead to unequal skills in the workforce. Hence, using regular
low fidelity simulation training programs will be a good approach for hospitals. Tiwari RR et al
presented a detailed analysis of various issues in nursing education in India [15].
In children, especially those below five years, IV cannulation is difficult, time consuming and
often requires multiple skin pricks and nursing resources making it a cost intensive process. The
reasons may range from small, poorly visible veins to distressed and fearful children. Being
skilled in various parameters such as proper technique of insertion and fixation, appropriate
cannula selection, adequate monitoring and maintenance has significant impact beyond the
immediate clinical scenario [16]. A study which evaluated the effects of various equipment used
for venepuncture on the antecubital vein of an adult manikin, found that simulation education
was beneficial in improving IV cannulation skills of experienced nurses [17]. Similarly, in
medical students a randomized controlled trial involving undergraduate students revealed that IV
cannulation-related skills acquired in a skills laboratory is superior to bedside teaching, which
enabled students to perform IV cannulation more professionally [18]. In a prospective evaluation
of success rates in IV cannulation in children, it was found that 53% did successful cannulation
on the first attempt, 67% within two attempts, and 91% within four attempts [19]. In a
randomized controlled trial comparing manikins with actual practice on one another in nursing
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students, there was evidence of equivalence between the methods with the risk of harm being
lesser with the use of manikins [20].
The current study showed improvement in knowledge as well as skills amongst nurses from all
departments irrespective of patient exposure/years of experience. This indicates that the training
module using manikin is effective in improving the skills of IV cannula insertion in nurses for
Neonatal/paediatric population. This has important implications for training of nursing students
who may not have enough exposure to paediatric patients during their initial training, especially
in an Indian setting. The current study does not show actual improvement of skill on real patients
in terms of number of attempts required for successful cannulation. This can however be
addressed in the future through technics such as video audits.
Strengths and limitations of the study
The main strength of the study lies in an organized effort to develop and test a contextual
training module for IV cannulation in pediatric nurses with a reasonable scientific rigor.
However, there were some practical issues that should be considered before a general
standardized module could be developed in future. The limitation being retention of skills over
longer periods of time was not evaluated – but it is likely that skills are being retained as IV
cannulation is a frequent practice in most of the areas of hospital. Another limitation is the post
training evaluation on real patients, which probably would have assessed the respective skills in
real life situations. However, this was not done due to ethical considerations, feasibility of
having so many patients available at a given time, and possible inter-patient variability of
cannulation difficulty level (difficulty level of cannulation would be uniform on manikin pre and
post training). Training on manikin will provide safe environment for nurses to practice and
improve their skills thereby preparing them and increasing confidence to perform cannulation on
actual patients.
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However, improvement in skills as documented on training on manikin in controlled
environment may not result in improvement in real life situations like stressful/ICU
environments. This could be due to variable factors including more patient load and availability
of staff per patient, patient’s clinical severity, patient temperament, personnel available to
immobilize the child etc.
Future implications – In India, nursing education has a general approach, with lack of
opportunities during training to learn more about specialities like paediatrics, oncology, ICUs
etc. Also, most of the nurses have only a Diploma as a qualification, and a very few sub-
speciality training courses/fellowships are available for them for a post-diploma/degree. Most of
the nurses learn during their work experience. We feel that the inclusion of training on a manikin
in nursing curriculum, repeated refresher trainings for nurses during their service and long term
follow up of actual effect of these trainings on real patient care needs to be done in future. There
is also a need to make paediatric sub-speciality courses available for nurses, especially in
branches like paediatric intensive care, neonatal intensive care and paediatric cardiology.
Conclusion
Training using manikin improves IV cannulation skills of paediatric nurses. The module can be
refined and tested further to evolve it as a standard module to train and evaluate IV cannulation
skills of paediatric nurses at various levels (education, pre-employment, reinforcement etc.)
Conflict of interest: None
“We have read and understood BMJ policy on declaration of interests and declare that we
have no competing interests.”
Authors’ Contribution:
Binoy Shah contributed to the design and plan of analysis of the study, data analysis,
writing the manuscript, intellectual contribution and final approval of this manuscript. Dipen
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Patel contributed to the design of the study, data acquisition, data analysis and writing the
manuscript. Vallaree Morgaonkar contributed to the design of the study, data acquisition, data
analysis and writing the manuscript. Archana Nimbalkar helped in design the planning strategy,
data analysis, wrote the manuscript and approved the final manuscript. Ajay Phatak contributed
to design of study, plan of analysis, data analysis, writing the manuscript and final approval of
the same. Somashekhar Nimbalkar contributed to the design and planning of the study, data
analysis, revision of the manuscript for important intellectual content, and final approval of this
manuscript.
Acknowledgements: Dr Apurva Chawla for assistance in conducting the study. Dr Amee Amin
and Dr Maunil Bhatt for language check.
Legends:
Figure 1: Box plot depicting improvement in knowledge score.
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References:
1. Pettit J. Assessment of an Infant with a Peripheral Intravenous device. Advances in
Neonatal Care 2003;3(5):230-240. doi: 10.1053/S1536-0903(03)00171-1.
2. Willis J. Intravenous therapy: an expanding role with implications for education. Nurs
Times 1999;95(25):48-9.
3. Frey AM. Success Rates for Peripheral IV Insertion in a Children's Hospital. Journal of
Infusion Nursing 1998;21(3):160-5.
4. Wilkinson R. Nurses concern about IV therapy and devices. Nurs Stand 1996;10(35):35-
37.
5. Clarke HF. Using research to make a difference in clinical nursing practice. International
Pediatric Conference; Canada 1995;1 - 4.
6. Keenlyside D. Every little detail counts,” Infection control in IV therapy. Prof Nurse
1992;7(4):226-32.
7. Lundgren A, Wahren LK. Effect of education on evidenced- based care and handling of
peripheral intravenous line. J Clin Nurs 1999;8(5):577-85.
8. Courtenay M. Pharmacology and medicines management for nurses: George Downie,
Jean Mackenzie and Arthur Williams (editors) Edinburgh, Churchill Livingstone, 2003,
ISBN 0443071764.
9. Hadaway LC. What can you do to decrease catheter related infections? Nursing
2002;32(9):46-8.
10. Kneebone R, Nestel D, Yadollahi F, et al. Assessing procedural skills in
context:exploring the feasibility of integrated procedural performance instrument (IPPI).
Med Educ 2006;40(11):1105-14. DOI:10.1111/j.1365-2929.2006.02612.x
11. The Nursing Council of New Zealand. Principals for peripheral intravenous cannula
insertion and administration of Primary Care specified intravenous therapies for
Registered Nurses. Appendix B: One point lesson – IV Cannulation: 8,9. Available from
https://www.ccdhb.org.nz/working-with-us/nursing-and-midwifery-workforce-
development/primary-and-community-nursing/principals-of-intravenous-cannulation-for-
registered-nurses-in-primary-care-final.pdf. Accessed on 20 August, 2017.
12. OSCE Skills. Intravenous Cannulation (IV). Available from http://www.osceskills.com/e-
learning/subjects/intravenous-cannulation/ accessed on 17 August, 2017.
Page 15 of 26
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13. Nimbalkar A, Patel D, Kungwani A, et al. Randomized control trial of high fidelity vs
low fidelity simulation for training undergraduate students in neonatal resuscitation. BMC
Res Notes 2015;8:636. doi: 10.1186/s13104-015-1623-9.
14. Larsen P, Eldridge D, Brinkley J, et al. Pediatric peripheral intravenous access:does
nursing experience and competence really make a difference? J Infus Nurs
2010;33(4):226-35. doi: 10.1097/NAN.0b013e3181e3a0a8.
15. Tiwari RR, Sharma K, Zodpey SP. Situational analysis of nursing education and work
force in India. Nurs Outlook 2013;61(3):129-36. doi: 10.1016/j.outlook.2012.07.012.
16. Goff DA, Larsen P, Brinkley J, et al. Resource utilization and cost of inserting peripheral
intravenous catheters in hospitalized children. Hosp Pediatr 2013;3(3):185-91.
17. Fujii C, Ishii H, Takanishi A. A Comparison of the Effects of Different Equipment used
for Venipuncture to Aid in Promoting More Effective Simulation Education. J Blood
Disord Transfus 2014;5:228. doi:10.4172/2155-9864.1000228.
18. Lund F, Schultz J-H, Maatouk I et al. Effectiveness of IV Cannulation Skills Laboratory
Training and Its Transfer into Clinical Practice: A Randomized, Controlled Trial. PLoS
ONE 2012;7(3): e32831. doi: 10.1371/journal.pone.0032831.
19. Lininger RA. Pediatric peripheral i.v. insertion success rates. Pediatr Nurs
2003;29(5):351-4.
20. Jones RS, Simmons A, Boykin GL Sr et al. Measuring intravenous cannulation skills of
practical nursing students using rubber mannequin intravenous training arms. Mil Med
2014;179(11):1361-7. doi: 10.7205/MILMED-D-13-00576.
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Table 1: Socio-demographic profile of the participants
Characteristics Frequency (%)
N= 79
Gender
Male 5(6)
Female 74(94)
Education
General Nursing and Midwifery (GNM) 61(77.2)
Diploma-General Nursing and Midwifery (DGNM) 7(8.9)
Registered Nurse Registered Midwife (RNRM) 6(7.6)
Auxiliary Nurse Midwifery (ANM) 4(5.1)
B.Sc. (Nursing) 1(1.3)
Appointment Type
Contractual 64(81)
Permanent 15(19)
Posting
Paediatric wards:
Neonatal Intensive Care Unit (NICU) 22(27.8)
Paediatric Intensive Care Unit (PICU) 9(11.4)
Paediatric Ward 8(10.1)
Cardiac Intensive Care Unit (CICU) 6(7.6)
Gynaecology ward 17(21.5)
Privilege Gold 8(10.1)
Special Bed Unit (SBU) 9(11.4)
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Experience
0 – 5 years 43(54.4)
6 – 10 years 15(19)
11 – 15 years 9(11.4)
16 years or more 12(15.2)
Mean(SD)[IQR] 7.52(6.86) [2, 13]
Income (per month in Indian Rupees)
Up to 10000 23(29.5)
11000 – 15000 28(35.4)
16000 – 25000 12(15.2)
>25000 16(20.3)
Mean(SD)[IQR] 17238(9181) [10000, 24000]
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Table 2: Comparison of pre-training performance of nurses
Nurses’ characteristics Knowledge
Score
Mean(SD)
p Skills
n(%) correct
p
Ward Posted
Paediatric wards:
Neonatal Intensive Care Unit
(NICU)
5.82(1.40) 0.006 16(72.7) 0.024*
Paediatric Intensive Care Unit
(PICU)
5.11(1.05) 4(44.4)
Paediatric Ward 5.87(0.99) 4(50)
Cardiac Intensive Care Unit (CICU) 4.67(1.21) 0(0)
Gynaecology ward 5.29(2.29) 5(29.4)
Privilege Gold 6.00(0.76) 4(50)
Special Bed Unit (SBU) 3.44(1.51) 3(33.3)
Education
General Nursing and Midwifery (GNM) 5.20(1.79) 0.75 27(44.3) 0.30*
Diploma-General Nursing and
Midwifery (DGNM)
5.71(1.11) 3(42.9)
Registered Nurse Registered Midwife
(RNRM)
5.83(1.17) 5(83.3)
Auxiliary Nurse Midwifery (ANM) 5.50(0.58) 1(25.0)
B.Sc. (Nursing) Not
Applicable
0(0.0)
Appointment Type
Contractual 5.28(1.66) 0.91 27(42.2) 0.21
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Permanent 5.33(1.68) 9(60.0)
Experience
0 – 5 years 5.16(1.80) 0.55 16(37.2) 0.40*
6 – 10 years 5.13(1.30) 9(60.0)
11 – 15 years 5.33(1.41) 5(55.6)
16 years or more 5.92(1.68) 6(50.0)
*Fisher’s Exact test
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Table 3: Comparison of knowledge scores before and after the training programme.
Questions Pre-Training
(N=79)
n(%) of
correct answers
Post-Training
(N=75)
n(%) of
correct answers
When we use IV therapy in children? 70(88.6) 74(98.7)
When we should not give IV therapy? 19(24.1) 51(68.0)
Check list before administration contains….. 56(70.9) 66(88.0)
Mention toddler age group 50(63.3) 68(90.7)
Ideal solution for flushing 61(77.2) 61(81.3)
IV Cannula for neonates should be without
injection port. (True/False)
30(38.0) 55(73.3)
TPN will be administered via a dedicated lumen of
a central venous catheter. TPN may not be
administered peripherally. (True/False)
27(34.2) 36(48.0)
Tick IV therapy related complications 29(36.7) 43(57.3)
To prevent infiltration ……. 61(77.2) 65(86.7)
Inspection of IV line after every _______ hour 15(19.0) 45(60.0)
Mean(SD) Total Score out of 10* 5.32(1.57) 7.52(1.58)
* Mean(SD) was calculated for 75 participants who completed both the assessments.
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Table 4: Comparison of IV Cannulation skill before and after the training programme.
Steps Pre-Training
(N=79)
n(%) of
correct performance
Post-Training
(N=75)
n(%) of
correct performance
Ensures the equipment availability required for the
procedure 53(67.1) 70(93.3)
Checks identity of patient wrist band -(Hospital no.) 13(16.5) 29(38.7)
Assistant applies proximal pressure ^ 79(100) 75(100)
Does hand hygiene. ^ 64(81.0) 71(94.7)
Cleans area with antiseptic 43(54.4) 68(90.7)
Appropriate IV cannula 30 ° to skin 27(34.2) 73(97.3)
Proper insertion of catheter in vein (flash back of
blood in cannula seen) ^ 71(89.9) 75(100)
Completes successful insertion of cannula in 1-2
attempts (i.e. gets blood on aspiration in syringe)^ 58(73.4) 73(97.3)
Cleans blood spillage 17(21.5) 37(49.3)
Assistant removes proximal pressure 77(97.5) 72(96.0)
Attaches blocker 76(96.2) 75(100)
Removes gloves 68(86.1) 69(92.0)
Fixes dressing properly. 77(97.5)
Participants exhibiting satisfactory skill 36(48.0) 69(92.0)
Mean(SD) Total Score out of 10* 7.91(1.11) 9.22(0.66)
* Mean(SD) was calculated for 75 participants who completed both the assessments.
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^ Identified as critical steps.
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165x134mm (300 x 300 DPI)
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Confidential: For Review OnlyPretest/post-test Questionnaire
Name:
Sociodemographic:
Education:
Experience:
Income:
Appointment type:
Ward/ICU Posting (tick applicable): Pediatric ward/PICU/NICU/Cardiac ICU/Gynecology-SBU
ward
1. When we use IV therapy in children ?
a) Emergency / lifesaving medication
b) Medication which cannot be tolerated orally
c) When fluid and electrolyte balance cannot be
mainained by enteral feeds and supplements
d) Blood and blood products
e) All of the above.
2. When we should not give IV therapy?
a) When alternative routes of administration (e.g. oral) would be as effective
b) Where the patency of the intravenous access device in is doubt
c) Where nurse workload exceeds the ability to carry out the procedure safely
d) Where the prescription is illegible
e) All of the above
3. Check list before administration contains…..
a) The infant’s name, MRD number, current weight, date of birth, allergies
b) The correct fluid / drug
c) The correct dose / units (written in words and figures for controlled drugs) and frequency
d) The correct start date and time and completion (if applicable) date and time
e) All of the above
4. Mention toddler age group
a) Up to 1 year
b) Up to 3 years
c) Up to 6 years
d) Up to 12 years
5. Ideal solution for flushing
a) 5% dextrose
b) 0.9% NaCl
c) Distilled water
d) Water for injection
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Confidential: For Review Only6. IV Cannula for neonates should be without injection port.
a) True b) False
7. TPN will be administered via a dedicated lumen of a central venous catheter. TPN may not be
administered peripherally
a) True b) False
8. Tick IV therapy related complications
a) Occlusion
b) Infiltration
c) Extravasation
d) Phlebitis
e) Infection
f) ALL
9. To prevent infiltration …….
a) Smallest gauge catheter should be used
b) Large gauge catheter should be used
10. Inspection of IV line after every _______________ hours
a) 1 hour
b) 3 hours
c) 4 hours
d) 6 hours
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Educational intervention to improve IV cannulation skills in
paediatric nurses using low fidelity simulation: Indian experience.
Journal: BMJ Paediatrics Open
Manuscript ID bmjpo-2017-000148.R2
Article Type: Original article
Date Submitted by the Author: 04-Oct-2017
Complete List of Authors: Morgaonkar, Vallaree; Pramukhswami Medical College, Department of
Pediatrics Shah, Binoy; Pramukhswami Medical College, Department of Pediatrics Nimbalkar, Somashekhar; Pramukhswami Medical College, Department of Pediatrics; Charutar Arogya Mandal, Central Research Services Phatak, Ajay; Pramukhswami Medical College, Central Research Services Patel, Dipen; Pramukhswami Medical College, Department of Pediatrics Nimbalkar, Archana; Pramukhswami Medical College, Department of Physiology
Keywords: Neonatology, Evidence Based Medicine, Nursing, Clinical Procedures, Pain
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Category: Original Article
Title: Educational intervention to improve IV Cannulation skills in pediatric nurses using low
fidelity simulation: Indian experience.
Authors: Vallaree Anant Morgaonkar1, Binoy Viresh Shah
1, Somashekhar Marutirao
Nimbalkar1,2, Ajay Gajanan Phatak
2, Dipen Vasudev Patel
1, Archana Somashekhar Nimbalkar
3.
Affiliation of Authors:
1 - Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat, India.
Pin-388325
2 - Central Research Services, Charutar Arogya Mandal, Karamsad, Anand, Gujarat, India. Pin -
388325.
3 - Department of Physiology, Pramukhswami Medical College, Karamsad, Anand, Gujarat,
India. Pin-388325
Corresponding Author: Prof. Somashekhar Nimbalkar, Professor of Pediatrics, Department of
Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat, India. Pin-388325.
Email: [email protected]
Source of funding: Nil
Financial Disclosure: None of the authors have any financial disclosure to make
Conflict of Interest: None of the authors have any conflict of interests to disclose
Word Count: 2684
Reference Count: 20
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Title: Educational intervention to improve IV Cannulation skills in paediatric nurses using low
fidelity simulation: Indian experience.
Abstract:
Introduction: Inserting, monitoring and maintaining IV access are essential components of
nursing. We evaluated simulation training on manikin to improve cannulation skills.
Methods: Nursing staff managing paediatric patients were asked to cannulate NITA
NewbornTM – 1800 manikin before and after appropriate training. Skills were assessed by a
single assessor using an OSCE checklist. Four steps were identified as critical. A score of
8/10(80%) was considered satisfactory. Knowledge was assessed by 10 questions. A training
module consisting of theoretical aspects, PowerPoint presentations, videos and hands on training
over a manikin was conducted. Post training assessment was done one week later.
Results: Seventy-five (80.6%) nurses who completed pre and post-assessments were assessed
for paired comparisons of knowledge and skill. The majority of the nurses were females, had
contractual appointment, were in their early career phase and from the paediatric wards. The
mean (SD) post training knowledge score was greater vis-a-vis pre-training score [7.52(1.58) vs
5.32(1.57), p<0.001]. A similar result was observed for total OSCE scores [9.22(0.66) vs
7.91(1.11), p<0.001]. Significantly higher proportion of participants exhibited IV cannulation
satisfactorily after the training vis-a-vis pre-training assessment [69(92%) vs 36(48%), p<0.001]
Conclusion: Training using a manikin improves IV cannulation skills of paediatric nurses. The
module can be refined and tested further to evolve as a standard module to train and evaluate IV
cannulation skills of paediatric nurses at various levels (education, pre-employment,
reinforcement etc.)
Keywords: Simulation, Cannulation, Nurses, India
What is Known: Simulation improves task training in healthcare personnel
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What this study adds: Training using low fidelity simulation improved IV cannulation skills of
paediatric nurses.
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Educational intervention to improve IV Cannulation skills in paediatric nurses using low fidelity
simulation: Indian experience.
Introduction:
Paediatric nurses are often required to place intravenous (IV) lines in neonates and children as
part of the routine care. Cannulation of a vein is one of the most important procedures that
paediatric nurses need to perform with precision and minimal discomfort to the children.
Cannulation not only involves placing the IV cannulas at an appropriate location, but also
requires the nurses to monitor and maintain access to the circulatory system [1].
Nurses need to undergo training (cognitive and psychomotor) and supervised practice to be
proficient in the skill of IV cannulation. The skill of IV cannulation must be practiced regularly
to maintain a high level of competency [2]. This is important to gain quick and efficient IV
access in paediatric populations when required. Children may have small sized and fragile veins
and may not co-operate during cannulation due to fear - making it more difficult than in adults.
There have been studies about cannulation skills of nurses in adults; but very little data is
available in paediatric and neonatal patients. The high success rates of nurses who were
evaluated have been attributed to the frequent performance of IV cannulation in adult population
[3]. Assessment of paediatric IV cannulation skills would help highlight the areas for
improvement and plan further training for the nurses that is targeted and focused.
There are different ways in which IV cannulation skills could be taught and evaluated. In
the Indian setup, the traditional way of training has been by practice on actual patients under
supervision of a senior Nurse/doctor, after an initial period of observation and evaluation of
knowledge regarding cannulation. This method though effective, is more of an opportunistic
learning and uniform attainment of skills cannot be guaranteed. While training methodologies
have remained same over time, there has been rapid advancement in IV cannulation over the
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previous decades with the equipment improving from hypodermic needles to scalp veins to
intravenous cannulas that are currently being used across India. Widespread dissatisfaction with
the provided education has been reported in the pre-internet era. [4] The current era has many
websites which do provide guidelines, reports and videos which can facilitate self-learning.
However, supervised learning may be more appropriate as one of the main responsibilities of a
nurse is safety of the patient to whom she is providing care [5].
This can be achieved by detailed planning of training by experts who have profound
understanding of the techniques and associated risks involved, while the therapy itself is
empowering to the nurse [6]. Education in evidence-based care followed by routine practice in
wards provides nurses the opportunity to improve their ability to use cognitive knowledge in the
clinical settings [7]. In the end, the care of the patient before and after the procedure and
satisfactory maintenance of the IV line rests with a nurse [8]. A nurse has to be aware of the
various complications such as thrombophlebitis, catheter embolism, bleeding, nerve, tendon or
ligament damage, needle stick injuries and sepsis [9].
At the study site, the nursing profession has a high turnover rate with new nurses joining every
year. The composition of the nursing staff is of variable experience across different departments.
A module was developed and tested to train nurses in the paediatric IV cannulation skill.
We developed and tested a module to train the nurses in paediatric cannulation using an infant
manikin and subsequently assessed the impact of the training.
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Materials and Methods
Study Settings: Shree Krishna Hospital, Karamsad is a tertiary care teaching hospital in rural
Gujarat with recruitment of nurses occurring throughout the year due to a high attrition rate.
Most nurses are trained as General Nurse Midwifery (GNM) or equivalent diploma, with very
few possessing a graduate degree in Nursing. Nurses from Neonatal Intensive Care unit (NICU),
Paediatric Intensive Care unit (PICU), Paediatric ward, Post Natal Gynaecology ward, Special
Bed Unit (SBU) (private sharing rooms) and Privilege gold ward (private single rooms) were
included in the training sessions.
Study design: We conducted an interventional study to assess knowledge and skills of Nurses
regarding IV cannulation before and after training.
Sample size: In absence of any background data, moderate effect size of 0.40 was considered for
sample size calculation. A sample of size 68 was required to detect effect size of 0.4 (related to
skills score) at 5% level of significance with 90% power. However, authors believed that it is
unethical to select some nurses for the training and exclude the others. The authors also felt that
it was a good opportunity to train all nurses uniformly while conducting the study. Hence, all the
93 nurses eligible for the training were included hoping that we will have about 70-75 nurses
completing both pre and post intervention assessments.
Training Module: The nurses were trained on a newborn manikin to improve psychomotor
skills while knowledge was shared by interactive lectures.
Nurses were trained in batches of 20-25 with each training session lasting four hours.
Each session consisted of a pre training assessment of knowledge and skills, and an interactive
lecture for knowledge followed by hands on training on mannequins for skills in a closed group
(5-6 per group). NITA NewbornTM
– 1800 mannequin was used for training and assessment. The
sequence of training session was-
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1. Assessment of knowledge using Multiple Choice Questions (MCQs) (Supplementary File 1),
2. Assessment of IV cannulation skills using Objective Structured Clinical Examination (OSCE)
checklist, on a manikin.
3. Actual Training- by investigators using a training module consisting of PowerPoint
presentations, videos and hands-on training on a manikin and finally a discussion with a group of
20-25 nurses on the theoretical aspects of IV cannulation. The discussion contained theoretical as
well as practical aspects and was active in nature.
4. Post training assessment was done one week later using OSCE and a manikin for assessment
of skills and MCQs for assessment of knowledge.
The knowledge questionnaire (MCQ) was prepared based on the information provided in
Interactive lectures in order to assess the effect of training by comparing the knowledge before
and after the training.
IV cannulation skills in all nurses were assessed by single assessor using OSCE checklist both
before and after training. Participants were graded on a scale of 0-10 depending on accuracy of
steps performed.
Using the guidelines of Integrated Procedural Performance Instrument (IPPI) [10] and some
other available checklists for IV cannulation in adults [11-12], a checklist was prepared and
consensually validated by a senior anaesthesiologist for its use in our skill lab for undergraduate
students. The checklist was contextually modified and consensually validated among four
neonatologists and two senior nursing in-charge.
Four out of twelve steps were identified as ‘critical’ by all investigators after reviewing similar
checklists used in adults. Participants scoring greater than 80% and performing all critical steps
correctly were considered to possess satisfactory skill.
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Statistical analysis: Descriptive statistics were used to describe baseline characteristics of the
study population. The impact of the training was assessed using paired sample t-test and test of
difference between proportions depending on the nature of variables involved. The analysis was
done using STATA (14.2). The study was approved by the institutional ethics committee.
Results:
A total of 93 nurses providing care mainly to infants were invited to participate in the training.
Seventy nine (85%) nurses appeared for the pre training assessment followed by training. Four
nurses could not attend post-training assessment (one nurse went on a maternity leave, one nurse
was admitted to the hospital for Typhoid and 2 nurses were posted in the peripheral centres for a
month during the post-training assessment. Thus, 75(81%) nurses completed both the pre and
post assessments and only these records were used for paired comparisons of knowledge and
skill.
The majority of the participating nurses were females, contractual workers, in their early career
and from paediatric wards. The mean (SD) income of the nurses was INR17,062(9,105) [IQR:
10,000, 24,000]. Only one nurse had a graduate degree (B.Sc.) in nursing. [Table 1]
At baseline, significantly higher proportion of NICU nurses (73%) performed IV Cannulation
satisfactorily as compared to other departments (p=0.02, Fisher’s exact test). The mean (SD)
knowledge score was 5.29(1.65). Albeit low, it was similar across departments except Special
Bed Unit nurses with mean (SD) score of 3.44 (1.51). Education, experience and appointment
type were not significantly associated with knowledge score or IV Cannulation skills. [Table 2]
The mean (SD) post training knowledge score was significantly greater compared to the pre-
training score [7.52(1.58) vs 5.32(1.57), p<0.001]. [Figure 1] [Table 3] The mean (SD) post-
training OSCE score was significantly greater compared to the pre-training score [9.22(0.66) vs
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7.91(1.11), p<0.001]. Significant proportion of participants exhibited IV cannulation
satisfactorily after the training compared to pre-training assessment [69(92%) vs 36(48%),
p<0.001]. [Table 4] Out of the six participants who could not exhibit the skill satisfactorily after
the training, three failed in both the criteria (attaining 80% total score and performing all critical
steps), while three failed in performing all critical steps despite attaining a passing score. In the
pre-training assessment about one-fifth (7 out of 36) participants failed in performing all critical
steps despite attaining a passing score. Surprisingly one participant who exhibited the skill
satisfactorily in the pre-training assessment failed to exhibit the same in the post-training
assessment again due to failure in performing all the critical steps.
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Discussion
We report that the training module is effective in improving the skills and knowledge of nurses
in IV cannulation. Further, NICU nurses fared better in almost all aspects of IV cannulation.
To the best of our knowledge, this is the first well documented training module developed and
tested in India for IV cannulation in paediatric nurses. Evidence from same centre revealed that
low fidelity simulation was as effective as high fidelity simulation in training neonatal
resuscitation to undergraduate medical students [13].
It is well known that more experience and high self-rated competence is associated with better
skills in IV cannulation [14]. NICU nurses performed better as compared to the nurses from
other areas. This could be explained by the factors like more patient exposure, regular training of
nurses by fellows and residents; blame free culture and policy of not transferring to other wards
leading to low attrition rate.
The study site established a WHO level III NICU after initial hiccups. There was a fire in the
NICU a decade ago and episodes of widespread infection before efforts of the current NICU was
initiated. Currently, the NICU is well equipped and a blame free culture is instilled amongst the
NICU staff. Further, as a policy decision, NICU nurses are not transferred to the other wards for
past 8-9 years and get satisfactory rewards resulting in low attrition rate. The unit also conducts a
fellowship program for neonatology and one of the components for residents is regular training
of nurses. They also have more patient exposure and repeated need to insert iv cannulas in
neonates. The nurses have opportunity to participate in more academic training programs as
compared to others in the institute as the physician leaders of the NICU are involved in many
regional and national learning programs.
The mean (SD) scores do provide useful information on measuring change but it does not
provide enough information on attainment of acceptable level. Identifying and incorporating
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critical steps is crucial for comprehensive analysis of impact of any educational intervention
involving assessment of skills. These steps can be given greater attention during training.
Nursing education in India has a generalized approach with lack of specialization even at major
centers; learning on the job in respective department/hospital being common. Learning on the job
may have variable exposure to procedure and cannot guarantee satisfactory skills for IV
cannulation in children. Simulation technique on high/low fidelity manikins is proven beneficial
in case of adult cannulation. Our study addresses the lack of studies in the newborn/paediatric
populations. An additional factor to be considered in the Indian context is the high turnover of
nurses which may lead to unequal skills in the workforce. On top of these, the further problems
with nursing education in India can be found through Tiwari RR et al [15].
Hence, using regular low fidelity simulation training programs will be a good approach for
hospitals. In children, especially those below five years, IV cannulation is difficult, time
consuming and often requires multiple skin pricks and nursing resources making it a cost
intensive process. The reasons may range from small, poorly visible veins to distressed and
fearful children. Being skilled in various parameters such as proper technique of insertion and
fixation, appropriate cannula selection, adequate monitoring and maintenance has significant
impact beyond the immediate clinical scenario [16]. A study which evaluated the effects of
various equipment used for venepuncture on the antecubital vein of an adult manikin, found that
simulation education was beneficial in improving IV cannulation skills of experienced nurses
[17]. Similarly, in medical students a randomized controlled trial involving undergraduate
students revealed that IV cannulation-related skills acquired in a skills laboratory is superior to
bedside teaching, which enabled students to perform IV cannulation more professionally [18]. In
a prospective evaluation of success rates in IV cannulation in children, it was found that 53% did
successful cannulation on the first attempt, 67% within two attempts, and 91% within four
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attempts [19]. In a randomized controlled trial comparing manikins with actual practice on one
another in nursing students, there was evidence of equivalence between the methods with the risk
of harm being lesser with the use of manikins [20].
This study showed improvement in knowledge as well as skills amongst nurses from all
departments irrespective of patient exposure/years of experience. This indicates that the training
module using manikin is effective in improving the skills of IV cannula insertion in nurses for
Neonatal/paediatric population. This has important implications for training of nursing students
who may not have enough exposure to paediatric patients during their initial training, especially
in an Indian setting. The current study does not show actual improvement of skill on real patients
in terms of number of attempts required for successful cannulation. This can however be
addressed in the future through technics such as video audits.
Strengths and limitations of the study
The main strength of the study lies in an organized effort to develop and test a contextual
training module for IV cannulation in paediatric nurses with a reasonable scientific rigor.
However, there were some practical issues that should be considered before a general
standardized module could be developed in future. The limitation being retention of skills over
longer periods of time was not evaluated – but it is likely that skills are being retained as IV
cannulation is a frequent practice in most of the areas of hospital. Another limitation is the post
training evaluation on real patients, which probably would have assessed the respective skills in
real life situations. However, this was not done due to feasibility of having so many patients
available at a given time and possible inter-patient variability of cannulation difficulty level
(difficulty level of cannulation would be uniform on manikin pre and post training). Training on
manikin will provide safe environment for nurses to practice and improve their skills thereby
preparing them and increasing confidence to perform cannulation on actual patients. Also, due to
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the ethics/workforce morale issues of offering training to all the nurses, we were unable to
provide a control/non-intervention group for this study.
However, improvement in skills as documented on training on manikin in controlled
environment may not result in improvement in real life situations like stressful/ICU
environments. This could be due to variable factors including more patient load and availability
of staff per patient, patient’s clinical severity, patient temperament, personnel available to
immobilize the child etc.
Future implications – In India, nursing education has a general approach, with lack of
opportunities during training to learn more about specialities like paediatrics, oncology, ICUs
etc. Also, most of the nurses have only a Diploma as a qualification, and a very few sub-
speciality training courses/fellowships are available for them for a post-diploma/degree. Most of
the nurses learn during their work experience. We feel that the inclusion of training on a manikin
in nursing curriculum, repeated refresher trainings for nurses during their service and long term
follow up of actual effect of these trainings on real patient care needs to be done in future. There
is also a need to make paediatric sub-speciality courses available for nurses, especially in
branches like paediatric intensive care, neonatal intensive care and paediatric cardiology.
Conclusion
Training using manikin showed improvement in post-training score of IV cannulation skill of
paediatric nurses; however, this finding needs further confirmation by a randomised control trial,
as our study does not have a control group. The module can be refined and tested further to
evolve it as a standard module to train and evaluate IV cannulation skills of paediatric nurses at
various levels (education, pre-employment, reinforcement etc.)
Conflict of interest: None
“We have read and understood BMJ policy on declaration of interests and declare that we
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have no competing interests.”
Authors’ Contribution:
Binoy Shah contributed to the design and plan of analysis of the study, data analysis,
writing the manuscript, intellectual contribution and final approval of this manuscript. Dipen
Patel contributed to the design of the study, data acquisition, data analysis and writing the
manuscript. Vallaree Morgaonkar contributed to the design of the study, data acquisition, data
analysis and writing the manuscript. Archana Nimbalkar helped in design the planning strategy,
data analysis, wrote the manuscript and approved the final manuscript. Ajay Phatak contributed
to design of study, plan of analysis, data analysis, writing the manuscript and final approval of
the same. Somashekhar Nimbalkar contributed to the design and planning of the study, data
analysis, revision of the manuscript for important intellectual content, and final approval of this
manuscript.
Acknowledgements: Dr Apurva Chawla for assistance in conducting the study. Dr Amee Amin
and Dr Maunil Bhatt for language check.
Legends:
Figure 1: Box plot depicting improvement in knowledge score.
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References:
1. Pettit J. Assessment of an Infant with a Peripheral Intravenous device. Advances in
Neonatal Care 2003;3(5):230-240. doi: 10.1053/S1536-0903(03)00171-1.
2. Willis J. Intravenous therapy: an expanding role with implications for education. Nurs
Times 1999;95(25):48-9.
3. Frey AM. Success Rates for Peripheral IV Insertion in a Children's Hospital. Journal of
Infusion Nursing 1998;21(3):160-5.
4. Wilkinson R. Nurses concern about IV therapy and devices. Nurs Stand 1996;10(35):35-
37.
5. Clarke HF. Using research to make a difference in clinical nursing practice. International
Pediatric Conference; Canada 1995;1 - 4.
6. Keenlyside D. Every little detail counts,” Infection control in IV therapy. Prof Nurse
1992;7(4):226-32.
7. Lundgren A, Wahren LK. Effect of education on evidenced- based care and handling of
peripheral intravenous line. J Clin Nurs 1999;8(5):577-85.
8. Courtenay M. Pharmacology and medicines management for nurses: George Downie,
Jean Mackenzie and Arthur Williams (editors) Edinburgh, Churchill Livingstone, 2003,
ISBN 0443071764.
9. Hadaway LC. What can you do to decrease catheter related infections? Nursing
2002;32(9):46-8.
10. Kneebone R, Nestel D, Yadollahi F, et al. Assessing procedural skills in
context:exploring the feasibility of integrated procedural performance instrument (IPPI).
Med Educ 2006;40(11):1105-14. DOI:10.1111/j.1365-2929.2006.02612.x
11. The Nursing Council of New Zealand. Principals for peripheral intravenous cannula
insertion and administration of Primary Care specified intravenous therapies for
Registered Nurses. Appendix B: One point lesson – IV Cannulation: 8,9. Available from
https://www.ccdhb.org.nz/working-with-us/nursing-and-midwifery-workforce-
development/primary-and-community-nursing/principals-of-intravenous-cannulation-for-
registered-nurses-in-primary-care-final.pdf. Accessed on 20 August, 2017.
12. OSCE Skills. Intravenous Cannulation (IV). Available from http://www.osceskills.com/e-
learning/subjects/intravenous-cannulation/ accessed on 17 August, 2017.
Page 15 of 25
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16
13. Nimbalkar A, Patel D, Kungwani A, et al. Randomized control trial of high fidelity vs
low fidelity simulation for training undergraduate students in neonatal resuscitation. BMC
Res Notes 2015;8:636. doi: 10.1186/s13104-015-1623-9.
14. Larsen P, Eldridge D, Brinkley J, et al. Pediatric peripheral intravenous access:does
nursing experience and competence really make a difference? J Infus Nurs
2010;33(4):226-35. doi: 10.1097/NAN.0b013e3181e3a0a8.
15. Tiwari RR, Sharma K, Zodpey SP. Situational analysis of nursing education and work
force in India. Nurs Outlook 2013;61(3):129-36. doi: 10.1016/j.outlook.2012.07.012.
16. Goff DA, Larsen P, Brinkley J, et al. Resource utilization and cost of inserting peripheral
intravenous catheters in hospitalized children. Hosp Pediatr 2013;3(3):185-91.
17. Fujii C, Ishii H, Takanishi A. A Comparison of the Effects of Different Equipment used
for Venipuncture to Aid in Promoting More Effective Simulation Education. J Blood
Disord Transfus 2014;5:228. doi:10.4172/2155-9864.1000228.
18. Lund F, Schultz J-H, Maatouk I et al. Effectiveness of IV Cannulation Skills Laboratory
Training and Its Transfer into Clinical Practice: A Randomized, Controlled Trial. PLoS
ONE 2012;7(3): e32831. doi: 10.1371/journal.pone.0032831.
19. Lininger RA. Pediatric peripheral i.v. insertion success rates. Pediatr Nurs
2003;29(5):351-4.
20. Jones RS, Simmons A, Boykin GL Sr et al. Measuring intravenous cannulation skills of
practical nursing students using rubber mannequin intravenous training arms. Mil Med
2014;179(11):1361-7. doi: 10.7205/MILMED-D-13-00576.
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Table 1: Socio-demographic profile of the participants
Characteristics Frequency (%)
N= 79
Gender
Male 5(6)
Female 74(94)
Education
General Nursing and Midwifery (GNM) 61(77)
Diploma-General Nursing and Midwifery (DGNM) 7(9)
Registered Nurse Registered Midwife (RNRM) 6(8)
Auxiliary Nurse Midwifery (ANM) 4(5)
B.Sc. (Nursing) 1(1)
Appointment Type
Contractual 64(81)
Permanent 15(19)
Posting
Paediatric wards:
Neonatal Intensive Care Unit (NICU) 22(28)
Paediatric Intensive Care Unit (PICU) 9(11)
Paediatric Ward 8(10)
Cardiac Intensive Care Unit (CICU) 6(8)
Gynaecology ward 17(22)
Privilege Gold 8(10)
Special Bed Unit (SBU) 9(11)
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Experience
0 – 5 years 43(55)
6 – 10 years 15(19)
11 – 15 years 9(11)
16 years or more 12(15)
Mean(SD)[IQR] 7.52(6.86) [2, 13]
Income (per month in Indian Rupees)
Up to 10000 23(30)
11000 – 15000 28(35)
16000 – 25000 12(15)
>25000 16(20)
Mean(SD)[IQR] 17238(9181) [10000, 24000]
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Table 2: Pre-training performance of nurses
Nurses’ characteristics Knowledge
Score
Mean(SD)
Skills
n(%) correct
Ward Posted
Paediatric wards:
Neonatal Intensive Care Unit
(NICU)
5.82(1.40) 16(73)
Paediatric Intensive Care Unit
(PICU)
5.11(1.05) 4(44)
Paediatric Ward 5.87(0.99) 4(50)
Cardiac Intensive Care Unit (CICU) 4.67(1.21) 0(0)
Gynaecology ward 5.29(2.29) 5(29)
Privilege Gold 6.00(0.76) 4(50)
Special Bed Unit (SBU) 3.44(1.51) 3(33)
Education
General Nursing and Midwifery (GNM) 5.20(1.79) 27(44)
Diploma-General Nursing and
Midwifery (DGNM)
5.71(1.11) 3(43)
Registered Nurse Registered Midwife
(RNRM)
5.83(1.17) 5(83)
Auxiliary Nurse Midwifery (ANM) 5.50(0.58) 1(25)
B.Sc. (Nursing) Not
Applicable
0(0.0)
Appointment Type
Contractual 5.28(1.66) 27(42)
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Permanent 5.33(1.68) 9(60)
Experience
0 – 5 years 5.16(1.80) 16(37)
6 – 10 years 5.13(1.30) 9(60)
11 – 15 years 5.33(1.41) 5(56)
16 years or more 5.92(1.68) 6(50)
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Table 3: Comparison of knowledge scores before and after the training programme.
Questions Pre-Training
(N=79)
n(%) of
correct answers
Post-Training
(N=75)
n(%) of
correct answers
When we use IV therapy in children? 70(87) 74(99)
When we should not give IV therapy? 19(24) 51(68)
Check list before administration contains____ 56(71) 66(88)
Mention toddler age group 50(63) 68(91)
Ideal solution for flushing 61(77) 61(81)
IV Cannula for neonates should be without
injection port. (True/False)
30(38) 55(73)
TPN will be administered via a dedicated lumen of
a central venous catheter. TPN may not be
administered peripherally. (True/False)
27(34) 36(48)
Tick IV therapy related complications 29(37) 43(57)
To prevent infiltration ____ 61(77) 65(87)
Inspection of IV line after every _______ hour 15(19) 45(60)
Mean(SD) Total Score out of 10* 5.32(1.57) 7.52(1.58)
* Mean (SD) was calculated for 75 participants who completed both the assessments.
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Table 4: Comparison of IV Cannulation skill before and after the training programme.
Steps Pre-Training
(N=79)
n(%) of
correct performance
Post-Training
(N=75)
n(%) of
correct performance
Ensures the equipment availability required for the
procedure 53(67) 70(93)
Checks identity of patient wrist band - (Hospital no.) 13(17) 29(39)
Assistant applies proximal pressure ^ 79(100) 75(100)
Does hand hygiene. ^ 64(81) 71(95)
Cleans area with antiseptic 43(54) 68(91)
Appropriate IV cannula 30 ° to skin 27(34) 73(97)
Proper insertion of catheter in vein (flash back of
blood in cannula seen) ^ 71(90) 75(100)
Completes successful insertion of cannula in 1-2
attempts (i.e. gets blood on aspiration in syringe)^ 58(73) 73(97)
Cleans blood spillage 17(22) 37(49)
Assistant removes proximal pressure 77(98) 72(96)
Attaches blocker 76(96) 75(100)
Removes gloves 68(86) 69(92)
Fixes dressing properly. 77(98) 75(100)
Participants exhibiting satisfactory skill 36(48.0) 69(92.0)
Mean(SD) Total Score out of 10* 7.91(1.11) 9.22(0.66)
* Mean (SD) was calculated for 75 participants who completed both the assessments.
^ Identified as critical steps.
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165x134mm (300 x 300 DPI)
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Confidential: For Review OnlyPretest/post-test Questionnaire
Name:
Sociodemographic:
Education:
Experience:
Income:
Appointment type:
Ward/ICU Posting (tick applicable): Pediatric ward/PICU/NICU/Cardiac ICU/Gynecology-SBU
ward
1. When we use IV therapy in children ?
a) Emergency / lifesaving medication
b) Medication which cannot be tolerated orally
c) When fluid and electrolyte balance cannot be
mainained by enteral feeds and supplements
d) Blood and blood products
e) All of the above.
2. When we should not give IV therapy?
a) When alternative routes of administration (e.g. oral) would be as effective
b) Where the patency of the intravenous access device in is doubt
c) Where nurse workload exceeds the ability to carry out the procedure safely
d) Where the prescription is illegible
e) All of the above
3. Check list before administration contains…..
a) The infant’s name, MRD number, current weight, date of birth, allergies
b) The correct fluid / drug
c) The correct dose / units (written in words and figures for controlled drugs) and frequency
d) The correct start date and time and completion (if applicable) date and time
e) All of the above
4. Mention toddler age group
a) Up to 1 year
b) Up to 3 years
c) Up to 6 years
d) Up to 12 years
5. Ideal solution for flushing
a) 5% dextrose
b) 0.9% NaCl
c) Distilled water
d) Water for injection
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a) True b) False
7. TPN will be administered via a dedicated lumen of a central venous catheter. TPN may not be
administered peripherally
a) True b) False
8. Tick IV therapy related complications
a) Occlusion
b) Infiltration
c) Extravasation
d) Phlebitis
e) Infection
f) ALL
9. To prevent infiltration …….
a) Smallest gauge catheter should be used
b) Large gauge catheter should be used
10. Inspection of IV line after every _______________ hours
a) 1 hour
b) 3 hours
c) 4 hours
d) 6 hours
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Educational intervention to improve IV Cannulation skills in
pediatric nurses using low fidelity simulation: Indian experience.
Journal: BMJ Paediatrics Open
Manuscript ID bmjpo-2017-000148.R3
Article Type: Original article
Date Submitted by the Author: 27-Nov-2017
Complete List of Authors: Morgaonkar, Vallaree; Pramukhswami Medical College, Department of
Pediatrics Shah, Binoy; Pramukhswami Medical College, Department of Pediatrics Nimbalkar, Somashekhar; Pramukhswami Medical College, Department of Pediatrics; Charutar Arogya Mandal, Central Research Services Phatak, Ajay; Pramukhswami Medical College, Central Research Services Patel, Dipen; Pramukhswami Medical College, Department of Pediatrics Nimbalkar, Archana; Pramukhswami Medical College, Department of Physiology
Keywords: Neonatology, Evidence Based Medicine, Nursing, Clinical Procedures, Pain
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Category: Original Article
Title: Educational intervention to improve IV Cannulation skills in pediatric nurses using low
fidelity simulation: Indian experience.
Authors: Vallaree Anant Morgaonkar1, Binoy Viresh Shah
1, Somashekhar Marutirao
Nimbalkar1,2, Ajay Gajanan Phatak
2, Dipen Vasudev Patel
1, Archana Somashekhar Nimbalkar
3.
Affiliation of Authors:
1 - Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat, India.
Pin-388325
2 - Central Research Services, Charutar Arogya Mandal, Karamsad, Anand, Gujarat, India. Pin -
388325.
3 - Department of Physiology, Pramukhswami Medical College, Karamsad, Anand, Gujarat,
India. Pin-388325
Corresponding Author: Prof. Somashekhar Nimbalkar, Professor of Pediatrics, Department of
Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat, India. Pin-388325.
Email: [email protected]
Source of funding: Nil
Financial Disclosure: None of the authors have any financial disclosure to make
Conflict of Interest: None of the authors have any conflict of interests to disclose
Word Count: 2388
Reference Count: 19
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Title: Educational intervention to improve IV Cannulation skills in paediatric nurses using low
fidelity simulation: Indian experience.
Abstract:
Introduction: Inserting, monitoring and maintaining IV access are essential components of
nursing. We evaluated simulation training on a manikin to improve cannulation skills.
Methods: Nursing staff managing paediatric patients were asked to cannulate NITA
NewbornTM – 1800 manikin before and after appropriate training. Skills were assessed by a
single assessor using an OSCE checklist. Four steps were identified as critical. A score of
8/10(80%) was considered satisfactory. Knowledge was assessed by 10 questions. A training
module consisting of theoretical aspects, PowerPoint presentations, videos and hands on training
over a manikin was conducted. Post training assessment was done one week later.
Results: Seventy-five (80.6%) nurses who completed pre and post-assessments were assessed
for paired comparisons of knowledge and skill. The majority of the nurses were females, had
contractual appointment, were in their early career phase and from the paediatric wards. The
mean (SD) post training knowledge score was greater vis-a-vis pre-training score [7.52(1.58) vs
5.32(1.57), p<0.001]. A similar result was observed for total OSCE scores [9.22(0.66) vs
7.91(1.11), p<0.001]. Significantly higher proportion of participants exhibited IV cannulation
satisfactorily after the training vis-a-vis pre-training assessment [69(92%) vs 36(48%), p<0.001]
Conclusion: Training using manikin showed improvement in post-training score of IV
cannulation skill of paediatric nurses; however, this finding needs further confirmation by a
randomised control trial, as our study does not have a control group.
Keywords: Simulation, Cannulation, Nurses, India
What is Known: Simulation improves task training in healthcare personnel
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What this study adds: Training using low fidelity simulation may improve IV cannulation skills
of paediatric nurses.
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Educational intervention to improve IV Cannulation skills in paediatric nurses using low fidelity
simulation: Indian experience.
Introduction:
Paediatric nurses are often required to place intravenous (IV) lines in neonates and children as
part of the routine care. Cannulation of a vein is one of the most important procedures that
paediatric nurses need to perform with precision and minimal discomfort to the children.
Cannulation not only involves placing the IV cannulas at an appropriate location, but also
requires the nurses to monitor and maintain access to the circulatory system [1].
Nurses need to undergo training (cognitive and psychomotor) and supervised practice to be
proficient in the skill of IV cannulation. The skill of IV cannulation must be practiced regularly
to maintain a high level of competency [2]. This is important to gain quick and efficient IV
access in paediatric populations when required. Children may have small sized and fragile veins
and may not co-operate during cannulation due to fear - making it more difficult than in adults.
There have been studies about cannulation skills of nurses in adults, but very little data is
available in paediatric and neonatal patients. The high success rates of nurses who were
evaluated have been attributed to the frequent performance of IV cannulation in the adult
population [3]. Assessment of paediatric IV cannulation skills would help highlight the areas for
improvement and plan further training for the nurses that is targeted and focused.
There are different ways in which IV cannulation skills could be taught and evaluated. In
the Indian setup, the traditional way of training has been by practice on actual patients under
supervision of a senior Nurse/doctor, after an initial period of observation and evaluation of
knowledge regarding cannulation. This method, though effective, is more of an opportunistic
learning and uniform attainment of skills cannot be guaranteed. While training methodologies
have remained same over time, there has been rapid advancement in IV cannulation over the
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previous decades with the equipment improving from hypodermic needles to scalp veins to
intravenous cannulas that are currently being used across India. Widespread dissatisfaction with
the provided education has been reported in the pre-internet era. [4] The current era has many
websites which do provide guidelines, reports and videos which can facilitate self-learning.
However, supervised learning may be more appropriate as one of the main responsibilities of a
nurse is safety of the patient to whom she is providing care [5].
This can be achieved by detailed planning of training by experts who have profound
understanding of the techniques and associated risks involved, while the therapy itself is
empowering to the nurse [6]. Education in evidence-based care followed by routine practice in
wards provides nurses the opportunity to improve their ability to use cognitive knowledge in the
clinical settings [7]. In the end, the care of the patient before and after the procedure and
satisfactory maintenance of the IV line rests with a nurse [8]. A nurse has to be aware of the
various complications such as thrombophlebitis, catheter embolism, bleeding, nerve, tendon or
ligament damage, needle stick injuries and sepsis [9].
At the study site, the nursing profession has a high turnover rate with new nurses joining every
year. The composition of the nursing staff is of variable experience across different departments.
A module was developed and tested to train nurses in the paediatric IV cannulation skill.
We developed and tested a module to train the nurses in paediatric cannulation using an infant
manikin and subsequently assessed the impact of the training.
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Materials and Methods
Study Settings: Shree Krishna Hospital, Karamsad is a tertiary care teaching hospital in rural
Gujarat with recruitment of nurses occurring throughout the year due to a high attrition rate.
Most nurses are trained as General Nurse Midwifery (GNM) or equivalent diploma, with very
few possessing a graduate degree in Nursing. Nurses from Neonatal Intensive Care unit (NICU),
Paediatric Intensive Care unit (PICU), Paediatric ward, Post Natal Gynaecology ward, Special
Bed Unit (SBU) (private sharing rooms) and Privilege gold ward (private single rooms) were
included in the training sessions.
Study design: We conducted an interventional study to assess knowledge and skills of Nurses
regarding IV cannulation before and after training.
Sample size: In absence of any background data, moderate effect size of 0.40 was considered for
sample size calculation. A sample of size 68 was required to detect effect size of 0.4 (related to
skills score) at 5% level of significance with 90% power. However, authors believed that it is
unethical to select some nurses for the training and exclude the others. The authors also felt that
it was a good opportunity to train all nurses uniformly while conducting the study. Hence, all the
93 nurses eligible for the training were included hoping that we will have about 70-75 nurses
completing both pre and post intervention assessments.
Training Module: The nurses were trained on a newborn manikin to improve psychomotor
skills while knowledge was shared by interactive lectures.
Nurses were trained in batches of 20-25 with each training session lasting four hours.
Each session consisted of a pre training assessment of knowledge and skills, and an interactive
lecture for knowledge followed by hands on training on mannequins for skills in a closed group
(5-6 per group). NITA NewbornTM
– 1800 mannequin was used for training and assessment. The
sequence of training session was-
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1. Assessment of knowledge using Multiple Choice Questions (MCQs) (Supplementary File 1),
2. Assessment of IV cannulation skills using Objective Structured Clinical Examination (OSCE)
checklist, on a manikin.
3. Actual Training- by investigators using a training module consisting of PowerPoint
presentations, videos and hands-on training on a manikin and finally a discussion with a group of
20-25 nurses on the theoretical aspects of IV cannulation. The discussion contained theoretical as
well as practical aspects and was active in nature.
4. Post training assessment was done one week later using OSCE and a manikin for assessment
of skills and MCQs for assessment of knowledge.
The knowledge questionnaire (MCQ) was prepared based on the information provided in
Interactive lectures in order to assess the effect of training by comparing the knowledge before
and after the training.
IV cannulation skills in all nurses were assessed by single assessor using OSCE checklist both
before and after training. Participants were graded on a scale of 0-10 depending on accuracy of
steps performed.
Using the guidelines of Integrated Procedural Performance Instrument (IPPI) [10] and some
other available checklists for IV cannulation in adults [11-12], a checklist was prepared and
consensually validated by a senior anaesthesiologist for its use in our skill lab for undergraduate
students. The checklist was contextually modified and consensually validated among four
neonatologists and two senior nursing in-charge.
Four out of twelve steps were identified as ‘critical’ by all investigators after reviewing similar
checklists used in adults. Participants scoring greater than 80% and performing all critical steps
correctly were considered to possess satisfactory skill.
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Statistical analysis: Descriptive statistics were used to describe baseline characteristics of the
study population. The impact of the training was assessed using paired sample t-test and test of
difference between proportions depending on the nature of variables involved. The analysis was
done using STATA (14.2). The study was approved by the institutional ethics committee.
Results:
A total of 93 nurses providing care mainly to infants were invited to participate in the training.
Seventy nine (85%) nurses appeared for the pre training assessment followed by training. Four
nurses could not attend post-training assessment (one nurse went on a maternity leave, one nurse
was admitted to the hospital for Typhoid and 2 nurses were posted in the peripheral centres for a
month during the post-training assessment. Thus, 75(81%) nurses completed both the pre and
post assessments and only these records were used for paired comparisons of knowledge and
skill.
The majority of the participating nurses were females, contractual workers, in their early career
and from paediatric wards. The mean (SD) income of the nurses was INR17,062(9,105) [IQR:
10,000, 24,000]. Only one nurse had a graduate degree (B.Sc.) in nursing. [Table 1]
At baseline, significantly higher proportion of NICU nurses (73%) performed IV Cannulation
satisfactorily as compared to other departments (p=0.02, Fisher’s exact test). The mean (SD)
knowledge score was 5.29(1.65). Albeit low, it was similar across departments except Special
Bed Unit nurses with mean (SD) score of 3.44 (1.51). Education, experience and appointment
type were not significantly associated with knowledge score or IV Cannulation skills. [Table 2]
The mean (SD) post training knowledge score was significantly greater compared to the pre-
training score [7.52(1.58) vs 5.32(1.57), p<0.001]. [Figure 1] [Table 3] The mean (SD) post-
training OSCE score was significantly greater compared to the pre-training score [9.22(0.66) vs
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7.91(1.11), p<0.001]. A significant proportion of participants exhibited IV cannulation
satisfactorily after the training compared to pre-training assessment [69(92%) vs 36(48%),
p<0.001]. [Table 4] Out of the six participants who could not exhibit the skill satisfactorily after
the training, three failed in both the criteria (attaining 80% total score and performing all critical
steps), while three failed in performing all critical steps despite attaining a passing score. In the
pre-training assessment about one-fifth (7 out of 36) participants failed in performing all critical
steps despite attaining a passing score. Surprisingly one participant who exhibited the skill
satisfactorily in the pre-training assessment failed to exhibit the same in the post-training
assessment again due to failure in performing all the critical steps.
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Discussion
Training showed improvement in post-training score of IV cannulation skill of paediatric nurses;
however, this needs further confirmation by a randomised control trial, as our study does not
have a control group. Further, NICU nurses fared better in almost all aspects of IV cannulation.
Evidence from the same training centre revealed that low fidelity simulation was as effective as
high fidelity simulation in training neonatal resuscitation to undergraduate medical students [13].
It is well known that more experience and high self-rated competence is associated with better
skills in IV cannulation [14]. NICU nurses had better performance levels in this study, which
was on a neonatal manakin, confirming these previous findings. This could be explained by
factors such as more patient exposure, regular training of nurses by fellows and residents; blame
free culture and policy of not transferring to other wards leading to low attrition rate.
Currently, the NICU is well equipped and a blame free culture is instilled amongst the NICU
staff. Further, as a policy decision, NICU nurses are not transferred to the other wards for past 8-
9 years and get satisfactory rewards resulting in low attrition rate. The unit also conducts a
fellowship program for neonatology and one of the components for residents is regular training
of nurses. They also have more patient exposure and repeated need to insert iv cannulas in
neonates. The nurses have opportunity to participate in more academic training programs as
compared to others in the institute as the physician leaders of the NICU are involved in many
regional and national learning programs.
The mean (SD) scores do provide useful information on measuring change but it does not
provide enough information on attainment of acceptable level. Identifying and incorporating
critical steps is crucial for comprehensive analysis of impact of any educational intervention
involving assessment of skills. These steps can be given greater attention during training.
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Nursing education in India has a generalized approach with lack of specialization even at major
centers; learning on the job in respective department/hospital being common. Learning on the job
may have variable exposure to procedure and cannot guarantee satisfactory skills for IV
cannulation in children. Simulation technique on high/low fidelity manikins is proven beneficial
in the case of adult simulation. Our study addresses the lack of studies in the newborn/paediatric
populations.
Being skilled in various parameters such as proper technique of insertion and fixation,
appropriate cannula selection, adequate monitoring and maintenance has significant impact
beyond the immediate clinical scenario [15]. A study which evaluated the effects of various
equipment used for venepuncture on the antecubital vein of an adult manikin, found that
simulation education was beneficial in improving IV cannulation skills of experienced nurses
[16]. Similarly, in medical students a randomized controlled trial involving undergraduate
students revealed that IV cannulation-related skills acquired in a skills laboratory is superior to
bedside teaching, which enabled students to perform IV cannulation more professionally [17]. In
a prospective evaluation of success rates in IV cannulation in children, it was found that 53%
successfully cannulated on the first attempt, 67% within two attempts, and 91% within four
attempts [18]. In a randomized controlled trial comparing manikins with actual practice on one
another in nursing students, there was evidence of equivalence between the methods with the risk
of harm being lesser with the use of manikins [19].
This study showed improvement in knowledge as well as skills amongst nurses from all
departments irrespective of patient exposure/years of experience. The current study does not
show actual improvement of skill on real patients in terms of number of attempts required for
successful cannulation. This can however be addressed in the future through technics such as
video audits.
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The main strength of the study lies in an organized effort to develop and test a contextual
training module for IV cannulation in paediatric nurses with a reasonable scientific rigor.
However, there were some practical issues that should be considered before a general
standardized module could be developed in future. The limitation being retention of skills over
longer periods of time was not evaluated – but it is likely that skills are being retained as IV
cannulation is a frequent practice in most of the areas of hospital. Another limitation is the post
training evaluation on real patients, which probably would have assessed the respective skills in
real life situations.
However, improvement in skills as documented on training on manikin in controlled
environment may not result in improvement in real life situations like stressful/ICU
environments. This could be due to variable factors including more patient load and availability
of staff per patient, patient’s clinical severity, patient temperament, personnel available to
immobilize the child etc.
Training using manikin showed improvement in post-training score of IV cannulation skill of
paediatric nurses; however, this finding needs further confirmation by a randomised control trial,
as our study does not have a control group. The module can be refined and tested further to
evolve it as a standard module to train and evaluate IV cannulation skills of paediatric nurses at
various levels (education, pre-employment, reinforcement etc.)
Conflict of interest: None
“We have read and understood BMJ policy on declaration of interests and declare that we
have no competing interests.”
Authors’ Contribution:
Binoy Shah contributed to the design and plan of analysis of the study, data analysis,
writing the manuscript, intellectual contribution and final approval of this manuscript. Dipen
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Patel contributed to the design of the study, data acquisition, data analysis and writing the
manuscript. Vallaree Morgaonkar contributed to the design of the study, data acquisition, data
analysis and writing the manuscript. Archana Nimbalkar helped in design the planning strategy,
data analysis, wrote the manuscript and approved the final manuscript. Ajay Phatak contributed
to design of study, plan of analysis, data analysis, writing the manuscript and final approval of
the same. Somashekhar Nimbalkar contributed to the design and planning of the study, data
analysis, revision of the manuscript for important intellectual content, and final approval of this
manuscript.
Acknowledgements: Dr Apurva Chawla for assistance in conducting the study. Dr Amee Amin
and Dr Maunil Bhatt for language check.
Legends:
Figure 1: Box plot depicting improvement in knowledge score.
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References:
1. Pettit J. Assessment of an Infant with a Peripheral Intravenous device. Advances in
Neonatal Care 2003;3(5):230-240. doi: 10.1053/S1536-0903(03)00171-1.
2. Willis J. Intravenous therapy: an expanding role with implications for education. Nurs
Times 1999;95(25):48-9.
3. Frey AM. Success Rates for Peripheral IV Insertion in a Children's Hospital. Journal of
Infusion Nursing 1998;21(3):160-5.
4. Wilkinson R. Nurses concern about IV therapy and devices. Nurs Stand 1996;10(35):35-
37.
5. Clarke HF. Using research to make a difference in clinical nursing practice. International
Pediatric Conference; Canada 1995;1 - 4.
6. Keenlyside D. Every little detail counts,” Infection control in IV therapy. Prof Nurse
1992;7(4):226-32.
7. Lundgren A, Wahren LK. Effect of education on evidenced- based care and handling of
peripheral intravenous line. J Clin Nurs 1999;8(5):577-85.
8. Courtenay M. Pharmacology and medicines management for nurses: George Downie,
Jean Mackenzie and Arthur Williams (editors) Edinburgh, Churchill Livingstone, 2003,
ISBN 0443071764.
9. Hadaway LC. What can you do to decrease catheter related infections? Nursing
2002;32(9):46-8.
10. Kneebone R, Nestel D, Yadollahi F, et al. Assessing procedural skills in
context:exploring the feasibility of integrated procedural performance instrument (IPPI).
Med Educ 2006;40(11):1105-14. DOI:10.1111/j.1365-2929.2006.02612.x
11. The Nursing Council of New Zealand. Principals for peripheral intravenous cannula
insertion and administration of Primary Care specified intravenous therapies for
Registered Nurses. Appendix B: One point lesson – IV Cannulation: 8,9. Available from
https://www.ccdhb.org.nz/working-with-us/nursing-and-midwifery-workforce-
development/primary-and-community-nursing/principals-of-intravenous-cannulation-for-
registered-nurses-in-primary-care-final.pdf. Accessed on 20 August, 2017.
12. OSCE Skills. Intravenous Cannulation (IV). Available from http://www.osceskills.com/e-
learning/subjects/intravenous-cannulation/ accessed on 17 August, 2017.
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13. Nimbalkar A, Patel D, Kungwani A, et al. Randomized control trial of high fidelity vs
low fidelity simulation for training undergraduate students in neonatal resuscitation. BMC
Res Notes 2015;8:636. doi: 10.1186/s13104-015-1623-9.
14. Larsen P, Eldridge D, Brinkley J, et al. Pediatric peripheral intravenous access:does
nursing experience and competence really make a difference? J Infus Nurs
2010;33(4):226-35. doi: 10.1097/NAN.0b013e3181e3a0a8.
15. Goff DA, Larsen P, Brinkley J, et al. Resource utilization and cost of inserting peripheral
intravenous catheters in hospitalized children. Hosp Pediatr 2013;3(3):185-91.
16. Fujii C, Ishii H, Takanishi A. A Comparison of the Effects of Different Equipment used
for Venipuncture to Aid in Promoting More Effective Simulation Education. J Blood
Disord Transfus 2014;5:228. doi:10.4172/2155-9864.1000228.
17. Lund F, Schultz J-H, Maatouk I et al. Effectiveness of IV Cannulation Skills Laboratory
Training and Its Transfer into Clinical Practice: A Randomized, Controlled Trial. PLoS
ONE 2012;7(3): e32831. doi: 10.1371/journal.pone.0032831.
18. Lininger RA. Pediatric peripheral i.v. insertion success rates. Pediatr Nurs
2003;29(5):351-4.
19. Jones RS, Simmons A, Boykin GL Sr et al. Measuring intravenous cannulation skills of
practical nursing students using rubber mannequin intravenous training arms. Mil Med
2014;179(11):1361-7. doi: 10.7205/MILMED-D-13-00576.
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Table 1: Socio-demographic profile of the participants
Characteristics Frequency (%)
N= 79
Gender
Male 5(6)
Female 74(94)
Education
General Nursing and Midwifery (GNM) 61(77)
Diploma-General Nursing and Midwifery (DGNM) 7(9)
Registered Nurse Registered Midwife (RNRM) 6(8)
Auxiliary Nurse Midwifery (ANM) 4(5)
B.Sc. (Nursing) 1(1)
Appointment Type
Contractual 64(81)
Permanent 15(19)
Posting
Paediatric wards:
Neonatal Intensive Care Unit (NICU) 22(28)
Paediatric Intensive Care Unit (PICU) 9(11)
Paediatric Ward 8(10)
Cardiac Intensive Care Unit (CICU) 6(8)
Gynaecology ward 17(22)
Privilege Gold 8(10)
Special Bed Unit (SBU) 9(11)
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Experience
0 – 5 years 43(55)
6 – 10 years 15(19)
11 – 15 years 9(11)
16 years or more 12(15)
Mean(SD)[IQR] 7.52(6.86) [2, 13]
Income (per month in Indian Rupees)
Up to 10000 23(30)
11000 – 15000 28(35)
16000 – 25000 12(15)
>25000 16(20)
Mean(SD)[IQR] 17238(9181) [10000, 24000]
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Table 2: Pre-training performance of nurses
Nurses’ characteristics Knowledge
Score
Mean(SD)
Skills
n(%) correct
Ward Posted
Paediatric wards:
Neonatal Intensive Care Unit
(NICU)
5.82(1.40) 16(73)
Paediatric Intensive Care Unit
(PICU)
5.11(1.05) 4(44)
Paediatric Ward 5.87(0.99) 4(50)
Cardiac Intensive Care Unit (CICU) 4.67(1.21) 0(0)
Gynaecology ward 5.29(2.29) 5(29)
Privilege Gold 6.00(0.76) 4(50)
Special Bed Unit (SBU) 3.44(1.51) 3(33)
Education
General Nursing and Midwifery (GNM) 5.20(1.79) 27(44)
Diploma-General Nursing and
Midwifery (DGNM)
5.71(1.11) 3(43)
Registered Nurse Registered Midwife
(RNRM)
5.83(1.17) 5(83)
Auxiliary Nurse Midwifery (ANM) 5.50(0.58) 1(25)
B.Sc. (Nursing) Not
Applicable
0(0.0)
Appointment Type
Contractual 5.28(1.66) 27(42)
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Permanent 5.33(1.68) 9(60)
Experience
0 – 5 years 5.16(1.80) 16(37)
6 – 10 years 5.13(1.30) 9(60)
11 – 15 years 5.33(1.41) 5(56)
16 years or more 5.92(1.68) 6(50)
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Table 3: Comparison of knowledge scores before and after the training programme.
Questions Pre-Training
(N=79)
n(%) of
correct answers
Post-Training
(N=75)
n(%) of
correct answers
When we use IV therapy in children? 70(87) 74(99)
When we should not give IV therapy? 19(24) 51(68)
Check list before administration contains____ 56(71) 66(88)
Mention toddler age group 50(63) 68(91)
Ideal solution for flushing 61(77) 61(81)
IV Cannula for neonates should be without
injection port. (True/False)
30(38) 55(73)
TPN will be administered via a dedicated lumen of
a central venous catheter. TPN may not be
administered peripherally. (True/False)
27(34) 36(48)
Tick IV therapy related complications 29(37) 43(57)
To prevent infiltration ____ 61(77) 65(87)
Inspection of IV line after every _______ hour 15(19) 45(60)
Mean(SD) Total Score out of 10* 5.32(1.57) 7.52(1.58)
* Mean (SD) was calculated for 75 participants who completed both the assessments.
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Table 4: Comparison of IV Cannulation skill before and after the training programme.
Steps Pre-Training
(N=79)
n(%) of
correct performance
Post-Training
(N=75)
n(%) of
correct performance
Ensures the equipment availability required for the
procedure 53(67) 70(93)
Checks identity of patient wrist band - (Hospital no.) 13(17) 29(39)
Assistant applies proximal pressure ^ 79(100) 75(100)
Does hand hygiene. ^ 64(81) 71(95)
Cleans area with antiseptic 43(54) 68(91)
Appropriate IV cannula 30 ° to skin 27(34) 73(97)
Proper insertion of catheter in vein (flash back of
blood in cannula seen) ^ 71(90) 75(100)
Completes successful insertion of cannula in 1-2
attempts (i.e. gets blood on aspiration in syringe)^ 58(73) 73(97)
Cleans blood spillage 17(22) 37(49)
Assistant removes proximal pressure 77(98) 72(96)
Attaches blocker 76(96) 75(100)
Removes gloves 68(86) 69(92)
Fixes dressing properly. 77(98) 75(100)
Participants exhibiting satisfactory skill 36(48.0) 69(92.0)
Mean(SD) Total Score out of 10* 7.91(1.11) 9.22(0.66)
* Mean (SD) was calculated for 75 participants who completed both the assessments.
^ Identified as critical steps.
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165x134mm (300 x 300 DPI)
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Confidential: For Review OnlyPretest/post-test Questionnaire
Name:
Sociodemographic:
Education:
Experience:
Income:
Appointment type:
Ward/ICU Posting (tick applicable): Pediatric ward/PICU/NICU/Cardiac ICU/Gynecology-SBU
ward
1. When we use IV therapy in children ?
a) Emergency / lifesaving medication
b) Medication which cannot be tolerated orally
c) When fluid and electrolyte balance cannot be
mainained by enteral feeds and supplements
d) Blood and blood products
e) All of the above.
2. When we should not give IV therapy?
a) When alternative routes of administration (e.g. oral) would be as effective
b) Where the patency of the intravenous access device in is doubt
c) Where nurse workload exceeds the ability to carry out the procedure safely
d) Where the prescription is illegible
e) All of the above
3. Check list before administration contains…..
a) The infant’s name, MRD number, current weight, date of birth, allergies
b) The correct fluid / drug
c) The correct dose / units (written in words and figures for controlled drugs) and frequency
d) The correct start date and time and completion (if applicable) date and time
e) All of the above
4. Mention toddler age group
a) Up to 1 year
b) Up to 3 years
c) Up to 6 years
d) Up to 12 years
5. Ideal solution for flushing
a) 5% dextrose
b) 0.9% NaCl
c) Distilled water
d) Water for injection
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Confidential: For Review Only6. IV Cannula for neonates should be without injection port.
a) True b) False
7. TPN will be administered via a dedicated lumen of a central venous catheter. TPN may not be
administered peripherally
a) True b) False
8. Tick IV therapy related complications
a) Occlusion
b) Infiltration
c) Extravasation
d) Phlebitis
e) Infection
f) ALL
9. To prevent infiltration …….
a) Smallest gauge catheter should be used
b) Large gauge catheter should be used
10. Inspection of IV line after every _______________ hours
a) 1 hour
b) 3 hours
c) 4 hours
d) 6 hours
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