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Confidential: For Review O

nly

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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BMJ Paediatrics Open on 17 June 2018 by guest. P

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ecember 2017. D

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nlyCategory: 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

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


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


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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nly

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9. L.Hadaway, “ What can you do to decrease catheter related infections? ,”

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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

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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

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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

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vol.29,no.5, pp.351-354, 2003.

17. R.Jones, A.Simmons, G.Boykin, D.Stamper, J.Thompson, “Measuring

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nly

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)



^ Identified as critical steps.

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Figure 1: Box plot depicting improvement in knowledge score.

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Confidential: For Review Only

Educational intervention to improve IV cannulation skills in

paediatric nurses using low fidelity simulation: Indian experience.


Manuscript ID bmjpo-2017-000148.R1


Date Submitted by the Author: 22-Aug-2017



Keywords: Neonatology, Evidence Based Medicine, Nursing, Clinical Procedures, Pain




jpaedsopen.bmj.com

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Category: Original Article







1, Archana Somashekhar Nimbalkar

3.


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.


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]




Word Count: 2684

Reference Count: 20

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Title: Educational intervention to improve IV Cannulation skills in paediatric nurses using low


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.)


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


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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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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.


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


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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.



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.)


“We have read and understood BMJ policy on declaration of interests and declare that we

have no competing interests.”




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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:


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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]


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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(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)



30(38.0) 55(73.3)

TPN will be administered via a dedicated lumen of

a central venous catheter. TPN may not be


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)



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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)


blood in cannula seen) ^ 71(89.9) 75(100)


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)




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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.




Date Submitted by the Author: 04-Oct-2017







jpaedsopen.bmj.com

/bm


ecember 2017. D

ownloaded from



1









3.



Pin-388325


388325.


India. Pin-388325







Word Count: 2684

Reference Count: 20

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Abstract:


nursing. We evaluated simulation training on manikin to improve cannulation skills.



single assessor using an OSCE checklist. Four steps were identified as critical. A score of



over a manikin was conducted. Post training assessment was done one week later.


for paired comparisons of knowledge and skill. The majority of the nurses were females, had



5.32(1.57), p<0.001]. A similar result was observed for total OSCE scores [9.22(0.66) vs



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.)



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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


Introduction:

Paediatric nurses are often required to place intravenous (IV) lines in neonates and children as


paediatric nurses need to perform with precision and minimal discomfort to the children.


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


knowledge regarding cannulation. This method though effective, is more of an opportunistic



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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].




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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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.









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1. Assessment of knowledge using Multiple Choice Questions (MCQs) (Supplementary File 1),







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


and after the training.



steps performed.




students. The checklist was contextually modified and consensually validated among four

neonatologists and two senior nursing in-charge.




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Results:


Seventy nine (85%) nurses appeared for the pre training assessment followed by training. Four



month during the post-training assessment. Thus, 75(81%) nurses completed both the pre 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:


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)


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-


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7.91(1.11), p<0.001]. Significant proportion of participants exhibited IV cannulation


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



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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].


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.



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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


[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


training module for IV cannulation in paediatric nurses with a reasonable scientific rigor.






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.






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.)



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manuscript.



Legends:


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References:




Times 1999;95(25):48-9.




37.




1992;7(4):226-32.





ISBN 0443071764.


2002;32(9):46-8.



Med Educ 2006;40(11):1105-14. DOI:10.1111/j.1365-2929.2006.02612.x









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Res Notes 2015;8:636. doi: 10.1186/s13104-015-1623-9.



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.










2003;29(5):351-4.



2014;179(11):1361-7. doi: 10.7205/MILMED-D-13-00576.

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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]


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


Score

Mean(SD)

Skills

n(%) correct

Ward Posted

Paediatric wards:


(NICU)

5.82(1.40) 16(73)


(PICU)

5.11(1.05) 4(44)



Gynaecology ward 5.29(2.29) 5(29)


Special Bed Unit (SBU) 3.44(1.51) 3(33)

Education

General Nursing and Midwifery (GNM) 5.20(1.79) 27(44)


Midwifery (DGNM)

5.71(1.11) 3(43)


(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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(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)



30(38) 55(73)




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) was calculated for 75 participants who completed both the assessments.

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Steps Pre-Training

(N=79)

n(%) of

correct performance

Post-Training

(N=75)

n(%) of

correct performance


procedure 53(67) 70(93)

Checks identity of patient wrist band - (Hospital no.) 13(17) 29(39)


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)


blood in cannula seen) ^ 71(90) 75(100)


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)





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165x134mm (300 x 300 DPI)

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Name:

Sociodemographic:

Education:

Experience:

Income:

Appointment type:


ward













e) All of the above






e) All of the above


a) Up to 1 year

b) Up to 3 years

c) Up to 6 years

d) Up to 12 years


a) 5% dextrose

b) 0.9% NaCl

c) Distilled water


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a) True b) False



a) True b) False


a) Occlusion

b) Infiltration

c) Extravasation

d) Phlebitis

e) Infection

f) ALL





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.




Date Submitted by the Author: 27-Nov-2017







jpaedsopen.bmj.com

/bm


ecember 2017. D

ownloaded from



1









3.



Pin-388325


388325.


India. Pin-388325







Word Count: 2388

Reference Count: 19

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Abstract:


nursing. We evaluated simulation training on a manikin to improve cannulation skills.



single assessor using an OSCE checklist. Four steps were identified as critical. A score of



over a manikin was conducted. Post training assessment was done one week later.


for paired comparisons of knowledge and skill. The majority of the nurses were females, had



5.32(1.57), p<0.001]. A similar result was observed for total OSCE scores [9.22(0.66) vs



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.



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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


Introduction:

Paediatric nurses are often required to place intravenous (IV) lines in neonates and children as


paediatric nurses need to perform with precision and minimal discomfort to the children.


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


knowledge regarding cannulation. This method, though effective, is more of an opportunistic



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5






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].




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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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.









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1. Assessment of knowledge using Multiple Choice Questions (MCQs) (Supplementary File 1),







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


and after the training.



steps performed.




students. The checklist was contextually modified and consensually validated among four

neonatologists and two senior nursing in-charge.




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Results:


Seventy nine (85%) nurses appeared for the pre training assessment followed by training. Four



month during the post-training assessment. Thus, 75(81%) nurses completed both the pre 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:


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)


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-


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9

7.91(1.11), p<0.001]. A significant proportion of participants exhibited IV cannulation


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



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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].


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.





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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


[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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training module for IV cannulation in paediatric nurses with a reasonable scientific rigor.






real life situations.






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.)







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manuscript.



Legends:


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References:




Times 1999;95(25):48-9.




37.




1992;7(4):226-32.





ISBN 0443071764.


2002;32(9):46-8.



Med Educ 2006;40(11):1105-14. DOI:10.1111/j.1365-2929.2006.02612.x









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Res Notes 2015;8:636. doi: 10.1186/s13104-015-1623-9.



2010;33(4):226-35. doi: 10.1097/NAN.0b013e3181e3a0a8.










2003;29(5):351-4.



2014;179(11):1361-7. doi: 10.7205/MILMED-D-13-00576.

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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]


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


Score

Mean(SD)

Skills

n(%) correct

Ward Posted

Paediatric wards:


(NICU)

5.82(1.40) 16(73)


(PICU)

5.11(1.05) 4(44)



Gynaecology ward 5.29(2.29) 5(29)


Special Bed Unit (SBU) 3.44(1.51) 3(33)

Education

General Nursing and Midwifery (GNM) 5.20(1.79) 27(44)


Midwifery (DGNM)

5.71(1.11) 3(43)


(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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(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)



30(38) 55(73)




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)



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Steps Pre-Training

(N=79)

n(%) of

correct performance

Post-Training

(N=75)

n(%) of

correct performance


procedure 53(67) 70(93)

Checks identity of patient wrist band - (Hospital no.) 13(17) 29(39)


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)


blood in cannula seen) ^ 71(90) 75(100)


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)





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165x134mm (300 x 300 DPI)

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Name:

Sociodemographic:

Education:

Experience:

Income:

Appointment type:


ward













e) All of the above






e) All of the above


a) Up to 1 year

b) Up to 3 years

c) Up to 6 years

d) Up to 12 years


a) 5% dextrose

b) 0.9% NaCl

c) Distilled water


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a) True b) False



a) True b) False


a) Occlusion

b) Infiltration

c) Extravasation

d) Phlebitis

e) Infection

f) ALL





a) 1 hour

b) 3 hours

c) 4 hours

d) 6 hours

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