Simulated and Interactive Practice in Nursing

Introduction

Practicing medical procedures is a vital part of gaining experience as a nurse. In the past, practitioners have used cadavers, animals, and even living people to practice skills such as placing an IV or diagnosing an illness. In modern times, simulation bodies and interactive multimedia can help nurses gain the much-needed confidence he or she needs to begin practicing on patients.  

Simulated Practice

Inserting an emergency IV can be one of the most intimidating for the nurse and painful for the patient and can result in collapsed veins, pain, and loss of time. When a patient arrives, they are often in distress and may need an IV for many different reasons. For example, a patient experiencing severe blood loss may run the risk of fatally low blood pressure unless they receive an immediate blood transfusion supplied through an IV. Another patient may arrive with symptoms of dehydration and require an immediate saline IV to stop the side effects of organ damage or failure. Medication often must be administered quickly, to provide pain or symptom relief to a patient to minimize the suffering of an individual. Beginning an IV quickly and efficiently can be one of the most important skills for a nurse to learn through remediation and retention; however, it is often one of the most intimidating because it is generally the first real medical procedure student nurses are expected to do. Since it is so vitally important of a skill, confidence is essential to the patient’s and the nurse’s well-being. For nursing students who are not yet capable of placing an IV correctly, a simulation arm can be used. This is not meant to be used as a replacement for human practice, as many student nurses practice on each other to build the skill, but to be the first step to build confidence in placing an IV. 

Learning Objectives

1. Student will identify and place an IV within 12 seconds of starting placement

2. Students will assemble and prime the IV line correctly, before readying the area for puncture.

3. Student will angle the needle in a shallow insert at approximately 30 degrees and show proper catheter advancement, inserting the needle about 1 centimeter, the hand holding the needle not moving.

4. Student will complete the connection properly and check for rate of flow and remove tourniquet.

Simulation 

This simulation involves a Deluxe IV training arm from simulaids.com. The arm has a rubber-like texture that feels similar to skin and “blood” that runs through the arm. While the simulated arm won’t respond to pain in the way a human will, it will help students gain confidence in the practice of placing an IV. 

To practice the feeling of approaching a patient, the set-up of the arm should be in an area of the room that the students are not gathered, either on the ground or on a stretcher high table to help students get the feeling for different situations. Students should then approach the “patient” and immediately begin a visual and tactile search for the best vein to insert the IV, checking the antecubital, basilica and cephalic sites to decide the best placement. The proper sized cannula must be placed for patients receiving blood or are being prepped for surgical procedures so attention must be given to the size and age of the patient (How to Start IVs). Before placing the IV, the student must prime the IV line after removing it from the packaging. While holding the bag upside down, students will insert the cannula and hang it on the pole, the IV needs to be primed to remove an air bubble. 

If veins are difficult to identify or are recessed, a rubber tourniquet may be needed to access the vein. The best vein is a long and straight vein that feels firm to the touch. Sanitize the skin in the surrounding area once a vein has been identified and wipe with a sterile wipe. Students should then bring the needle close to the vein that will be punctured with the needle pointing downward to reduce pain and damage. Plunge needle at a 30-degree angle to avoid causing unnecessary trauma to the vein (Whitehead). After placing the IV correctly, students will check the connection and the rate of flow to ensure that patients are receiving their blood, solution, or medication. The student will then remove the tourniquet from the patient’s arm.

As students advance to higher levels of mastery, different obstacles can be presented; such as, high or low blood pressure, having two simulation arms available with one arm being the “better” choice, noise or commotion occurring in the same room, or even verbal responses to help students get used to the idea that often patients may make a noise when an IV is placed.

Multimedia Presentation

Making split second decisions when patients are in distress can be nerve-wracking and many nursing students “freeze up” when presented with choices in patient care. According to Evidence-Based Nursing, “nurses are expected to access, appraise, and incorporate research evidence into their professional judgment” (Introduction). To help student nurses anticipate the doctor’s and the patient’s needs, nurses need to evaluate the situation and decide what equipment or procedure is needed. For example, if a call comes in for a patient who is a victim of a car crash, there may be multiple possibilities for care or procedures. In the hypothetical, the patient 60 years old, overweight, is bleeding heavily and complaining of chest pain. The nurse can anticipate that the doctor may ask for an IV, bandages, a crash cart, or so on and gather the needed supplies before the patient has even arrived by ambulance (Fry, Johnston p.280). The extra few moments the nurse has removed from the process can be the difference between life and death for a patient. While there is no comparison to real-life decision making, creating a multi-media presentation that has different options for nurses to choose from would give them an exercise in decision making. In the early stages of training, the student nurses can collaborate in groups and discuss some of the cases, eventually cutting down the time and then moving to independent work where students must rely only on themselves. 

Student Objectives

1. Students will make decide a course of action for a patient in under 60 seconds.

2. Students will then decide what materials (IV, medication, crash cart, etc.) are needed in under 30 seconds from the deciding the course of action.

3. Students will work collaboratively, taking turns communicating to other students clear and direct orders. Each student must assign other students to a task in under 30 seconds from deciding the materials.

Multimedia Presentation

The presentation will include either written, auditory or visual cues such as a written order, mp3 clip or a picture of a patient in need of care. Each PowerPoint slide will present one of the above media and also have a timer on the slide to show nurses the amount of time left. While students may be slow at this at first, the pace of the timer should speed up with each practice, letting students work in groups at first and eventually independently to help them make decisions without input. For example, listening is an important part of understanding what a patient needs, so an mp3 clip can play a patient describing his or her condition and nurses have to decide what the possible treatments needed may be. 

After making decisions and taking notes on what the students think is needed, the next slide will allow them to make a comparison in what equipment or medication they “grabbed.” Reflection is an extremely important part of this exercise so students will need time, with the guidance of an experienced nurse and through ongoing professional development, so students can learn how to process information quickly and under stress while also making the decisions that are the best for the patient. 

The instructor plays a key part of the success of a multimedia presentation, since he or she can decide whether or not the solutions student nurses are providing are valid. At first, decision making may be difficult for students because they are learning the content and the skill but giving them training specifically in decision making can help them be successful in their program, and in their careers.

Conclusion

Experience, a wise man or woman once said, is the best teacher. However, since nursing students need support before they get the experience, simulation and interactive practice can be valuable for building confidence. Simulated bodies for physical practice or multi-sensory practices for cognitive practice can provided the needed scaffolding to medical experience.

References

Aston, L., Wakefield, J., & McGown, R. (2010). The student nurse guide to decision making in practice. Berkshire, England: Open University Press.

How to Start IVs: 8 Tips to Improve Your IV Success « PICC Nurse Blog. (n.d.).PICC, IV, Insertion, Phlebotomy training, classes, nurse education, certification, nurse consultants. Retrieved from http://piccresource.com/piccnurseblog/how-to-start-ivs-8-tips-to-improve-your-iv-success/

Nurses, information use, and clinical decision making—the real-world potential for evidence-based decisions in nursing -- Thompson et al. 7 (3): 68 -- Evidence-Based Nursing . (n.d.). Evidence-Based Nursing - BMJ Journals. Retrieved from http://ebn.bmj.com/content/7/3/68.full

Whitehead, S. (n.d.). Six techniques to nail the IV every time. The EMT Spot. Retrieved from theemtspot.com/2009/08/04/six-techniques-to-nail-the-iv-every-time/