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Technical report
peer-reviewed

# The Development of an Intramuscular Injection Simulation for Nursing Students

### Abstract

Intramuscular (IM) injections are preferred over subcutaneous injections for administering medicine such as epinephrine and vaccines as the muscle tissue contains an increased vascular supply that provides ideal absorption of the drug being administered. However, administering an IM injection requires clinical judgment when choosing the injection site, understanding the relevant anatomy and physiology as well as the principles and techniques for administering an IM injection. Therefore, it is essential to learn and perform IM injections using injection simulators to practice the skill before administering to a real patient. Current IM injection simulators either favor realism at the expense of standardization or are expensive but do not provide a realistic experience. Therefore, it is imperative to develop an inexpensive but realistic intramuscular injection simulator that can be used to train nursing students so that they can be prepared for when they enter the clinical setting.

This technical report aims to provide an overview of the development of an inexpensive and realistic deltoid simulator geared to teach nursing students the skill of IM injections. After development, the IM simulators were tested and validated by practicing nurses. An 18-item survey was administered to the nurses, and results indicated positive feedback about the realism of the simulator, in comparison to previous models used, such as the Wallcur® PRACTI-Injecta Pads (Wallcur LLC, San Diego, CA). Feedback to improve the density of the simulator as well as the shape and size to make it a more realistic experience was provided.

### Introduction

Intramuscular (IM) injections are the preferred route of administration for medicine in clinical settings. This preference over subcutaneous injections, which is a drug administration route that is right below the dermis and epidermis layer, is due to the increased vascular supply that is available in muscle tissue, providing ideal absorption of the drug being administered [1]. There are challenges if IM injection misses the muscle and is not deposited in the fat, resulting in some or all of the medicine being wasted. Moreover, side effects can be swelling, redness, tingling or numbness, drainage at the injection site, prolonged bleeding if a blood vessel is pierced, and possibly some pain. Therefore, it is vital to utilize injection simulators to practice the skill away from the patient. Studies show that there is only a 32% to 52% success rate in performing IM injections, and the remaining unsuccessful administrations can result in adverse health and psychiatric effects on their patients. It has been shown that further education and training in the simulation of the IM injections can increase the success rate to 75% [1,2]. The use of an IM injection simulation to practice this skill will provide an immersive learning strategy to improve competency and confidence when performing this skill on an actual patient [3].

Currently, there are two types of simulators being used: animal and synthetics. Animal models are realistic, but there are issues with the ethics of using these: standardization, health, and safety. On the contrary, synthetic models are good alternatives; however, they are costly, often lack realism, and do not provide the variability that is often needed for learning [4]. With the advent of additive manufacturing, such as 3D printing, we are now able to design and build inexpensive, realistic, and variable synthetic simulators [5-8]. Developing inexpensive IM injection simulations directed to nursing students will allow the aspiring nurses to become well acquainted with the skill before entering the clinical setting. Furthermore, this will generate the confidence and proper technique to allow the best experience for the patient [9,10].

This technical report will provide an inexpensive and realistic simulation for nursing students to perform IM injections successfully. Currently, there is no technical report available describing the manufacturing process to develop an IM injection simulation that is simple yet provides a realistic outcome at a small cost. We aim to describe and share the development of a realistic, customizable, and inexpensive IM injection model, along with the assessment of the perceived realism and potential for use as an educational tool of the model. The outcome will be that the inexpensive and realistic IM simulation will provide nursing students with a tool that they can utilize to practice this necessary skill, so they are better prepared for when they enter the clinical setting.

### Technical Report

#### Context

The IM injection simulators were designed to be used as a training tool for pre-licensure nursing students and to train first responders. One could also consider this task trainer as a low-cost tool for the maintenance of skills for in-hospital nursing staff. Because the manufacturing is based on off-the-shelf supplies available in local stores and on-line (e.g., silicone), these simulators can be also used for injection skills development and upkeep in rural and remote areas.

#### Inputs

We have used the following materials to build the IM injection simulators: Jumbo cupcake trays, stirring sticks, mixing containers, Dragon SkinTM NV 10 (silicone base), SlackerTM (silicone softener), Silc-PigTM (color) (Smooth-On, Inc., Pennsylvania), absorption sponge, and Ease-Release spray.

#### Process

Construction of the Simulator

Jumbo cupcake trays with a diameter of 3.5 inches (89 mm) were used as our molds for the IM injection simulators. Smooth-On Dragon Skin™ 10 NV silicone and Silc-Pig™ neutral tones were used to create the thin dermis layer, using a 1-part A:1-part B mix ratio. It was set to cure for 75 minutes without a heat source but can be placed at a temperature of 75˚C-85˚C to allow for a 10-minute curing time. To create a less stiff fat layer, Smooth-On Dragon Skin™ 10 NV was used in addition to Slacker™, creating a ratio of 1-part A:1-part B:2-part slacker. This mixture was colored yellow using Silc-Pig™ and poured to fill approximately half of the cupcake trays. The addition of the slacker required a longer curing time of approximately four hours without the heat source and one hour with the heat source. A sponge cut to a 2.5 inch (63.5 mm) diameter was placed atop the fat layer to absorb the injected liquid. The muscle layer was created using 1-part A:1-part B:1-part slacker to generate a stiffer layer than the fat but not as stiff as the dermis layer. The muscle layer was colored red using Silc-Pig™ and poured to fill the remainder of the cupcake tray and cover the sponge. This step took approximately two hours to cure without the heat source and 45 minutes with the heat source. The heat source used was the Ultimaker S5 heated print bed set at 75˚C-85˚C. One-inch (25.4 mm) pieces of plastic straws were added to the muscle layer before it was left to cure so that when finished, the straw can be removed, leaving behind a drainage hole for the liquid that will be absorbed in the sponge. Once completely cured, each simulator was removed from the mold (Figure 1).

### Conclusions

Silicone IM injection models are a cost-effective and more realistic approach to aid in the education of nursing students. With the feedback, we can modify the model to create an even more realistic experience that will allow nursing students to get hands-on experience in IM injections to be better prepared when entering the clinical setting.

### References

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2. Boyd AE, DeFord LL, Mares JE, et al.: Improving the success rate of gluteal intramuscular injections. Pancreas. 2013, 42:878-82.
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4. Van Rossum JHA: Schmidt's schema theory: the empirical base of the variability of practice hypothesis: a critical analysis. Hum Mov Sci. 1990, 9:387-435. 10.1016/0167-9457(90)90010-B
5. DeZeeuw J, O'Regan NB, Goudie C, Organ M, Dubrowski A: Anatomical 3D-printed silicone prostate gland models and rectal examination task trainer for the training of medical residents and undergraduate medical students. Cureus. 2020, 12:e9020. 10.7759/cureus.9020
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7. Gallagher PO, Bishop N, Dubrowski A: Investigating the perceived efficacy of a silicone suturing task trainer using input from novice medical trainees. Cureus. 2020, 9:e6612. 10.7759/cureus.6612
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14. Shoulder IM pad mold. (2020). Accessed: November 21, 2020: https://www.thingiverse.com/thing:4661201.

Technical report
peer-reviewed

### Author Information

###### Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Interdisciplinary Committee on Ethics in Human Research (ICEHR) issued approval 20192928. The local research ethics board (ICEHR) has deemed this report as product development and assessment, not research. File number: 20192928. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Technical report
peer-reviewed

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