Dry versus moist heat application for peripheral IV catheter insertion success

¶ … dry versus moist heat on peripheral IV catheter insertion in a hematology-oncology outpatient population.

Fink, Regina M, RN, Phd, A.O.C.N., F.A.A.N., Hjort, Ellen, R.N., N.D., Wenger, Barbara, RN, M.S., O.C.N., Cook, P. F., Phd., Cunningham, Mary, RN, B.S.N., O.C.N., Orf, Aimee, RN, B.S.N., O.C.N.,... Zwink, Jennifer, RN, B.S.N., O.C.N. (2009).

Oncology Nursing Forum, 36(4), E198-204. Retrieved from http://search.proquest.com/docview/223114041?accountid=35812

You must submit the full article in PDF form. Critiques submitted without the PDF will not be accepted.

What is the problem the study was conducted to research? (3)

Response: The problem was centered on the objective. The objective was to see if improvement came from dry versus moist heat application with regards to a patient\'s arm and IV catheter insertion. The dry versus moist heat application would last seven minutes and be measured for efficacy. The objective highlighted the issue with peripheral IV catheter insertion and general IV insertion. IV insertion is a frequently seen nursing practice involved in several areas of healthcare such as antibiotics, chemotherapy, and other medical procedures involving patients with cancer and must be managed and implemented in a manner that reduces insertion time and insertion attempts.

Why is the problem an important one for nursing to research? (3)

Response: Because IV insertion is a common nursing practice, it is important to understand which way is the most effective. Many times nurses are unsuccessful on the first attempt. Sometimes it may take several attempts. This causes discomfort for the patient and results in time wasted for both the nurse and the patient. If heat improves the insertion rate, it is worth identifying which method works best.

Study Purpose

What is the purpose of the study? (2)

Response: The purpose/objective of the study is to determine which method of heat application works best: dry or moist. The heat application relates to improving the success rate of IV insertion. Researchers also wanted to test the effectiveness heat application had in improving the feasibility, safety, acceptability, and comfort of IV insertion.

Research Question

What is the main research question? (4)

Response: The main research question is varied. However, it focuses on whether dry or moist heat application aids in improving IV insertion rates. They set the time limit for the heat application for seven minutes and measured outcomes on randomly assigned patients for dry and moist heat application. Successful outcomes were determined by insertion attempts and insertion time. They also monitored how heat application made the patients feel in regards to accepting IV insertion.

Hypothesis/hypotheses

What is the study hypothesis? If it is not stated, what would you say the hypothesis is? (4)

Response: The research question and objective did not have a preference over dry or moist heat application. Nevertheless, the study seemed to lean more towards moist heat application as seen in the literature review with the burns patients received in previous studies from dry heat application thanks to microwavable hot packs. Furthermore, the study stated almost 100%of the infusion nurses had assumptions that moist heat would be the best mode over dry heat application. Therefore, the hypothesis is moist heat application would be the best mode for promoting successful IV insertion.

Study Variables

Identify and describe the major study variables. Identify the study variables by examining the purpose, the objectives, questions, or hypotheses, and the results section of the research article.

INDEPENDENT

Define the meaning of the term \"independent variable\" (1)

Response: An independent variable means a variable that is not altered by other variables and stands alone. A good example of an independent variable is a person\'s age.

Identify the independent variables in this study and provided a definition of the variable (1)

Response: The independent variables are age, gender, weight, and race. The study noted the average patient was 59 years old, male, and Caucasian with a weight of 170.

How is the independent variable carried out in this study? (1)

Response: The researchers analyzed the effect of independent variables using ANCOVA or analysis of covariance. They wanted to see if age, and weight specifically, affected dependent variables such as insertion rate.

DEPENDENT

Define the meaning of the term \"dependent variable\" (1)

Response: A dependent variable means a variable that depends on other factors. An excellent example of a dependent variable is a test score. Test scores change based on how much a person studies, to how well a person is at taking tests.

Identify the dependent variables in this study and provide a definition of the variable (1)

Response: Dependent variables were patient anxiety, insertion time, and number of IV insertion attempts. Insertion time also included prewarming and postwarming vein status.

How is the dependent variable MEASURED in this study? (1)

Response: They input the data collected during the study of the dependent variables into SPSS version 16 software. They used descriptive statistics to analyze the information and tested group equivalence using chi-square and t tests.

Conceptual Model/Theoretical Framework -- This is determined in the literature review... it does not refer to the methodology.

Is the framework explicitly expressed or must the reviewer extract the framework from implicit statements in the literature review? JUSTIFY your response!(1)

Response: The framework is explicitly expressed because the literature review initially begun with investigation of which methods facilitated successful IV starts and minimized anxiety and pain, as well as improved patient comfort. It then moved on to moist and dry heat applications and a final conclusion of lack of literature declaring the most effective option.

Is the framework based on scientific, substantive, or tentative theory? (1)

Response: It is tentative because it starts to build based on certain propositions. For example, the hypothesis of whether or not moist/dry heat application is more effective can only have a conclusion based on results. Therefore, it is tentative.

Does the framework identify, define, and describe relationships among the concepts of interest? Provide examples and rationale for your response. (1)

Response: The framework identifies the need for effective methods that improve IV insertion rates and what moist and dry heat applications have been used in the past. For example, placing an arm in warm water and microwaving chemical warm packs. These are moist and dry heat applications respectively.

How is the framework related to the body of knowledge in nursing? (1)

Response: It shows the desire to implement through use of best practices, an effective strategy that will not only improve the rate of a commonly performed procedure, but will also improve the quality of care a patient receives.

Review of the Related Literature

Are the articles relevant with previous studies and theories described? (2)

Response: The articles are relevant because they directly answer the question of if heat application is helpful in improving comfort for patients as well as what dry and moist heat application methods have been implemented thus far. There was some variation however, when discussing topical skin coolants as this went on a different direction then the hypothesis and problem discussed in the study. They also began discussing analgesic use for IV insertion, having noted prospective studies and continued controversy over \"which local anesthetic injected intradermally provided optimal analgesia for IV insertion\" (Fink et al., 2009, p. E199).

Are the references current? Identify the number of sources within past 10 years and the number of sources within past five years. (2)

Response: The researchers performed the study in 2009. Most of the references were current for that time with the exception of 6 articles from 1976, 1987, 1993, 1998 and 1997. 23 articles were within the 10-year timeframe. 17 articles were within the 5-year timeframe.

Describe the current knowledge about the research problem. (2)

Response: The literature review provided information on ways medical professionals have attempted to improve IV insertion rates. Although heat application is a commonly used method, the practice is often not based on evidence. What information is available is on intradermal inject to improve IV insertion, nursing factors that improve IV insertion rates (self-positioning, specialized certification, and years of experience), and actual moist and dry heat applications.

Specify the gap in the literature that justifies the need for the research. (2)

Response:

The gap in the literature comes from little evidence pointing to the effectiveness of heat application to improve IV insertion rates as well as which mode of heat application works best. They noted that although dry heat application appears less complicated and less expensive, microwaveable hot packs (for example) can cause serious second and third degree burns from deep penetration as well as uneven heating.

Study METHODOLOGY

NAME the specific quantitative methodology of the study. (2)

Response: The quantitative methodology used for the study was experimental because patients were measured before and after heat application and IV insertion for comfort, as well as during the process in relation to number of IV insertions and time taken to perform a successful IV catheter insertion.

Provide a clear description/definition of this methodology (in your own words); use an article or your text to support the definition and provide a citation. (2)

Response: The experimental quantitative study utilized a two-group, randomized controlled design to study heat application effectiveness in relation to dry or moist heat application. One study searched for randomized controlled studies in order to see the effectiveness of nonpharmalogical treatments for ADHD. \"The authors undertook meta-analyses of the efficacy of dietary (restricted elimination diets, artificial food color exclusions, and free fatty acid supplementation) and psychological (cognitive training, neurofeedback, and behavioral interventions) ADHD treatments\" (Sonuga-Barke et al., 2013, p. 275). By using a randomized controlled trial, the study washes away population bias, analysis can be performed with widely accepted statistical tools, and it is easier to mask versus observational studies. This kind of design has the only anticipated difference among the experimental and control groups.

Why was the choice of this methodology appropriate for this study? JUSTIFY YOUR RESPONSE. (2)

Response: It was appropriate because they needed more than one group in order to test both methods. Without an additional group to compare results, they would not derive a definite conclusion as to which method was better. Furthermore, making it controlled and randomized allotted to test specifically for efficacy not relation, which is typically seen in qualitative research studies. They needed to measure before, during, and after, which can only be done using the experimental quantitative methodology.

Sample and Setting

Identify inclusion and exclusion sample criteria. (1)

Response:

Participants had to be hematologic outpatients that experienced cancer or other malignancies to be included. Anyone without those conditions were excluded.

Indicate the method used to obtain the sample. Provide a definition of the method and discuss why it was an appropriate choice for this study (1)

Response:

Researchers used variance analysis. Variance analysis is the quantitative examination of the difference between planned and actual behavior. This choice was appropriate because expectations are different than executions.

State the sample size. Indicate if a power analysis was conducted to determine the sample size. (1)

Response:

Power analysis was conducted using t-tests and the sample size also accounted for attrition. The power analysis revealed 128 for sample size. Take into account attrition, the sample size grew to 136.

Identify the SPECIFIC characteristics of the sample. (1)

Response: The patients were hematologic patients with cancer that nurses need frequent IV access to.

Identify the sample mortality (or attrition) number and percentage. (1)

Response: There was no mortality number but the total number of patients that participated in the study 136. However the attrition number was 8 additional participants added.

Indicate the type of consent obtained and institutional review board approval. (1)

Response:

Researchers told through an oncology nurse, potential participants about the study and offered them a brochure asking whether they wanted to be communicated by an investigator to educate themselves more about the project. The study did not specify what type of consent was needed and instead said after getting the participants\' consent they proceeded with the study.

Identify the study setting and indicate if it is appropriate for the study purpose. JUSTIFY YOUR RESPONSE! (1)

Response: It was a clinical setting within an academic infusion center. The appropriateness is low because of the business of the location and the often high patient to nurse ratios making participant selection difficult.

Identification and Control of Extraneous Variables

Define extraneous variables (1)

Response: Extraneous variables are unwanted variables that have an influential effect on the relationship between variables a researcher examines. Although they are not variables of interest, they still impact outcomes (Jalota, Radke, Kalira, Shi, & Apfel, 2010).

What are the extraneous variables in this study? In what way(s) were appropriate measures used to control for the influence of the extraneous variables? Describe fully. If not addressed, explain how you know this and identify the extraneous variables you would note. (1)

Response: Patient anxiety appeared to not have an important impact on which mode was most useful, however, it appeared to have an impact on IV insertion success rate. What did play a role was patient comfort which showed higher VAS scores for dry heat.

Study Instruments/Tools

Identify the instruments used in the research (2)

Response: The researchers used a VAS or visual analog scale to assess patient\'s pre and post anxiety levels. They also used a Mon-a-Therm 4070 temperature monitoring system to observe room, baseline, as well as postheating forearm/hand skin temperatures. They also used an interval numeric rating scale and reliable scale.

FOR EACH INSTRUMENT: (5)

Instrument #1; Name of Instrument:

Discuss how the instrument was developed or purpose of use. Cite the source for the background information about the instrument.

Response: Mon-a-Therm 4070 temperature monitoring system to observe room, baseline, as well as post heating forearm/hand skin temperatures

Identify the type of measurement strategy (i.e. Likert scale, visual analog scale, physiological Measure, questionnaire, observation, or interview).

Response: VAS stands for visual analog scale and was used in order to assess anxiety as is used for other studies (Abend, Dan, Maoz, Raz, & Bar-Haim, 2014).

Identify the level of measurement (nominal, ordinal, interval/ratio) achieved by the measurement strategy. Provide a definition of the level of measurement(s) you identified and justify WHY you believe the instruments represent this level of measurement.

Response: Ordinal because of the simplicity of the response input. Ordinal scales measure non-numeric concepts such as discomfort, satisfaction and so forth (Kerzner, 2009).

Data Collection Methods

Detail how the data were collected. (2)

Response: two groups were randomly assigned via the use of compter-generated codes, the se of moist or dry heat application methods for 7 minutes. They used a stopwatch to measure the time for each application and measured anxiety levels preinsertion and post insertion. They also measured skin temperature heating differences. They collected information also from questionnaires all RNs had to complete in the cancer infusion center.

In what way(s) is the data collection procedures appropriate for this study? (2)

Response: The scales and the questionnaire allowed for proper data collection. The scales measured the comfort and anxiety levels of the participants. The questionnaires gathered impressions and potential markers for better insertion rates among the RNs.

In what way were appropriate steps taken to protect the rights of the subjects? (2)

Response: Participants were given the option to join or not. Their names were not used as part of the study, only things like age, weight, gender, and race. They were also assigned randomly to each group. This enabled greater ability to focus on the observations and not on the participants.

Statistical Analysis Procedures

Identify the statistical procedures used in the study: (6)

Statistical Procedure #1 ( Name and definition):

Response: Power analysis is used to calculate minimum sample size requirements (Ching, Huang, & Garmire, 2014).

How was it used in the study?

Response: It was used to determine the sample size.

Statistical Procedure #2 ( Name and definition):

Response: Descriptive statistics are brief descriptive coefficients summarizing any given data set and are broken down into measures of variability, spread and central tendency (Bickel & Lehmann, 2012).

How was it used in the study?

Response: The study used it to display demographics including outcome variables of interest.

Statistical Procedure #3 ( Name and definition):

Response: ANCOVA is a kind of ANOVA used as control for possible confounding variables.

How was it used in the study?

Response: The study used ANCOVA in order to determine effect of independent variables in relation to pre and postinsertion anxiety.

Complete the table below with the analysis techniques conducted in the study: (4)

Statistical Procedure

Statistical Findings

Significance (provide a narrative description of the significance as well as the actual statistical values

T-Tests

Power Analysis (ability to locate a moderate effect size) determined the necessary sample size of 128 in order to discover any differences among groups.

d- 0.9, power of 0.8, family-wise alpha set at 0.05.

The test helped set the number of absolutely necessary participants and provided a figure higher to account for attrition.

ANCOVA

In relation to patient-reported anxiety, no major difference was discovered among heat modalities or among nurses on post-insertion patient-reported anxiety scores. The overall decline of anxiety post insertion from preinsertion was 2.7 times more probably to result in first attempt successful IV insertion.

It highlighted the anxiety of patients and how it can play a factor in successful IV insertion attempts.

Reliability and Visual Analog Scales

Mean VAS scores were 94. For dry heat, 89 for moist heat. Reliability scales showed F=128 and p=0.285.

This provided the basis from which to assess patient comfort levels and see if either dry heat or moist heat application made a difference.

What are the specific results of the study? Provide DEPTH and write IN YOUR OWN WORDS. (4)

Response:

StrengthsLimitations

What are two major strengths of the scientific merit of this study? (This does not refer to findings of the study) (2)

Response: The first strength was the ability to clarify and suggest which heat application was best. By discovering dry heat application was not only more cost-effective, but also easier to administer, this further added to the conclusion that dry heat application is best. Another important strength of the study was noting no differences between either heat application method and patient-reported anxiety. This shows either method can be used, however, the dry heat application will result in faster IV insertion times and reduced error overall.