Effect Of Upper Lumber Massage On Relieving Pain Among Infants Undergoing Venipuncture

Background

Question:

Discuss about the Qualitative Research in Multicultural Psychology.

This report critically evaluates a research article from the ‘Pain Management Nursing’ Journal. The article published in this journal is likely to be considered significant because it is a peer reviewed journal focusing mainly on pain management and its application in nursing practice. It is published in many developing countries and as this journal mainly provides professional support in pain management, it is likely to give useful insight to nurse about the evidence based practice needed to manage infant pain during venipuncture. The article by Chik, Ip & Choi, (2016) is evaluated in this report and all the author are qualified in the field of nursing. Yuen-Man Chik has a RN, BSN in the field of pediatric and adolescent medicine, Wan-Yim Ip has work experience in the Faculty of Medicine in Nethersole School of Nursing and Kai-Chow Choi has BSC and PhD degree and work experience in Nethersole School of Nursing. All the author have work experience in Hongkong Nursing school and the research has also been conducted in Hongkong (Chik, Ip & Choi 2016). As all the author focus on improvement of nursing practice and Chik has experience in adolescent medicine, their research article is likely to support nurse in her decision regarding initiating massage as an intervention for pain management in neonatal care unit.

The research by Chik, Ip & Choi, (2016) aimed to investigate about the effect of upper lumber message on relieving pain among infants undergoing venipuncture. The importance of the research on this topic is understood from the background of the research which explains that venipuncture is often done in infants to mitigate the negative effects of pain, however the author pointed out the limitation in infant pain manage due to little knowledge about infant pain reactivity. This research became important because although it is an effect nonpharmacological approach to pain management, however very few research has been done to evaluate the effect of massage on pain relief in infants. The author particularly focussed on massage as a solution to pain relief by reviewing its efficacy by conducting literature review. The article presented adequate evidence to prove the therapeutic effect of pain in infants undergoing venipuncture. All the articles reviewed mainly gave the common result that massage was associated with lower pain score and heart level in intervention group compared to control group before going for heelstick. Despite the presence of evidence regarding therapeutic effect of massage, the significance of Chik, Ip & Choi, (2016) work is that it aimed to evaluate the effect of massage on relieving pain during venipuncture.

Research Design

The research also had links to nursing practice because venipuncture is mostly performed by nurses and so it is critical that they possess knowledge to manage pain in infants during such procedures. The responsibility of nurse in managing pain is also important because of the magnitude of pain response in children during hospital stay. For instance, literature review section showed that many physiological changes occur in infants due to procedural pain. This is also consistent with the research by Czarnecki et al., (2011) which suggested that non-pharmacological measures should be adapted by nurse to provide optimal comfort to patient during procedural pain. Although such procedure cannot be completely eliminated due to health needs of children, however nurse can enhance their practice by using non-pharmacological measure to reduce pain. Hence, in relevance with the research problem, the objective of the study was to assess pain response in infants and find out the impact of lumbar massage on reducing pain response in children undergoing venipuncture.

Considering the aim of the research, Chik, Ip & Choi, (2016) used the most appropriate research design of crossover double-blind, randomized controlled trial. As there was no evidence regarding the impact of massage on pain relief during venipuncture, hence this research focused mainly on evaluation a nursing intervention related to pain management. Hence, randomized controlled trial is the best study design for this purpose as it is specially designed to test a new treatment or intervention. In the research, Chik, Ip & Choi, (2016) enhanced the interpretability of research findings by taking two groups. The first massage group received upper limb massage intervention on the first occasion and usual care on the second occasion and vice versa in the 2^nd group. As each crossover patients act as their own control, they reduce the effect of confounding variables in the study (Hui, D., Zhukovsky, D. S., & Bruera, E. (2015). Hence, the threats or biasness in internal construct is minimized by the use of cross over RCT design. In addition, the process of randomly assigning infants to two groups with the use of random numbers minimized the likelihood of differential treatment of outcomes in research study (Karanicolas, Farrokhyar, & Bhandari, 2010).

The strength of any research evidence is also determined by the selection of appropriate sample for the study and the use of effective sampling technique to ensure that the target population is represented in the study (Ritchie, Lewis & Elam, 2013).. This consideration was met by Chik, Ip & Choi, (2016) as exclusion and inclusion criteria ensured that sample represented the target population. The research mainly aimed to manage pain in infants and the inclusion criteria defined the sample taken in detail. For example, the study included infants born at gestational age of 30 to 40 weeks, age within a week of birth and most importantly all must be requiring venipuncture for the detection of infection. To avoid getting anomalous results, children having central nervous system anomaly or those receiving intermuscular blocking agent before getting the intervention were excluded. This was important because due to the affect of intermuscular blocking agent, massage will not have an effect on infants. The crossover and randomized sampling design minimizes sample biases as the process of providing different treatment to each patient’s during different time intervals yields more efficient comparison of treatments than any other research design (Jones & Kenward, 2014). Parents of 91 infants were assessed for eligibility and the final sample size was 80. Adequate follow up regarding participants discontinuing intervention in between was also kept, however no power analysis was done by the researcher which is a drawback of the study.

Sample Selection

The review of the data collection section of the article showed that Chik, Ip & Choi, (2016) used video recording to observe the behavioural state of infant. Secondly, to define physiological state of children during pain, heart rate was recorded using electrocardiogram and oxygen saturation by using an infrared oximeter. The key strength of data collection process is that the researcher just not used these instruments to analyse pain response of infants but also considered way to enhance the data collection process. For example, electrocardiogram was connected with data acquisition system and all behavioural and physiological data were time synchronize to clear understand the impact both before and after the intervention. Secondly, the PIPP tool used for recording pain score was a good decision as research has proved it is the most reliable tool to assess acute pain both in pre term and term infants (Gibbins et al., 2014). This ensured that the procedure was high both on validity and reliability.

The strength of the research is also understood from the way intervention was provided to both groups. The randomization process with the use of number table ensured intervenation was equally distributed in two groups. Efficient reporting was also seen in the article as intervention and its method of delivery was effectively described. The fidelity of the intervention was maintained by recruiting experienced NICU nurse for conducting the upper limb massage. During the delivery of the intervention, treatment group received massage involving the technique of stroking, milking, rolling and gentle squeezing and then a physician performed venipuncture on the infant. On the other hand, the control group received no massage, just usual care by holding hand to facilitate venipuncture. In addition, biasness was minimize by covering the upper limb of each infants with quilt irrespective of control and intervention group. On the whole, the validity of research procedure is confirmed by the process of blinding, providing intervention and taking approval from local ethical committee. Adhering to ethical norms ensure that knowledge, truth and avoidance of error is promoted in research work and trust and fairness in maintained during research process (Ponterotto, 2013).

The strength of the research study is that powerful analytic method was used to analysed research data. For instance, the statistical analysis was performed using the IBM SPSS Statistics 22.0 and the benefits of using this statistical tool was that the software had the capability to enhance decision making and improve productivity through simulation modelling and augmented integration with other tools (IBM SPSS Statistics 22.0. (2017).  The level of significance in the study was set at 0.5 which means there was an effort to minimise type 1 error. In addition, descriptive statistics was used to present the data by calculating standard deviation and frequency. The researcher also considered about evaluating difference in pain score by the use of generalized estimating equations (GEE models). This reflects the statistical quality in the work was maintained and numerical data for outcomes as well as different in research outcome was presented (Mertler & Reinhart, 2016). 

Data Collection

Another strength of statistical analysis is that Chik, Ip & Choi, (2016) considered the effect size by quantifying the difference in outcome in two groups on the basis of regression coefficient. The regression coefficient helped to estimate the size of the difference and the main implication of such statistical analysis is that it is useful for quantifying the effectiveness of a particular intervention (Polit, 2013). Furthermore, two tailed test was used which implies that researcher was of the opinion that extreme portions of distribution in outcome (pain relief) could be seen. The final results from the study was that improvement in pain scores were seen on the first occasion after giving massage compared to without massage. The GEE statistical model further proved the effectiveness of the massage intervention by showing that pain scores significantly decreased in patient who received massage compared to control group. Hence, the purpose of research has been achieved and it is also consistent with the research study by (Zargham-Boroujeni, Elsagh & Mohammadizadeh, 2017) which suggested that massage and breastfeeding as a pain control measure for infant undergoing venipuncture due to its role in lowering pain in infants.

Conclusion:

The main conclusion from the critical appraisal of the article by Chik, Ip & Choi, (2016) is that the research is considered reliable in proving that upper limb massage reduces pan in infants due to venipuncture. The use of validated and reliable pain score tool PIPP enhanced the reliability of the results and the author concluded that massage as pain relieving measure during venipuncture should be considered in future. The only limitation is that type of massage was not standardized according to clinical practice and more research is needed in this area. Despite this limitation, the research article has useful implication for nursing practice because nurses often need to take blood samples of infants and avoiding venipuncture is not possible for them. Hence, nurse can use massage as a technique to provide comfort to infants during venipuncture

The above research on impact of upper limb massage can inform nursing practice and enable the nurse in the case study to take appropriate decision. According to the case scenario, the nurse working in a neonatal intensive care unit at a large tertiary care hospital was asked by the CNC to commence massage for venipuncture pain in infants. Hence, the most important step needed by nurse in this situation was to review evidence based research article on the intervention and then take decision regarding applying the intervention in clinical setting. While evaluating the research article by Chik, Ip & Choi, (2016), the first criteria for nurse would be to check whether patient value is preserved by the intervention or not. The research article gave the idea that massage can be easily used by nurse before venipuncture to minimize pain in infants.

Intervention and Procedure

Another advantage of massage is that it is an easy to use technique requiring no extra cost or equipments. Secondly, the patient value is also protected as it is not an invasive procedure and would cause no harm to patient (Field, 2014). However, the only consideration that a nurse requires before implementing it in clinical practice is that they need to develop the clinical expertise regarding the technique of massage by complete massage education.

The nurse can also be sure to use this in neonatal care by comparing the findings with other available evidence. The articles used in the literature review section of the article as well as the (Zargham-Boroujeni, Elsagh, & Mohammadizadeh, (2017) also proved that massage is a natural, useful and free intervention that can be easily used by the nurse. No expense regarding special facility or equipment is also required Hence, in the context of the case study, the nurse can commence this intervention after getting proper massage education from experienced nurses.

Reference

Chik, Y., Ip, W., & Choi, K. (2016). The effect of upper limb massage on infants’ venipuncture pain. Pain Management Nursing, 18(1), 50-57. https://dx.doi.org/10.1016/j.pmn.2016.10.001

Czarnecki, M. L., Turner, H. N., Collins, P. M., Doellman, D., Wrona, S., & Reynolds, J. (2011). Procedural pain management: A position statement with clinical practice recommendations. Pain Management Nursing, 12(2), 95-111.

Field, T. (2014). Massage therapy research review. Complementary therapies in clinical practice, 20(4), 224-229.

Gibbins, S., Stevens, B. J., Yamada, J., Dionne, K., Campbell-Yeo, M., Lee, G., … & Taddio, A. (2014). Validation of the premature infant pain profile-revised (PIPP-R). Early human development, 90(4), 189-193.

Hui, D., Zhukovsky, D. S., & Bruera, E. (2015). Which treatment is better? Ascertaining patient preferences with crossover randomized controlled trials. Journal of pain and symptom management, 49(3), 625-631.

IBM SPSS Statistics 22.0. (2017). IBM SPSS Statistics 22.0 Available for Download – United States. Www-01.ibm.com [online] Available at: https://www-01.ibm.com/support/docview.wss?uid=swg21646821 [Accessed 8 Oct. 2017].

Jones, B., & Kenward, M. G. (2014). Design and analysis of cross-over trials. CRC Press.

Karanicolas, P. J., Farrokhyar, F., & Bhandari, M. (2010). Blinding: Who, what, when, why, how?. Canadian journal of surgery, 53(5), 345.

Mertler, C. A., & Reinhart, R. V. (2016). Advanced and multivariate statistical methods: Practical application and interpretation. Routledge.

 Pain Management Nursing. (2017).  Painmanagementnursing.org.  [online] Available at: https://www.painmanagementnursing.org/ [Accessed 8 Oct. 2017].

Polit, D. F. (2013). Statistics and Data Analysis for Nursing Research: Pearson New International Edition: Do I Really Need This Stuff?. Pearson Higher Ed.

Ponterotto, J. G. (2013). Qualitative research in multicultural psychology: Philosophical underpinnings, popular approaches, and ethical considerations. Qualitative Psychology, 1, 19.

Ritchie, J., Lewis, J., & Elam, R. G. (2013). Selecting samples. Qualitative research practice: A guide for social science students and researchers, 111.

Zargham-Boroujeni, A., Elsagh, A., & Mohammadizadeh, M. (2017). The effects of massage and breastfeeding on response to venipuncture pain among hospitalized neonates. Iranian journal of nursing and midwifery research, 22(4), 308.