In the fields of health care and medicine, injections are commonly used in vaccination/immunization, prevention, and treatment. Injections require the use of needles; needles are an efficient and effective means of delivering medications and other fluids. Most patients do not find injections to be comfortable; many are afraid of needles. One of the criteria for “really good injections” is “holding trauma to an absolute minimum” (McConnell, 1982). Trauma can refer to physical trauma – such as wheals – or the emotional trauma of the needle.
With regard to the physical trauma of the needle, it may appear to the patient that it does not matter which way the needle is inserted; it will hurt regardless. However, nurses realize that it can matter. Needle tips are beveled, and whether the bevel is up or down can make a difference. The bevel of needles can vary with the use of the needle (McConnell, 1982). The purpose of the article “Intradermal Injections: Traditional Bevel Up Versus Bevel Down” is to examine whether having the bevel up or down makes a difference in several aspects of injection (Tarnow & King, 2004). There is not a problem statement for this article per se – at least not one explicitly stated – in the introduction. The purpose statement is also not explicitly stated either, though it appears in the abstract.
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The literature review of the article is barely adequate. For such an important and potentially problematic task, the authors did not include a lot of literature – simply several textbooks and one article that the authors describe in detail. That article seems weak, but the authors use it as a foundation for their study, with “tighter control and improved research methods” (Tarnow & King, 2004, p. 276). The authors state they were unable to find any other articles on intradermal injection, which this author finds hard to believe, considering the push for evidence-based practice. In fact, this author located two articles which discussed intradermal injections and mentioned bevel positioning (McConnell, 1996; McConnell, 1982).
No theoretical framework is offered in the methods section of the article. However, research questions are presented – four questions in fact, concerning (1) the difference in placement regarding bevel up versus bevel down for intradermal injections, (2) the difference in time to give the injection as influenced by bevel up versus bevel down, (3) the difference in comfort level of the person receiving the injection between up and down, and (4) the difference in comfort level of the person administering the injection between up and down (Tarnow & King, 2004).
These questions form the variables of the study. Demographic variables were not an issue, per se – the authors used students in their junior year of a baccalaureate nursing program at a public medical center campus enrolled in a beginning clinical nursing course “during which parental injections were taught” (Tarnow & King, 2004, p. 276). Four clinical nursing faculty members were also involved in the study in terms of student evaluation and data collection. The sample size is 98 students. The authors describe the research design as “case-companion” situation “whereby subjects served as their own control” – that is, each student both received and administered two injections, one with the bevel up and one with the bevel down (Tarnow & King, 2004, p. 276).
In terms of measurement methods, the authors used a mixed-methods approach – quantitative data took the forms of the placement of injection (wheal, leaking, and bleeding) and timing the length of injection, while qualitative data took the form of subjects reporting comfort levels from the viewpoints of receiving and giving. A tool was developed for the recording of injection placement elements and timing. The qualitative data was acquired using a Likert scale-based tool, which is appropriate for the acquisition of subjective information. These tools were also used in the process for data collection, which was done with the assistance of the nursing faculty. The students reported the comfort level information; the investigators recorded the quantitative data. Data analysis was conducted like so: interval data – the time it took to perform the injection – was calculated using SAS 8.02 and SPSS 11.0 software. Nominal data was calculated using McNemar chi-square binomial exact test. Ordinal data – the subjective comfort level information – was analyzed using variance to compare comfort ratings. These analyses led the researchers to conclude the bevel-up was preferred for the administration of injections. Results were equivalent in terms of patient outcomes regarding bevel-up and bevel-down.
The implications of the findings suggest patient and practitioner outcomes both matter in terms of injections. Time was tricky since it can hinge on proficiency, and the sample used students who would not be as proficient as a nurse with years of practice. But as the authors point out, there needs to be more research done focused on nursing procedures, including intrandermal techniques. The clinical significance of the findings focuses on both patient and practitioner outcomes – how injections are administered and received.
Suggestions for further study include time in the context of proficiency, larger and more varied sample sizes of administration/receiving, measuring the size of the wheal (as the study only focused on the presence of the wheal and nothing more), and simply more comparisons of up versus down.
The missing elements include explicit statements of research purpose and question within the article itself. These elements are in the abstract but are not included in the article. An explicit framework is also missing. Recommendations for this article would be a more meaningful introduction which discussed these elements and the motivation the authors themselves had, rather than just leaping off the weak article from the literature review.
