Therapeutic opportunities when using vapocoolants for intravenous cannulation of children. The application of Nursing Therapeutics
Cliff Richardson1. RN, BSc (Hons), MSc, PhD
Elizabeth Ovens2. BA (Hons), BNurs (Hons)
1. Senior Lecturer. University of Manchester
2. Staff Nurse, Stepping Hill Hospital, Stockport.
Corresponding author
Cliff Richardson
Senior Lecturer
School of nursing, midwifery and social work
University of Manchester
Jean McFarlane Building
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Abstract
How nurses make a difference and influence outcome has been the subject of much debate over many years and is perhaps more relevant now due to health care funding being a scarce commodity. Nurses need justification and validation of what they do. Nursing therapeutics is a relatively new term that can help nurses and others to appreciate the multifariousness, complexity and value of what we do. It encapsulates the means by which a nurse delivers care that is both evidence-based and beneficial to their patients. This paper will spotlight how nurses can utilise common nursing interventions to ensure that the full impact of their skills is embedded into their care using the administration of vapocoolants as the focus. It will be illustrated that through each patient contact a nurse can establish therapeutic principles which can positively influence health outcomes.
Key phrases
Therapeutic relationship
Nursing therapeutics
Procedural pain
Nursing as a therapy
Nursing interventions
The 6C’s
Keywords
Nursing
Pain
Vapocoolants
Care
Compassion
Background
Modern health services require justification of all care in order to ensure positive effects on patient outcome. Whilst nurses deliver a complex range of diverse interventions and skills often contemporaneously within a highly pressured environment, there is not always strong empirical evidence to support these activities. Following some high profile break downs in care in the UK (Francis, 2013), there has been renewed focus on how to instil care and compassion into nursing via the Chief Nurse’s 6C’s initiative (DH, 2012). The 6C’s are care, compassion, communication, commitment, competence and courage and when utilised these are believed to enhance nursing care (DH, 2012). Using the principles of ‘Nursing therapeutics’ (Richardson et al., 2015), this article will explore how nurses can justify the use of time to show care, compassion and empathy whilst delivering effective care. The use of vapocoolants for venepuncture/cannulation in children will be used as an exemplar.
Nursing therapeutics is a term recently coined which combines the use of empirical evidence with day to day routine nursing tasks in order to identify the key elements of patient benefit (Richardson et al., 2015). In order to comprehensively cover all elements of this intricate subject there is a need to sequentially discuss the topics which in practice are delivered contemporaneously. Our presumption is that a skilled nurse simultaneously undertakes a nursing intervention and embeds care, compassion and empathy to enable the development of a therapeutic relationship. Therapeutic relationships have been identified to improve patient outcomes (Hewitt and Coffey, 2005, Canning et al., 2007, Lima-Basto et al., 2010), hence the nurse is able to act as a therapeutic instrument through nursing therapeutics if they have utilised evidenced based care alongside a full appreciation of how to develop a therapeutic relationship. The starting point is the therapeutic relationship which will be reviewed first, followed by an appreciation of the evidence underpinning the nursing intervention chosen, in this case the use of vapocoolants for venepuncture/cannulation. The final section will combine the evidence from both and explore how the nurse maximises the therapeutic opportunities.
Therapeutic relationships
Although Carl Rogers discussed therapeutic relationships in terms of psychotherapy his idea of holding an ‘unconditional positive regard’ for the patients (Rogers, 1951) could be a nurses starting point and would enable them to make the values of therapeutic relationships integral to everything they do in practice. A nursing therapeutic relationship therefore results from nurse-patient interaction and encompasses concepts that are traditionally linked to nursing, such as but not exclusive to; care, compassion, empathy, mutual understanding, trust and confidentiality (Brown Wilson, 2009, McCance et al., 2009, Snell et al., 2010, Porr et al., 2012). Whilst these nursing attributes are often considered laudable there is some evidence that suggests that developing a therapeutic relationship based on them improves outcome and accelerates recovery (Hewitt and Coffey, 2005, Canning et al., 2007, Lima-Basto et al., 2010). One useful model for building therapeutic relationships that could be adopted more widely by nurses was constructed by Muetzel and includes three overlapping concepts, partnership, intimacy and reciprocity (Muetzel, 1988).
Muetzel’s Model (1988)
Although Muetzel’s model has not been utilised widely, the three core elements are extensively discussed within nursing literature making it a valid model for nurses to consider using in their day to day practice (Richardson et al., 2015). Partnership is a two way process between the patient and the nurse where decision-making is shared and there is mutual recognition of each other’s knowledge, feelings, expertise, congruence and trust (McCloughen et al., 2011, Welch, 2005, Scanlon, 2006). Intimacy is where the nurse creates a presence, making the patient feel special (Zyblock, 2010). Befriending and showing a sincere concern through care, compassion and openness drives the connections between nurse and client/patient (Shattell et al., 2007). Interestingly in a large grounded theory interview study (n=145) of day-case patients, it was found that despite limited contact time, skilled nurses implanted elements of intimacy which enhanced the partnership and stayed with the patient even after they left the unit (Mottram, 2009). Reciprocity is the concept where both partners accept that there will be benefit. To develop functional therapeutic relationships nurses need to recognise that benefits accrue from caring for their patient (Shattell et al., 2007, Brown Wilson, 2009, Scanlon, 2006, Williams, 2001).
The three elements of Muetzel’s model are closely aligned with the 6C’s (DH, 2012). Using them both in conjunction to orchestrate therapeutic relationships should provide a strong framework for nursing care with a foundation to advance practise.
It is interesting that unlike the psychotherapist view of therapeutic relationship purported by Carl Rogers, nurses appear to generate their therapeutic relationship alongside the delivery of other interventions. For instance Mottram’s day case surgery nurses utilised their short time with the patient to admit them to the ward area whilst contemperaneously instilling therapeutic principles which stayed with the patients throughout their post-operative period (Mottram, 2009). This means that a highly skilled nurse would make every contact count as a therapeutic opportunity (MECC, 2015), for example though good pain management in children.
Effective management of procedural pain can positively influence the experiences of a child’s time in hospital and reduce the anxiety and discomfort associated with essential procedures such as venepuncture, immunisations and intravenous cannulation (Cohen Reis and Holubkov, 1997, Noel et al., 2012). Children, aged 4 to 11 years old, have described pain associated with needle procedures as the worst pain experienced in hospital (Kortesluoma et al., 2008). Effective and efficient nursing management of the pain associated with these procedures will enable the development of a therapeutic relationship and enhance the potential that the nurse has an influence on invasive procedures, other nursing interventions and ultimately, recovery (Hiley and Watson, 2007, Mattsson et al., 2013).
Children’s nurses regularly undertake or assist in painful procedures and the following sections will explore how they may maximise their therapeutic influence during such interventions utilising the use of vapocoolants prior to venepuncture/cannulation as an example.
Analgesia for venepuncture/cannulation; the case for topical vapocoolants?
One crucial element of nursing therapeutics is an understanding of the evidence behind the nursing intervention during which the nurse institutes the principles of the therapeutic relationship. This section therefore focuses on the evidence for analgesia for venepuncture/cannulation. Topical anaesthetics such as Ametop® and EMLA® have a strong evidence base for their effectiveness in reducing pain and are the most widely used topical anaesthetics for intravenous cannulation (Foster et al., 2013). Ethyl chloride and other vapocoolant sprays have decreased in popularity in recent years however they have an added advantage over the topical anaesthetics in that they are cheaper and the onset of pain relief is quicker (Soueid and Richard, 2007).
In a randomised, prospective study of 9-18 year old patients attending an emergency department (n=95) vapocoolant spray was compared with topical ice pack for analgesia for intravenous cannulation (Waterhouse et al., 2013). Pain scores between the groups were similar however vapocoolants were rated by the child to have ‘worked well’ in a larger percentage of cases (76% v 49%). A double-blind randomised controlled trial (n=80) comparing vapocoolant with placebo for venepuncture in an emergency department identified a significant reduction in pain (mean difference 19mm; 95% CI 6-32mm; p<0.01) when using vapocoolant in children aged 6-12 years (Farion et al., 2008). Successful first attempt at cannulation was also significantly better than the placebo group (85% v 62.5%; mean difference 22.5%; 95% CI 3.2-39.9%; p=0.03). The effects of ethyl chloride was compared with Ametop or no analgesia in a non-randomised prospective study (n=55) of children aged 6 months to 16 years attending an outpatient phlebotomy department (Soueid and Richard, 2007). No differences were identified between the vapocoolant and the Ametop groups suggesting equal effectiveness agreeing with the findings of another randomised non-inferiority cross-over trial (n=77) comparing ethyl chloride and Ametop in children aged 5-13 (Davies and Molloy, 2006).
Overall therefore as long as vapocoolants are administered correctly (Mawhorter et al., 2004) and the initial cold shock is mitigated against (Davies and Molloy, 2006), they give equivalent analgesia to Ametop and better analgesia than placebo in children. As the current studies have included few children under 4 years it is reasonable to suggest caution in this age group. It is likely that using a vapocoolant also facilitates a larger percentage of first attempt venepuncture but perhaps the main advantage of using a vapocoolant spray instead of a local anaesthetic is the short time it takes for onset of the pain relieving effects (see table 1). A reduction in time between the introduction of the need for venepuncture or intravenous cannulation and performing the intervention could reduce anxiety and the concomitant algesic effects of that anxiety.
Table 1. Time to analgesic effect of commonly used treatments for intravenous cannulation
Alternative pain reducing treatments / Preparation time to reach full effectCryogesic® (ethyl chloride vapocoolant spray) / <15 seconds
Nitrous Oxide / <1 minute
Buzzy® (ice/vibration therapy) / 2 minutes
Ametop Gel® (Tetracaine) / 30-45 minutes
EMLA Cream® (lidocaine/prilocaine) / 45-60 minutes
Adapted from (Twycross et al., 2013)
Therapeutic Relationship building when administering vapocoolants
Having established that vapocoolants have sufficient efficacy to recommend their use in practice the nurse can now create the conditions to augment the circumstances required to develop a therapeutic relationship whilst administering them. This can be achieved by applying Muetzel’s model and being mindful of the 6C’s whilst undertaking this nursing intervention. As we are applying the principles of nursing therapeutics to this specific intervention it is inevitable that there are fewer opportunities to substantiate our arguments within this section, however whenever we are able we have related our arguments to the wider literature.
Partnership
Utilising an unconditional positive regard approach the nurse will construct a partnership as soon as they meet the child and family for the first time. It is likely therefore that the partnership is developed prior to the requirement to perform interventions including those that are painful such as venepuncture/cannulation (Bidmead and Cowley, 2005). Knowing and understanding the child and family is pivotal and facilitates the provision of care associated with essential interventions which can be uncomfortable (Hill and Coyne, 2012, Mattsson et al., 2013, Jackson, 2010). Empathy is shown by allowing the child and family to discuss their feelings about the overall care plan and this will give the nurse insight into how they may react to venepuncture/cannulation (Hiley and Watson, 2007, Caws and Pfund, 1999). Continuing the discussion about the venepuncture/cannulation procedure and the analgesic method becomes an essential element of communication within the partnership. The nurse can offer information and advice to the child and family whilst the child and family can express their concerns and knowledge of what they think is best for them (Caws and Pfund, 1999). Explanation of the procedure and consent often causes anxiety which could be magnified if there is delay of 45 minutes before a local anaesthetic is effective. The nurse must acknowledge any fear, anxiety and worry with genuine understanding but be cognisant of the fact that delay may lead to rumination on the procedure and risks the development of negative thoughts towards the nurse (Vervoort et al., 2013, Noel et al., 2015). This could damage the potential to develop a functioning partnership and inevitably reduces the chances for creating a therapeutic relationship. The immediate effect of vapocoolants enables a quick response once consent is gained and minimises fear associated with the needle procedure. This enhances the potential of a functioning partnership after the cannulation which can be further developed and utilised if other invasive interventions are required.
Intimacy
Intimacy is established initially through nurse presence with the child and family (Watson, 1999, Finfgeld-Connett, 2006). Routine procedures such as completing admission paperwork are ideal vehicles for developing intimacy. Proximity by being present is one way for a nurse to advance intimacy and alongside communicating with the child and family, the committed nurse progresses smoothly towards a level of intimacy which facilitates invasive intervention such as venepuncture/cannulation (Fredriksson, 1999). Vapocoolant spray is applied to the skin, and cannulation requires physical touch. Both are therefore intimate procedures that would be better enabled if the nurse has nurtured a partnership and accounted for intimacy. Additionally the nurse or family can also utilise a form of therapeutic touch during the procedure to have a calming anxiolytic effect (Trigg and Mohammed, 2010). Showing compassion through concern, consideration and care for the child undergoing cannulation will further build intimacy which will be useful for future procedures of a similar kind.
Reciprocity
Reciprocity is linked to professionalization, increased self-confidence and quality improvement (Meier, 2013). Following successful pain-free cannulation the nurse gets rewarded with a feeling of warmth and the appreciation that their role has been effective in relieving a potentially stressful and painful episode for the child. This will inevitably improve the partnership between the nurse, child and family with the bond being essential for holistic care (Sherwood, 2000). The confirmation of the effects of their actions should encourage the nurse to have the courage to utilise their time to focus on the individual components of future therapeutic relationships as it is known that enhancing reciprocity by improving the balance between effort and reward is one aspect crucial to the retention of nurses (Li et al., 2013). To this end the nurse will begin to exploit all nursing contacts and become competent in influencing care trajectory and potentially having a significant effect on recovery.