an exploration of the efficacy of ... - king's college london · dr emma ream, senior lecturer...

Dr Emma Ream, Senior LecturerKing’s College London

Ms Catherine Oakley, Lead Cancer Nurse,Princess Royal University Hospital

Ms Jibby Medina, Research Associate.King’s College London

Professor Alison Richardson, Professor of Cancer &Palliative Nursing Care. King’s College London

AN EXPLORATION OF THE EFFICACYOF ARM MASSAGE IN FACILITATINGINTRAVENOUS CANNULATION FORADMINISTRATION OF CYTOTOXICCHEMOTHERAPY

Final Report November 2004

Exploration of the Efficacy of Arm massage 1

Acknowledgements

This study was supported by a European Oncology Nursing Society (EONS) – Roche

Research Award.

We thank the nurses, massage therapists and patients that took part in this study for their

contribution. Without their invaluable collaboration this research project would not have

been performed. In particular the research team would like to recognise the contributions

made by Dee Bryan, Bettina Donkin and Helen Hannon in the conduct of this work.

This report should be referenced as: Ream E, Oakley C, Medina J, Richardson A (2004)

An exploration of the efficacy of arm massage in facilitating intravenous cannulation for

administration of cytotoxic chemotherapy. King’s College London


Abstract

Purpose: The purpose of this exploratory study was to examine the outcomes of providing

massage to patients on a Chemotherapy Day Unit, prior to administration of

chemotherapy.

Multi-method design: Prospective, randomised controlled trial, interviews, focus group

Setting: Chemotherapy Day Unit within a cancer unit in South East England

Samples:

• 52 patients; 68% female. Aged 24-79 years (mean = 59yrs) with breast (50%),

colorectal (30%), haematological (12%) or lung (8%) cancer. All provided

questionnaire data: 28 (54%) patients in the arm massage group (15 of whom were

also interviewed) and 24 (46%) in the control group.

• 9 nurses; all female. Aged 24-49 years (mean = 34yrs). All provided questionnaire

data; 2 were interviewed.

• 7 massage therapists; all female. Aged 33-59 years (mean = 46yrs). All participated

in the focus group.

• 3 service stakeholders; all female. Aged 38-49 years (mean = 45yrs). All were

interviewed.

Methods: A multi-method study was conducted to determine the benefits of providing arm

massage prior to intravenous cannulation. Primarily this comprised a randomised

controlled trial (RCT), which investigated the impact of massage on the cannulation

process and patients’ experiences of it. Patients were randomised to either the arm

massage (experimental) group or the control (standard care) group. Data were collected

from patients on up to 6 cannulation episodes. Investigator-designed questionnaires were

completed by both patients and nurses on these occasions. These questionnaires

gathered data on pain and anxiety – both expected and experienced – and time taken to

cannulate. Semi-structured interviews were carried out with patients and service

stakeholders, along with a focus group conducted with the massage therapists, to further

inform understanding of the benefits of massage and the impact of its provision on the

chemotherapy service. Resulting quantitative and qualitative data were analysed and

triangulated to gain detailed understanding of its outcomes.


Results: Statistical modelling through backwards stepwise regression, suggested that

massage had a statistically significant effect on anxiety and pain, when combined with

other factors such as a patients’ age, gender, or drug regime. When analysed on its own,

its benefits appeared marginal.

In both study groups 25% of cannulations were unsuccessful on first attempt. In order to

understand this, factors other than massage – including the patients’ gender, age and the

drug regime they having – were analysed. These factors did impact significantly on the

outcome variables of anxiety, pain and time taken to cannulate. Female patients, younger

patients, and those on vesicant drug regimes, were significantly more likely to anticipate

and experience high levels of procedural pain. Further, they were more likely to feel

anxious, and typically took longer to cannulate.

Implications: Although massage, on its own, did not impact significantly on the main

outcomes of the study – pain, anxiety, and time taken to cannulate – the patient and

stakeholder interviews did highlight general positive effects and benefits of massage.

These were neither sought nor captured by the questionnaire tools utilised in this study.

Patients that did benefit were typically young and female. The qualitative data that were

collected suggest that massage made attendance for chemotherapy less stressful and

more palatable, and may have helped in making veins easier to see and palpate.

Many positive feelings and emotions were mentioned in the patient interviews with regards

to experiences of arm massage. Patients felt ‘privileged’ to receive the treatment, which

was ‘relaxing’ and perceived as a ‘treat’. Likewise, those providing it referred to being

‘privileged’ in being able to do so. Massage enhanced the experience of care for patients

having chemotherapy and had a positive impact on the environment in which they received

it.


Contents

Section Page

1 Introduction and Aims ................................................................................................ 11

1.1 Introduction ......................................................................................................... 11

1.2 Aims.................................................................................................................... 12

2 Literature Review ....................................................................................................... 13

2.1 Complementary therapies................................................................................... 13

2.1.1 General massage ........................................................................................ 14

2.1.2 Aromatherapy massage............................................................................... 16

2.2 The experience of chemotherapy........................................................................ 17

2.3 Cannulation for chemotherapy............................................................................ 18

2.4 CAM in the NHS.................................................................................................. 20

3 Method ....................................................................................................................... 23

3.1 Introduction ......................................................................................................... 23

3.2 Study aims .......................................................................................................... 23

3.3 Research questions ............................................................................................ 23

3.4 Massage treatment ............................................................................................. 24

3.5 Research design ................................................................................................. 24

3.6 Sampling............................................................................................................. 25

3.6.1 Patients........................................................................................................ 25

3.6.2 Nurses ......................................................................................................... 27

3.6.3 Stakeholders................................................................................................ 27

3.6.4 Massage therapists...................................................................................... 27

3.7 Access arrangements ......................................................................................... 28

3.7.1 Patient sample ............................................................................................. 28

3.7.2 Nurse sample............................................................................................... 28

3.7.3 Therapist sample ......................................................................................... 29

3.8 Instruments ......................................................................................................... 29

3.8.1 Questionnaires............................................................................................. 29

3.8.2 Patient telephone interview schedule .......................................................... 31

3.9 Stakeholder interview schedule .......................................................................... 31


3.10 Therapist focus group ......................................................................................... 32

3.11 Pilot work ............................................................................................................ 32

3.12 Data analysis ...................................................................................................... 32

3.12.1 Questionnaire data ...................................................................................... 32

3.12.2 Interview and focus group data.................................................................... 33

3.13 Ethics .................................................................................................................. 33

4 Results ....................................................................................................................... 35

4.1 Introduction ......................................................................................................... 35

4.2 Sample accrual and attrition ............................................................................... 35

4.2.1 Patient sample ............................................................................................. 35

4.2.2 Therapist sample ......................................................................................... 36

4.3 Demography of patient sample ........................................................................... 37

4.3.1 Demography of patients interviewed............................................................ 38

4.4 Demography of nurse sample............................................................................. 39

4.5 Demography of therapist sample ........................................................................ 40

4.6 Demography of stakeholders .............................................................................. 41

4.7 Patients’ cannulation experiences....................................................................... 41

4.7.1 Experience of pain ....................................................................................... 42

4.7.2 Anxiety......................................................................................................... 44

4.7.3 Time taken to cannulate .............................................................................. 46

4.7.4 Cannulation on first attempt ......................................................................... 48

4.8 Attitudes towards, and perceptions of, massage................................................. 48

4.9 Factors affecting cannulation .............................................................................. 52

4.9.1 Variable factors............................................................................................ 52

4.9.2 Demographic factors affecting cannulation.................................................. 62

4.9.3 Experience of first treatment ........................................................................ 73

4.10 Models explaining factors impacting on cannulation ........................................... 74

4.10.1 Model explaining anxiety prior to cannulation .............................................. 75

4.10.2 Model explaining anxiety following cannulation ........................................... 76

4.10.3 Model explaining anticipated pain prior to cannulation ................................ 77

4.10.4 Model explaining procedural pain ................................................................ 78

4.10.5 Model explaining time taken to cannulate.................................................... 78

4.11 Impact of massage service on delivery of chemotherapy day care..................... 79

4.12 Impact of massage service on cancer services................................................... 80

4.13 Summary of results ............................................................................................. 82


5 Discussion.................................................................................................................. 83

5.1 Introduction ......................................................................................................... 83

5.2 Massage and cannulation ................................................................................... 83

5.2.1 Massage and time taken to cannulate ......................................................... 84

5.2.2 Massage and cannula usage....................................................................... 85

5.2.3 Massage and procedural pain...................................................................... 86

5.2.4 Massage and feelings of anxiety.................................................................. 87

5.3 Massage and well being ..................................................................................... 88

5.4 Factors affecting cannulation .............................................................................. 89

5.5 Study limitations.................................................................................................. 90

5.6 Recommendations for practice ........................................................................... 91

5.7 Recommendations for future research................................................................ 92

6 References................................................................................................................. 95

7 Appendices ................................................................................................................ 99

Appendix 1: Arm massage protocol ............................................................................. 100

Appendix 2: Patient information sheet ......................................................................... 102

Appendix 3: Patient Consent form ............................................................................... 108

Appendix 4: Therapist information sheet ..................................................................... 109

Appendix 5: Patient Questionnaire .............................................................................. 115

Appendix 6: Nurse Questionnaire................................................................................ 120

Appendix 7: Patient Interview schedule....................................................................... 123

Appendix 8: Stakeholder interview schedule ............................................................... 124

Appendix 9: Focus group guide ................................................................................... 126

Appendix 10: Model explaining anxiety prior to cannulation (SPSS output) ................ 128

Appendix 11: Model explaining anxiety following cannulation (SPSS output).............. 129

Appendix 12: Model explaining anticipation of pain prior to cannulation (SPSS output)

.................................................................................................................................... 132

Appendix 13: Model explaining procedural pain (SPSS output) .................................. 134

Appendix 14: Model explaining time taken to cannulate (SPSS output) ...................... 135


Figures

Figure 3.1 Research design .............................................................................................. 24

Figure 3.2 Sequence of data collection ............................................................................. 25

Figure 4.1 Flow diagram of patient accrual and attrition.................................................... 36

Figure 4.2 Massage therapist accrual and attrition............................................................ 37

Figure 4.3 Time taken to cannulate according to gender .................................................. 63


TABLES

Table 2.1. Models of CAM provision ................................................................................. 21

Table 4.1 Patient demographics........................................................................................ 38

Table 4.2 Demographics of patients that were interviewed............................................... 39

Table 4.3 Nurse demographics ......................................................................................... 40

Table 4.4 Demography of therapists that participated in focus group ............................... 40

Table 4.5 Anticipated pain................................................................................................. 42

Table 4.6 Procedural pain following cannulation ............................................................... 43

Table 4.7 Anxiety prior to cannulation ............................................................................... 45

Table 4.8 Anxiety after treatment administration ............................................................... 46

Table 4.9 Time taken to cannulate (minutes) .................................................................... 47

Table 4.10 Association between massage and vein palpability/visibility prior to cannulation

.......................................................................................................................................... 47

Table 4.11 Feelings when massaged................................................................................ 50

Table 4.12 Feelings generated by massage according to gender..................................... 51

Table 4.13 Effect of ease of cannulation on time taken..................................................... 53

Table 4.14 Effect of ease of cannulation on procedural pain............................................. 54

Table 4.15 Effect of ease of cannulation on anxiety following cannulation........................ 54

Table 4.16 Effect of ease of cannulation on time taken to cannulate ................................ 55

Table 4.17 Impact of vein visibility/palpability on procedural pain ..................................... 55

Table 4.18 Impact of vein visibility/palpability on anxiety .................................................. 56

Table 4.19 Impact of vein visibility/palpability on time taken to cannulate......................... 56

Table 4.20 Association between vein palpability/visibility and cannulation on first attempt

.......................................................................................................................................... 57

Table 4.21 Time taken to cannulate according to the nurse that cannulated .................... 58

Table 4.22 Procedural pain according to the nurse that cannulated ................................. 59

Table 4.23 Anxiety following cannulation according to the nurse that cannulated............. 59

Table 4.24 Failed cannulation according to the nurse that cannulated ............................. 60

Table 4.25 Effect of cannula size on anxiety ..................................................................... 61

Table 4.26 Effect of cannula size on procedural pain........................................................ 61

Table 4.27 Association between gender and insertion of cannula on first attempt............ 62

Table 4.28 Time taken to cannulate (in mins) according to gender................................... 63


Table 4.29 Association between gender and vein palpability/visibility prior to cannulation ...

.......................................................................................................................................... 64

Table 4.30 Procedural pain following cannulation experienced according to gender ........ 64

Table 4.31 Association between gender and level of pain following cannulation .............. 65

Table 4.32 Anxiety following cannulation experienced according to gender ..................... 66

Table 4.33 Association between gender and anxiety following cannulation...................... 66

Table 4.34 Procedural pain following cannulation experienced according to age ............. 67

Table 4.35 Association between age and level of pain following cannulation ................... 68

Table 4.36 Anxiety experienced after cannulation according to age ................................. 68

Table 4.37 Association between age and anxiety experience after cannulation ............... 68

Table 4.38 Time taken to cannulate according to age....................................................... 69

Table 4.39 Association between age and time taken to cannulate.................................... 69

Table 4.40 Chemotherapy regime classifications.............................................................. 70

Table 4.41 Association between nature of regime and insertion of cannula on first attempt

.......................................................................................................................................... 70

Table 4.42 Time taken to cannulate (in mins) with vesicant and other regimes ................ 71

Table 4.43 Association between nature of regime and ease of cannulation ..................... 71

Table 4.44 Procedural pain following cannulation experienced with vesicant and other

regimes ............................................................................................................................. 72

Table 4.45 Association between nature of regime and level of pain following cannulation ...

.......................................................................................................................................... 72

Table 4.46 Anxiety following cannulation experienced with vesicant and other regimes... 73

Table 4.47 Association between nature of regime and anxiety following cannulation ....... 73

Table 4.48 Trends in anxiety and anticipated pain over time ............................................ 74

Table 4.49 Model of factors impacting on anxiety prior to cannulation.............................. 75

Table 4.50 Model of factors impacting on anxiety following cannulation ........................... 76

Table 4.51 Model of factors impacting on anticipated pain prior to cannulation ................ 77

Table 4.52 Model of factors affecting patients’ pain following cannulation ........................ 78

Table 4.53 Model of factors affecting time taken to cannulate patients............................. 79


1 Introduction and Aims

1.1 Introduction

Cancer is a life threatening disease. More than 270,000 new cases were diagnosed in

2000 in the UK (1). Of the one in three people who are diagnosed with cancer throughout

their lives (2), approximately 60% will receive chemotherapy during their treatment (3).

Chemotherapy is often a source of distress and discomfort for patients not least because

of its side effects. Further, the physical experience of cannulation can be for some

individuals a traumatic and painful experience (4).

It is widely recognised that the experience of having chemotherapy can be a dreaded one

for patients (4-7); the prospect of cannulation and the treatment process itself causes

stress and discomfort. This is often accompanied by anxiety and fear of pain and their

illness itself. Others report feeling distressed because of their lack of knowledge about

chemotherapy (4, 6); these feelings can impact negatively on the process (8). Attempts to

improve the manner in which patients are cannulated and the treatments given are likely to

enhance the process and outcome of treatment.

Therapies that fall under the umbrella of complementary and alternative medicine (CAM)

are increasingly being accessed by patients with cancer as a means to treat their

symptoms and enhance feelings of well being (9, 10). CAM has been found to have a

positive effect on nausea (11, 12) and pain perception (10, 12, 13), and significantly

reduces anxiety (10-14).

The Chemotherapy Day Unit, where the study was conducted, has been offering a

complementary therapy service to outpatients since August 2001. Tailor-made treatments

have been offered to patients. Patients have been having massage to the head, neck,

shoulders, arms, legs and feet; these treatments have been administered to enhance

wellbeing and alleviate psychological symptoms such as stress and anxiety.

Chemotherapy patients have received gentle effleurage arm massage while waiting for

treatment and it was suggested this might reduce anxiety and contribute to less traumatic

cannulation. It was also speculated that this might result in fewer cannulation attempts.


To investigate whether the massage was impacting on the experience of cannulation, a

multi-method study was undertaken.

1.2 Aims

The study aimed to determine:

1. The value of providing arm massage prior to intravenous cannulation

2. The potential impact of this therapy on the chemotherapy service

In order to explore these aims fully the following research questions were developed:

Does a 10-minute gentle effleurage arm massage with basic carrier oil prior to intravenous

cannulation for administration of chemotherapy:

1. Reduce time taken for successful cannulation

2. Reduce number of cannulas used

3. Reduce pain associated with the procedure

4. Reduce feelings of stress and distress in patients and health professionals

5. Enhance patients’ wellbeing

Further, the research was designed to address the following:

6. How does integration of a massage service impact on chemotherapy day care

services?

The report that follows provides an account of the study conducted to explore these

research questions. Chapter 3 outlines the relevant literature and provides the background

and context to the study. This is followed by a description of the methods used to execute

the study. Chapter 5 provides an account of the results derived from both the quantitative

and qualitative data analysis. Finally, in Chapter 6, a discussion of the main findings,

limitations of the study and recommendations for future research are presented.


2 Literature Review

2.1 Complementary therapies

Complementary therapies and alternative medicine (CAM) are increasingly being

accessed by cancer patients. Appraisals of CAM, such as those carried out by Rees et al

(9) and Buckley (15), have documented its popularity (16). Typically its provision is

enthusiastically received by patients; especially for emotional and psychological support.

Most commonly they are used alongside orthodox medical treatment, rather than as a

replacement.

Moreover, there has been increased integration of aspects of CAM into NHS cancer

services. Integration of complementary therapy approaches with orthodox cancer care

has been influenced by patients accessing (or seeking to access) CAM – surveyed to be

between 9% and 30% of patients with cancer – and by growing evidence of the value of

CAM in achieving positive patient outcomes.

The therapies shown by surveys to be the most widely used by cancer patients are the

touch ones, such as massage and aromatherapy (17), along with mind-body therapies,

such as relaxation (18). Although the evidence base for complementary therapies is still

limited, it does not imply that they are ineffective. Rather, it is a reflection of the limited

resources that have been devoted to research in the past, and that many of the trials have

been of poor methodological quality (15), and yielded inconsistent findings (14). The

therapy that appears to have the ‘best’ scientific evidence – as far as cancer care is

concerned – is acupuncture for chemotherapy and radiotherapy-induced nausea. Few

formal trials have been conducted into touch therapies such as aromatherapy, massage

and reflexology (18).

This project evaluates massage as preparation for cannulation prior to patients receiving

intravenous chemotherapy. In order to provide some context to the study a brief review of

the application of massage within cancer care will follow. Subsequent to this, studies


investigating patients’ experience of chemotherapy, and in particular aspects of the

experience that provoke anxiety and discomfort, will be reviewed. Finally, the current

provision of CAM within the context of the NHS will be outlined.

2.1.1 General massage

As stated above, some of the most popular complementary therapies accessed by patients

are the massage therapies; with aromatherapy massage being a popular choice.

Massage is used mainly for the relief of musculo-skeletal pain, including that caused by

tension. It has been suggested that a further benefit of massage is the relief of other kinds

of pain – such as cancer pain – by inducing a state of relaxation (18). Unfortunately

methods used to evaluate the benefits of massage for cancer patients vary greatly and

have yielded inconclusive evidence of its effect (18).

Massage has been examined in terms of its effect on a range of symptoms and specific

populations. Massage ranging from full-body massage (19) to localised massage of the

feet (20), has been administered to populations ranging from a sample of mixed cancer

patients (20), to solely female (9, 21) or male patients (10), or those undergoing

autologous bone marrow transplantation (ABMT) (11). Contexts have included the

palliative (22, 23), hospice (19) and inpatient oncology setting (24, 25). Samples have

ranged from 87 patients (20) to 8 single case studies (21). These studies have aimed to

assess massages’ ‘general effects’ (22, 23); its impact on symptom distress (10, 24, 26);

and its effect on specific symptoms such as nausea (20). Qualitative (15, 21, 22) and

quantitative (10, 20) evaluations have been carried out. Outcome measures used in

quantitative evaluations have included a number of measures such as the State-Trait

inventory to measure anxiety (11), Visual-Analogue Scales (VAS) to measure pain

perception (25), and the Hospital Anxiety and Depression Scale (HADS) (14, 26). These

studies and service evaluations have shown massage to have a range of effects from

being generally beneficial (14, 21, 23), to having an ability to reduce specific symptoms

such as nausea (11) and anxiety (10, 13). Studies prominent in the literature on cancer

care are outlined below.

Studies have found that general massage not only significantly reduces anxiety levels in

cancer patients (14), it has also been described as being “universally beneficial by


patients, it assisted relaxation and reduced physical and emotional symptoms” (p.67) (14).

In addition, therapeutic massage - of the feet, back, neck & shoulders - has also been

found to be a beneficial intervention for cancer patients, not only reducing anxiety levels,

but also promoting relaxation and alleviating pain perceptions (10).

Furthermore, therapeutic massage was found to reduce the perception of pain and reduce

anxiety (13) in radiotherapy and chemotherapy patients. Smith et al (13) found that –

following a therapeutic massage nursing intervention – patients’ symptom distress was

reduced, and subjective quality of sleep improved slightly (whereas sleep deteriorated

significantly in the control group).

In a study by Ahles et al (11), specifically with patients undergoing (ABMT), general

massage therapy was found to have immediate effects. Following receipt of their first

session of Swedish/Esalen shoulder, neck, face and scalp massage, patients’ distress,

fatigue, nausea, and anxiety were significantly reduced as compared to the control group.

Mid-treatment - patients had up to 9 sessions - anxiety was significantly reduced in both

the intervention and control groups (but this reduction did not differ significantly between

the groups). And at the pre-discharge assessment stage of the study, fatigue was found to

have significantly reduced in the massage group (it also significantly reduced in the control

group; consequently the 2 groups did not differ significantly).

Using a phenomenological qualitative approach Billhult & Dahlberg (21) evaluated the

experience of 10 consecutive days of massage of the hand/forearm, or foot/lower part of

the leg, in eight female patients on an oncology ward. Participants were interviewed and it

was found that the essential meaning of receiving massage as part of daily care was

described as “getting a meaningful relief from suffering” (p.180) (21). Furthermore, from

the qualitative data gathered through interview, Billhult & Dahlberg (21) found that the

massage provided relief from suffering because patients:

• Experienced being “special”

• Found it beneficial to have the opportunity to develop a positive relationship with the

‘therapist’

• Experienced a sense of feeling strong

• Experienced more of a balance between autonomy and dependence

• Found and reported that it just “feels good’’


Of significance is that such physical and emotional benefits were gained in a relatively

short period of massage.

Grealish et al (20) looked at the effect of foot massage on symptoms suffered by patients

hospitalised with cancer. On the occasions where the patients had massage (on 2 out of 3

evenings), a significant immediate effect on patients’ perceptions of pain and nausea was

found; massage additionally had a significant effect on the sensation of relaxation. These

authors recommended the use of foot massage as a complementary means of helping

patients to manage the symptoms of pain and nausea.

A further study examining the effects of massage on patients with cancer was carried out

by Wilkie et al (19). This study focused specifically on full-body massage (where this was

possible) as a potential non-pharmacologic therapy to relieve cancer pain. When

compared with a control group (routine hospice care), quantitative data analysis revealed

that, immediately after the massage, pain intensity, pulse rate, and respiratory rate were

significantly reduced. This led them to conclude that the massage intervention produced

immediate relaxation and pain relief.

2.1.2 Aromatherapy massage

Aromatherapy massage differs from other forms of massage in that essential oils are used

with the aim of improving both the emotional and physical well being of an individual; the

benefits of these oils is gained through touch and inhalation, whereas massage is solely a

touch therapy. In relation to cancer patients, aromatherapy is thought to enhance symptom

control and reduce psychological distress (27).

Hadfield (26), in working with a group of patients with malignant brain tumours, found that

aromatherapy massage (of the foot, hand or neck/shoulder) affected the autonomic

nervous system, inducing relaxation. Hadfield (26) concluded that an aromatherapeutic

massage intervention appeared to be a good way of offering support, and of improving the

quality of life in this particular population, who are often faced with restricted treatment

options and poor prognosis (26).


Focusing on symptom control, Evans (22) carried out an audit into the physiological and

psychological effects of aromatherapy massage (usually to the face and/or extremities) on

cancer patients receiving palliative and terminal care. Both the qualitative and descriptive

ststistical data indicated that most participants found it soothing and/or relaxing, and that

they felt ‘better’ afterwards. The massage was described as: “beneficial”, making patients

“feel much better”, and an “excellent supplement to the medical care provided” and

“good…for pain” (p.240) (22).

A recent Cochrane review (12) examined the evidence on the effectiveness of the use of

aromatherapy and massage on symptom relief and physical and psychological wellbeing.

It concluded that the impact of massage / aromatherapy in cancer patients was as follows:

• Its impact on depression was variable

• Three studies found a reduction in pain following the intervention

• Two studies found a reduction in nausea

• Individual trials measured reduction in other symptoms such as fatigue, anger,

hostility, and digestive problems, and improved communication, but none of these

findings were replicated

• Interventions were consistently found to have an effect on reducing anxiety

Despite the variable findings highlighted by this review, it has been suggested that stress

relieving techniques that have been found to enhance well being, such as massage,

should be made available to patients “to augment and ease the experience of cancer

treatment and recovery” (p.362) (28).

2.2 The experience of chemotherapy

Chemotherapy is something that many patients with cancer dread. Apart from the prospect

of the side effects of chemotherapy, there are number of psychological issues that arise as

result of receiving treatment (6). For some patients the very thought of going in for their

treatment is often a distressing component of the whole process; another major concern

for patients stems from contemplating a needle being inserted (usually in their arm) for the

administration of their chemotherapy treatments (4). In fact, it is non-physical symptoms

such as these that account for 54% of the 15 most severe side effects experienced by

patients receiving cancer chemotherapy, as rated in a survey by Coates et al (4).


Studies such as those carried out by Rhodes et al (6), McDaniel & Rhodes (7), and Ream

et al (8) have further confirmed the fact that patients often dread chemotherapy, with the

experience often dominated by the sensory aspect of insertion of a needle for the

Intravenous (IV) line. Furthermore, patients are known to be unhappy when difficulties

arise with IV access and needles (5); these difficulties are a key source of stress and

discomfort to patients (4). Concerns linked to the procedural element of receiving

chemotherapy are often accompanied by psychological responses; some patients express

uncertainty, fear, anxiety, and distress due to lack of knowledge of chemotherapy, and

cancer in general (6).

In reality, distress, anxiety and fear of pain are common reactions to a cancer diagnosis

and even the prospect of chemotherapy (8). It is because of these reactions and their

effects on the process of cannulation that it is viewed as important to attempt to not only

improve ease of cannulation but also reduce patients’ anxiety during drug administration.

2.3 Cannulation for chemotherapy

Chemotherapy is one of the most frequently administered treatments in patients with

cancer. In many instances this treatment is administered via peripherally-sited IV

cannulas. Insertion of these portals is usually technically easy - following training and with

experience - but can be problematic and time consuming in patients requiring repeated

cycles of chemotherapy (29), due to the toxic effects of the chemotherapy and the damage

caused to the veins by repeated cannulation.

Furthermore, patients often find cannulation painful (8). For some individuals the pain and

associated stress and distress results in their increasing needle phobia with each cycle of

treatment. Cannulation is often more difficult when individuals are afraid of needles or

fearful because previous attempts have been painful or unsuccessful (29). With these

facts in mind, Lenhardt et al (29) looked at the effect of local warming on the insertion of

peripheral venous cannulas for the administration of chemotherapy. Neurosurgical

patients’ hands and forearms were covered with a mitt for 15 minutes (passive warming),

and leukaemia patients’ hands and forearms were covered for 10mins with a carbon fibre

heating mitt (active warming). This was carried out to determine whether ‘active’ local


warming facilitated peripheral venous cannulation. It was found that it took significantly

less time, with fewer failed attempts, to insert a cannula in the active warming group.

These findings lead to the conclusion that active warming of the limb significantly facilitates

insertion of peripheral venous cannulas; reducing time and number of attempts.

Wendler (30) studied the effects of Tellington Touch (TT) – a form of touch therapy

entailing gentle physical touch (originally developed for the calming of horses) – on

patterns of mean blood pressure, heart rate, state anxiety, and procedural pain

(anticipated versus perceived pain) in a sample of healthy individuals awaiting

venipuncture. Participants were randomly assigned to the intervention (TT) or control

group (who received a social visit). The 5-minute intervention was delivered by a nurse -

trained in the TT procedure - to the upper back, upper arms and shoulders. Data collection

determined that those in the intervention group experienced decreases in mean blood

pressure and heart rate, which were both statistically and clinically significant (although

this change was transient).

Anxiety provoked by cannulation, and the anticipation of receiving chemotherapy, often

results in vasoconstriction rendering the procedure more difficult (29). As a result,

intravenous cannulation can have many associated costs. It can be costly in terms of the

health professionals’ time and the cannulas wasted in the process. It can also increase

treatment time and anxiety for patients.

In some instances, poor venous access and needle phobia necessitate insertion of central

venous catheters like Hickman catheters, or peripherally inserted central venous catheters

(PICCs) for administration of chemotherapy (31). Although these provide long-term

venous access in patients undergoing chemotherapy, there are greater associated costs;

the cost of insertion, whether surgically or angiographically are greater. Also the risk of

systemic sepsis is greater. For many patients it would appear advantageous if the

cannulation process could be enhanced through complementary, inexpensive and non-

invasive methods such as massage.


2.4 CAM in the NHS

Approximately half the hospices and oncology departments within the UK offer a form of

complementary therapy to patients, and over 50% of those that offer CAM are reported to

offer more than five different therapies (Kohn (In press) cited in NICE Guidance (32)).

Wilkes (17) carried out a survey, which included gathering information on provision of

complementary therapies in palliative care settings. He reported that of the 108 hospices

surveyed 70% of them offered massage, 68% offered aromatherapy, and 66% offered the

mind-body therapy of relaxation.

Later, Rees et al (9) evaluated the use of complementary therapies in cancer patients.

Based on data gathered from 714 women diagnosed with breast cancer in the South

Thames region, it was found that massage/ aromatherapy was the most commonly

received therapy (22% of the sample). Therapists were mostly visited to treat symptoms of

cancer rather than to cure it or slow it down. It was recorded that 70% of NHS hospital

oncology departments in England and Wales claimed to be using some form of CAM to

benefit cancer patients. Massage was reported to be offered in just over a third of these

NHS hospitals, and relaxation and aromatherapy were available in almost half the

departments. This study was the first in the UK to provide precise estimates for the use of

complementary medicine among this group of patients (9).

A national survey was carried out by Kohn (18) examining cancer patients’ use of

complementary therapies throughout the UK. As a result she has outlined five key discrete

models for the provision of CAM in cancer care (See Table 3.1).


Table 2.1. Models of CAM provision

MODEL PROVISION

1: Hospital based individuals

Provided within a hospital setting by professionals who

themselves practice complementary therapies; such as

nurses, doctors, physiotherapists and radiographers

2: Provision within a multi-disciplinary

setting

Provided within a multi-disciplinary setting (such as hospice or

information and support centre), and planned and managed as

a discrete service e.g. Richard Dimbleby Cancer Information

and Support Service at Guys and St Thomas' Hospital

3: Patient groups within a healthcare

setting

Whereby certain patients are offered access to therapeutic or

supportive techniques, within a healthcare setting. These

techniques or therapies are psychological treatments intended

to alter negative perceptions of cancer, and promote positive

attitudes, decreasing stress and potentially influencing survival

e.g. Behavioural Oncology Unit, Aberdeen Royal Infirmary.

4: Independent approaches within the

NHS

Whereby they are 'external' (that is independently organized to

cancer services), but still provided within context of NHS e.g.

NHS homeopathic hospitals

5: Independent organizations

Whereby organisations offer services for patients with cancer

independent of the NHS. Often aspects of the work carried

out by these organizations has subsequently been adapted for

use within the NHS e.g. Bristol Cancer Help Centre

Source: Kohn (18)

These models of delivery of CAM in cancer care have scope to overlap. For example,

cancer care within a given service could be delivered by adopting aspects of Models 1 and

3. These models are key to planning integration of CAM with orthodox cancer care,

whether they are provided within NHS facilities or commissioned by the NHS. Kohn (18)

considered that provision of CAM, in line with one or more of these models, will most likely

be determined by current patterns of prioritisation within services’ budgets; and will be

guided by current standards outlined by organisations such as NICE.


NICE recently published a guidance document (32) on improving supportive and palliative

care for adults with cancer. The recommendations emphasise collaboration between

stakeholders and service users in order to make decisions regarding:

• The range of complementary therapies to be provided within the context of the NHS

• The regulation of practice and training standards

• The nature of information to be provided on CAM to patients with cancer

The NICE guidelines are complemented by the National Council for Hospice and Specialist

Palliative Care Services (NCHSPC) guidelines (33) for the use of complementary

therapies in supportive and palliative care. These provide broad advice in relation to CAM

and on how to meet requirements of clinical governance. Together, these documents aim

to inform those responsible for developing CAM in the statutory and voluntary sectors; and

they emphasise the importance of integration of CAM within the NHS.

A complementary therapy service has been established within the Chemotherapy Day Unit

in the acute NHS Trust, in which the study was carried out, since August 2001. This has

provided patients waiting for intravenous chemotherapy with gentle effleurage arm

massage. Patients, nurses and therapists have reported that this has reduced patients’

anxiety, enabled less traumatic cannulation and can result in fewer cannulation attempts.

This study aimed to determine, primarily through conduct of a randomised controlled trial

(RCT) the benefits of providing arm massage prior to intravenous cannulation. However

qualitative data were also collected to further inform understanding potential impact of this

therapy on the chemotherapy service.

This study will provide new evidence on the impact and potential of this relatively easy-to-

use and non-invasive intervention. It will help to determine which individuals, if any,

benefit most from this approach and will reflect on barriers and facilitators to the process.

It will provide understanding, hitherto lacking, of the outcomes of arm massage for

cannulation in patients undergoing chemotherapy.


3 Method

3.1 Introduction

This chapter is organised to provide a description of the methods employed in the

investigation.

3.2 Study aims

The study aimed to investigate the impact of arm massage prior to chemotherapy.

Principally through the conduct of a randomised controlled trial (RCT) it sought to

determine:

1. The value of arm massage prior to intravenous chemotherapy

2. The potential impact of this therapy for the chemotherapy service

Patients, nurses and therapists provided data through completion of questionnaires, or

participation in interviews or a focus group. These three different elements, outlined in this

chapter, provided complementary and detailed data on the efficacy, suitability and

popularity of using gentle arm massage to assist cannulation for administration of

chemotherapy.

3.3 Research questions

This study addressed the following research questions:

Does a 10 minute gentle effleurage arm massage with basic carrier oil prior to intravenous

cannulation for administration of chemotherapy:

1. Reduce time taken for successful cannulation?

2. Reduce number of cannulas used?

3. Reduce pain associated with the procedure?

4. Reduce feelings of stress and distress in patients and health professionals?

5. Enhance patients’ wellbeing?


3.4 Massage treatment

The massage intervention was a standard procedure, guided by a detailed protocol

(Appendix 1). Each therapist received additional training in the procedure to ensure the

same treatment was administered to those in the experimental group. All therapists

followed operational policy that had been agreed by the Trust.

3.5 Research design

The research adopted a multi-method design. It entailed conduct of a randomised

controlled trial (RCT) to determine the efficacy of the massage intervention, and collection

of qualitative data through undertaking a range of interviews and a focus group. It was

envisaged that the combination of these approaches would allow the impact of the service

from different perspectives to be attained. Further, it would allow in-depth understanding

of the conditions required for such a service to be introduced, and provide insight into

which particular individuals derived more or less benefit from it (Figure 3.1).

Figure 3.1 Research design

The RCT element entailed collection of data through completion of paired questionnaires.

Both patients who were cannulated and the nurses who cannulated them completed a

questionnaire. Together, these paired questionnaires provided information on the same

Patient questionnaire

Nurse questionnaire

RCT element Qualitative element

Patient interviews (massage group)

Stakeholder interviews

Therapist focus group

Statistical analysis – descriptive, inferential & modelling

Qualitative analysis – Framework Analysis

Detailed understanding of the massage service & its impact


cannulation episode. They recorded time taken to cannulate, the ease with which the

cannula was placed and the number of attempts this required. Levels of pain and anxiety

experienced by the patient throughout were also recorded. Further details of the

questionnaires are given in section 3.8. These questionnaire data were collected from

individuals in both the intervention and control groups on their first ever cannulation for

chemotherapy and on subsequent cannulations for treatment, up to a maximum of 6

occasions. On completion of this element of the study, a random sample of patients were

invited to participate in a telephone interview to explore their experiences further.

Patients’, and the other samples’, involvement in the study is presented diagrammatically

below (Figure 3.2). The stakeholder interviews and therapist focus group were conducted

at the end of the study.

Figure 3.2 Sequence of data collection

3.6 Sampling

3.6.1 Patients

The study sought inclusion of 50 patients that had not previously received chemotherapy.

A convenience sample was drawn, thus the first 52 individuals that met the inclusion

criteria, and were willing to take part, were recruited to the study.

Control group

Experimental group

Questionnaires completed when cannulated (2-6 times)

Questionnaires completed when cannulated (2-6 times)

Interview when questionnaire element finished

Nurses Questionnaires completed after cannulating

Stakeholder Interviews at end of study

Therapists Focus group at end of study


To be eligible patients were:

• 18 years of age, or older

• due to commence first course of intravenous chemotherapy for treatment of breast,

lung, colorectal or haematological cancer

• able physically and emotionally to cope with the research protocol

• able to speak and write in English

Patients were excluded if they:

• had previously had intravenous chemotherapy

• were having chemotherapy via a peripherally inserted central catheter (PICC) or

Hickman line

• had signs of bilateral lymphoedema

The size of the study was not determined through conduct of power calculations as there

were limited data from previous studies on which to base this. Instead, the research

hers opted for a sample size that would allow data to be collected on 100 cannulation

episodes over the planned period when data would be collected. Retrospective review of

chemotherapy administered at the study site where data were collected had determined

that it was feasible to collect data on 100 cannulation episodes - 50 in the experimental

group and 50 in the control- over a 6 month period. It was also anticipated that this

number of cannulation episodes would be sufficient to determine between-group

differences, and allow statistical modelling of the factors impacting on cannulation to be

undertaken.

3.6.1.1 Randomisation of patients

Patients were randomised at the outset to either the experimental or control groups. Once

randomised to a study arm, they remained within that arm for the duration of the study.

Thus, those randomised to the massage arm had massage each time they attended for

chemotherapy, prior to placement of the cannula, and vice versa.

Patients were randomised through selection of a card detailing the group they were to be

allocated to. One hundred identical envelopes were filled detailing the group patient

participants were to be allocated to. These envelopes were sealed and placed in a secure

box. There were equal numbers (n=50) of envelopes with ‘Experimental group’ cards as

there were ‘Control group’ cards. On consenting to take part in the study an envelope was


selected from the shuffled envelopes in the box by the recruiting nurse. Thus, each patient

had an equal chance of being allocated to either of the two groups.

3.6.2 Nurses

All nurses that cannulated the sample of patients participating in the study were invited to

take part in the study. This included permanent members of nursing staff and those on 6-

month secondment as part of an educational Rotation Programme for inexperienced

cancer and palliative care nurses.

3.6.3 Stakeholders

A purposive sample of three stakeholders was invited to take part in an interview in which

to explore the running, impact and potential of the massage service. To gain a wide

perspective it was decided to involve the Lead Nurse for Cancer Services, the Manager of

the Volunteer Therapists and the Nurse managing the Chemotherapy Day Unit.

3.6.4 Massage therapists

In addition to attaining the patients’, nurses’ and stakeholders’ views, it was decided to

provide opportunity for the therapists to share their experiences of providing massage to

patients prior to chemotherapy and to understand the challenges and benefits of providing

such a service from their perspective.

Literature on the conduct of focus groups suggests that groups of between 4 to 12

members are recommended. The basis for this recommendation is that groups larger than

this can become unwieldy and inhibit all members sharing their insights. Conversely,

small groups can provide an insufficient range of perceptions. It was decided for this study

to conduct only one group and to invite all those providing massage on completion of the

study to attend. If all had attended this would have resulted in a group of nine therapists;

in the event a convenience sample of seven people could be present at the time the group

was scheduled, and all took part.


3.7 Access arrangements

3.7.1 Patient sample

As per usual care, patients met with their doctor in the outpatient clinic to discuss and

determine their treatment plan. When a decision was made for chemotherapy, the doctor

and clinical nurse specialist assessed whether the individual met the eligibility criteria for

this study. If they did, the clinical staff issued them with the Patient Information Sheet

concerning the study (Appendix 2). A verbal explanation of the study was given at this

time by the clinical staff, and patients were encouraged to read the sheet prior to their next

planned meeting with the oncology team prior to their treatment. They next met with the

chemotherapy team when they attended the treatment suite in the Day Unit for their ‘Work-

Up’ (usually a minimum of 24 hours later). This meeting provided patients with the

opportunity to discuss their treatment with a chemotherapy nurse. At this meeting

individuals were given further verbal explanation of the aims of the study, and their

potential role in it, by the chemotherapy nurse. Individuals willing to take part then signed

the consent form (Appendix 3).

In addition to providing written consent to take part, participants checked a box to indicate

whether or not they were happy to be interviewed over the telephone on completion of the

study. A sample of 15 was randomly selected from those that checked the box, and were

in receipt of massage. These patients were contacted by the nurses on the Day Unit to

check that they remained happy to be interviewed and for their names and contact details

to be forwarded to the research team. One of the researchers then telephoned them at

home and arranged a time when they could call back to interview them over the telephone.

3.7.2 Nurse sample

The nurses cannulating patients on the Day Unit were provided details of the study by

members of the research team who provided oral and written information regarding it. The

data collection process was discussed and considered in detail prior to the study

commencing. All nurses that agreed to take part (in the event all that worked on the unit)

provided written consent before the study commenced.


3.7.3 Therapist sample

The therapists met regularly with their manager, and at one such meeting the latter

provided them with details of the study and gave out information sheets (Appendix 4)

explaining plans for the conduct of the therapist focus group. The manager provided them

with the scheduled meeting date and time and gathered names of those willing and able to

attend. Willing participants signed their consent form prior to attending the focus group,

and returned them to the research team at the focus group.

3.8 Instruments

3.8.1 Questionnaires

Two brief self-report questionnaires were designed by the research team, one for

completion by patients on the occasions they were cannulated, and the other by the

nurses that performed the procedure. This pair of questionnaires was designed with the

study aims in mind; the study aimed to determine whether gentle effleurage arm massage

reduced pain associated with cannulation, reduced feelings of anxiety before and during

the procedure, and enhanced feelings of wellbeing. They were informed by work

conducted by Lenhardt (29) and Wilkinson et al. (23).

3.8.1.1 Patient Questionnaire

The questionnaire filled in by patients (Appendix 5) was made up of 3 sections and

completed by them in 2 stages.

Stage 1 - Prior to the cannula being placed: All the patients completed Section 1 detailing

their feelings of anxiety, and their perceptions of how uncomfortable they anticipated the

placement of the cannula would be. Patients did this by means of two separate 11-point

numeric rating scales ranging from 0 to 10 (i.e. one for pre-anxiety and one for pre-pain).

Stage 2 - After the patients had had their intravenous treatment: All the patients completed

Section 2 by recording how anxious they were following cannulation and the pain they

actually experienced during the procedure. Once again, patients did this by means of two


separate 11-point numeric rating scales ranging from 0 to 10 (i.e. one for post-anxiety and

one for post-pain).The patients further recorded the amount of time they spent in the unit.

Section 3 was completed solely by those in the massage group. This extra section detailed

their perceptions of massage on that occasion. They stated their expectation of the arm

massage, their level of satisfaction with it, and the level of pleasantness they experienced

from the process through fixed choice questionnaire items. They also recorded the feelings

that accompanied receiving the arm massage through fixed choice. Next, patients

responded to statements describing their thoughts and feelings - before, during and after

their massage - through the use of 4-point forced choice Likert scales. Finally, patients

stated their desire to repeat the arm massage experience prior to chemotherapy, and to

recommend it to a fellow patient, through fixed choice questionnaire items. Following these

items there was a space left available for additional comments to be made, regarding arm

and hand massage.

Through patients completing questions immediately before, and directly following, the

procedure, retrospective recall and associated difficulty recounting the experience were

minimised.

3.8.1.2 Nurse Questionnaire

Completion of the nurses’ questionnaire (Appendix 6) mirrored that of the patients; it was

made up of 3 sections and completed in two stages.

Stage 1 - Prior to the cannula being placed: Section 1 asked nurses to rate the condition of

patients’ veins immediately prior to attempting to cannulate. Nurses did this by means of

one fixed choice questionnaire item, made up of varying descriptions of vein visibility and

palpability.

Stage 2 - After the patients had had their intravenous treatment: In Section 2 nurses

detailed the amount of time taken to insert the cannula, the size of the cannula used and

the number of failed attempts at cannulation. This was followed by them rating the degree

of difficulty encountered when cannulating on a 5-point scale. They further recorded the

use of other measures used to achieve a successful cannulation; 5 options were available

including an “other” option, accompanied by the opportunity to specify the “other” option


used. They then completed a fixed choice questionnaire item, which recorded the

presence or absence of additional factors that might impinge on cannulation, accompanied

by an opportunity to specify as to the factor(s).

Section 3 required the nurse to record treatment and patient demographics. These

included the patients’ chemotherapy programme, their cycle of treatment (at the point of

completing the questionnaire), and their age, gender and type of cancer.

These questionnaire data allowed differences in ease of cannulation between the

experimental and control groups to be determined and described statistically.

3.8.2 Patient telephone interview schedule

Telephone interviews had previously been utilised by the research team to explore

sensory feelings experienced whilst chemotherapy was given (8). Experience gained from

these informed the development of a telephone interview schedule that was brief

(maximum half an hour) (Appendix 7), but encouraged disclosure and detail regarding their

experience of being cannulated, and of receiving massage. These interviews were tape

recorded and then transcribed verbatim for analysis.

The interviews centred on:

• Experience of receiving chemotherapy & of being cannulated

• Influential factors impacting on the process

• Experience and views of massage

• Potential for massage service in future

3.9 Stakeholder interview schedule

Face-to-face interviews were conducted with the three selected stakeholders and recorded

on audio tape. As with the patient interview schedule it was intended to keep interviews

under half an hour in duration but allow detailed and comprehensive discussion about the

massage service, its potential and factors that both impeded and facilitated the process.

To this end a semi-structured interview schedule was developed (Appendix 8) which

guided and prompted discussion. Key themes covered in these interviews were:

• Value of massage for patients

• Impact of massage on Day Unit/Cancer services/Hospital Trust


• Challenges affecting setting up/running of service


3.10 Therapist focus group

The massage therapists took part in a one-off focus group. It was anticipated that this

group would last approximately 1 hour, and it was facilitated and recorded by two

members of the research team. Both the focus group facilitators were from outside the

institution where data were collected in the hope that conversation generated would be

frank, and in the main uninhibited.

They were invited to discuss their perceptions of how patients responded to the

intervention treatment, and to reflect on factors that both impeded and facilitated the

process. They were also encouraged to consider patient characteristics that influenced

outcomes of the massage treatment. Conversation was also directed towards considering

the potential of the service and discussing the manner in which therapists themselves and

the service would need to be supported in future. The focus group guide that acted as an

aide-memoir during the group can be seen in the appendix (Appendix 9). It centred on:

• Process of providing massage

• Impact of massage

• Factors affecting its effects


3.11 Pilot work

The questionnaires and patient telephone interview schedule were piloted prior to the main

study. 23 patient and nurse questionnaires were piloted, and the interview schedule was

piloted twice. Minimal changes were required to wording within each. Both the

questionnaire and the telephone interviews took in the main under half an hour to

complete, which had been the aim.

3.12 Data analysis

3.12.1 Questionnaire data

Following descriptive tests, the quantitative data attained from the investigator-designed

patient and nurse questionnaires were subject to inferential analysis to determine the


relative efficacy of arm massage in facilitating cannulation. The data were largely of

ordinal level, and hence nonparametric tests were principally employed. On occasion

interval/ratio data were recoded into grouped data in order to carry out alternative or more

complex statistical tests. For example, pain and anxiety, rated on the 11-point numeric

scales ranging from 0-10 were recoded into low (scores 0-3), medium (scores of 4-6) and

high (scores of 7-10) pain/anxiety in order to be crosstabulated with categorical data (e.g.

massage group). A series of models were tested using backwards stepwise regression to

determine factors, including demographic ones, impacting on the cannulation process.

3.12.2 Interview and focus group data

The data attained from the telephone interviews with selected patients, and from the

therapists’ focus group, were transcribed verbatim and subject to Framework Analysis.

This allowed commonly held views and discrepancies in opinion to be described. In

combination, the analysis outlined above gave rise to complementary and insightful

findings relating to factors affecting cannulation and the impact of arm massage.

3.13 Ethics

The research proposal was submitted to, and a favourable opinion given by, the Local

Research Ethics Committee and associated Research and Development Committee.

They required no amendments to be made.

As with all research, care had to be taken during the study to ensure participants’

(patients’, nurses’ and therapists’) responses were anonymous. To this end, patients

completing questionnaires were allocated a study number; their name did not appear on

any documentation other than the consent form, which was stored away from the data that

were generated. All data were stored in accordance with the Data Protection Act (1998).

In presentation of qualitative data, all participants are allocated a pseudonym. In this way

comments are not attributable to any particular individual.

The conduct and progress of the study was monitored and guided by a Steering Group

which entailed representation of health professionals, massage therapists, a service user

(patient that had received treatment on the Day Unit) and members of the research team.

The group met regularly throughout the study.


4 Results

4.1 Introduction

The results chapter is organised to provide a description of the impact of the massage

service on patients being cannulated for chemotherapy, on the chemotherapy Day Unit

service and on the hospital more generally. It also presents outcomes of analysis

conducted to determine factors other than massage that influenced the cannulation

process. Before these findings are presented the chapter commences with an overview of

the sample accrual and attrition, and provides a description of the demography of the

different samples that provided data during the study.

4.2 Sample accrual and attrition

4.2.1 Patient sample

Sixty-eight eligible patients received treatment over the period that data were collected

(from the 2nd week of September 2003 to the of end June 2004). Fifty-four of these

individuals were recruited to the study over this 9-month period. They were randomly

allocated between the experimental group (n=28) and the control (n=24). Two people

withdrew from the study after consent but before data collection; one patient withdrew from

the experimental group due to being admitted to hospital and the other withdrew from the

control group because they had a PICC line inserted. In total data were collected on 266

cannulation episodes, 138 of these came from people within the intervention group and

128 from those in the control. Study participants provided data on between 2-6 occasions

when cannulated for treatment. The median number of episodes on which data were

collected was 5 occasions in the experimental arm and 6 occasions in the control (Figure

4.1).


Figure 4.1 Flow diagram of patient accrual and attrition

4.2.2 Therapist sample

The intention was to recruit 10 part-time massage therapists to work on the Day Unit to

provide arm massage to those in the intervention group. Initial recruitment resulted in 8

therapists commencing work on the Day Unit in July 2003 (2 months before data collection

commenced) (Figure 4.2). Over time, four of these left the service due to personal

reasons, notably their need for paid employment. As a consequence, a second

recruitment drive was required. This occurred in February 2004 and 5 further therapists

were recruited. As the study drew to a close, a further three therapists left the Day Unit

for reasons similar to those given by the therapists that left the service previously.

Identified as eligible (n=68)

Excluded (n=14)• Missed (n=2)• Refused (n=12)

Randomised n=54

Allocated to intervention (n=29)

Allocated to control (n=25)

Lost to follow up (n= 1)

• Withdrew (n=0)

• Decline in health (n=1)

Lost to follow up (n=1)

• Withdrew (n=1)


Available for analysis (n=28)

Data on 138 cannulations



Identified as eligible (n=68)

Excluded (n=14)• Missed (n=2)• Refused (n=12)

Randomised n=54

Allocated to intervention (n=29)

Allocated to control (n=25)

Lost to follow up (n= 1)

• Withdrew (n=0)


Lost to follow up (n=1)

• Withdrew (n=1)







Figure 4.2 Massage therapist accrual and attrition

4.3 Demography of patient sample

Demographic data were collected on the 52 patients recruited to the study. Twenty-eight

of these participants were randomised to receive massage prior to cannulation, and 24

were allocated to the control. The majority were receiving treatment for breast cancer

(50%) and consequently the sample comprised more women than men. Eight different

treatment regimes were administered to the study participants, and all were chemotherapy

naïve on recruitment. The mean age of participants was 59 years (SD 14) (see Table 4.1).

It was decided that cannulation data would be collected from participants on a minimum of

two and maximum of six occasions. The median number of occasions was 6 (Range 2-6).

Comparison between the two study groups confirmed that there were no statistically

significant differences between the two study groups’ demography.

Recruited in July 2003 N = 8

Left for personal / financial reasons N = 4

By February 2004 N = 4

Recruited in March 2004 N = 5

From March 2004 N = 9

At the end of data collection - June 2004

Left for personal / financial reasons N = 3

From July 2004

N = 6


Table 4.1 Patient demographics

Massage

(n = 28)

No Massage

(n = 24)

Total

(n = 52)

N (%) N (%) N (%)

Gender:

Female 19 (68) 16 (67) 35 (67)

Male 9 (32) 8 (33) 17 (33)

Cancer Type:

Breast 14 (50) 12 (50) 26 (50)

Lung 2 (7) 2 (8) 4 (8)

Colorectal 8 (29) 8 (34) 16 (30)

Haematological 4 (14) 2 (8) 6 (12)

Chemotherapy Type:

Weekly 5FU +/- folinic acid 8 (29) 8 (33) 16 (30)

Cisplatin & Etoposide 0 2 (8) 2 (4)

CHOP 2 (7) 2 (8) 4 (8)

FEC 10 (36) 10 (43) 20 (38)

Carboplatin & Etoposide 2 (7) 0 2 (4)

Epirubicin & Cyclophosphomide 2 (7) 2 (8) 4 (8)

ABVD 2 (7) 0 (0) 2 (4)

Single agent Epirubicin 2 (7) 0 (0) 2 (4)

Age (years):

Average (SD) 58 (15) 61 (13) 59 (14)

Range (years) 24 - 79 34 - 78 24 - 79

Cannulation occasions when data were collected:

Median (IQ range) 5 (1.75) 6 (1) 6 (1)

Range 2 - 6 3 - 6 2 - 6

4.3.1 Demography of patients interviewed

Structured interviews were conducted by telephone with 15 patients selected at random

from those allocated to receive massage prior to cannulation. As with the total sample of

patients, the majority of those interviewed were receiving treatment for breast cancer

(47%). Thus, the group that were interviewed comprised more women than men; by

chance the ratio of males to females in the interviewed sample was the same as within the

entire sample (67% female: 33% male). Furthermore, other demographic characteristics


of those interviewed were akin to the entire sample (see Tables 4.1 & 4.2), except for the

age of the group. The mean age of the interviewed participants was 52years (SD 15); 7

years younger than the entire sample’s mean age.

Table 4.2 Demographics of patients that were interviewed

N

(n = 15) %

Gender:

Female 10 67

Male 5 33

Cancer Type:

Breast 7 47

Lung 1 7

Colorectal 5 33

Haematological 2 13

Chemotherapy Type:

Weekly 5FU +/- folinic acid 5 33

Cisplatin & Etoposide 0 -

CHOP 1 7

FEC 5 33

Carboplatin & Etoposide 1 7

Epirubicin & Cyclophosphomide 1 7

ABVD 1 7

Single agent Epirubicin 1 7

Age (years):

Average (SD)

Range (years)

52 (15)

24-79

Cannulation occasions when data were collected:

Median (IQ range)

Range

5 (1)

3 – 6

4.4 Demography of nurse sample

Nine nurses worked on the Day Unit and cannulated patients who participated in the study

(Table 4.3). All were female and had been working in oncology on average for 5 years 2

months before commencing on the Day Unit. Some cannulated patients regularly (up to

86 times during the study) whilst others, notably the Lead Nurse for Cancer who helped if


required, cannulated infrequently during the study (once). Typically they were experienced

nurses. The average length of time they had been qualified was 9 years 11 months.

Table 4.3 Nurse demographics

Gender: (n = 9) Years qualified:

Female 9 Mean (SD) 9yrs 11mths (7yrs 8mths)

Male - Range 18mths to 24yrs

Age: Cannulations performed during study:

Mean (SD) 34yrs (8.5) Mean (SD) 29.6 (30)

Range 24 to 49 years Range 1 to 86 cannulations

Oncology experience before recruited to Day Unit:

Mean (SD) 5yrs 2mths (6yrs 2mths)

Range 0 to 17yrs

4.5 Demography of therapist sample

Thirteen therapists provided massage to patients randomised to the treatment arm. Of

these, seven participated in the focus group. These individuals were among the nine

working on the Day Unit when the focus group was conducted towards the end of the

study. All were female, and relatively mature. The mean age of the therapists who took

part in the focus group was 46 years. They varied in the length of time that they had been

providing massage to patients in the Day Unit, and in the time they had been involved with

the study. Typically they provided one half-day of massage per week (Table 4.4).

Table 4.4 Demography of therapists that participated in focus group

Gender: (n = 7) Years qualified:

Female 7 Mean (SD) 3yrs (2yrs 7mths)

Male - Range 1 to 8 years

Age: Sessions provided per week (1/2 day):

Mean (SD) 46yrs (8.5) Mean (SD) 1 session per week (0.19)

Range 33 to 59 years Range 1 to 1.5 sessions

Time providing massage on Day Unit:

Mean (SD) 9.9 months (6.6 months)

Range 2 to 23 months


4.6 Demography of stakeholders

Three stakeholders were interviewed; the Lead Nurse for Cancer Services, the manager of

the volunteer therapists and the nurse managing the Chemotherapy Day Unit.

The Lead Nurse for Cancer Services was a 38-year-old female who had been qualified

and working in oncology for 17 years and 3 months. She had cared for patients receiving

chemotherapy for 15 years. Her qualifications included a Diploma in Nursing, a BSc in

Cancer Nursing, and post registration courses in oncology and chemotherapy.

The manager of the volunteer therapists was a 48-year-old female who had been a

qualified therapist for 6 years, held a number of therapeutic and massage qualifications.

She had provided massage therapy on the Chemotherapy Day Unit for 2 years and 10

months, providing 4 half-day sessions at the unit per week.

The nurse managing the Chemotherapy Day Unit was a 49-year-old female who had been

qualified for 12 years and working in oncology for over 5 of these. She had cared for

patients receiving chemotherapy for over 5 years. Her qualifications included being a

registered general nurse (RGN) and she held a Care of Patients Requiring Chemotherapy

(N59) qualification.

4.7 Patients’ cannulation experiences

The study was conducted to evaluate the efficacy of arm massage in facilitating

cannulation and decreasing levels of anxiety and pain associated with the procedure. It

investigated whether a 10-minute gentle effleurage arm massage with basic carrier oil prior

to intravenous cannulation for administration of chemotherapy:

1. Reduced the time taken for successful cannulation?

2. Reduced the number of cannulas used?

3. Reduced the pain associated with the procedure?

4. Reduced feelings of stress and distress in patients?

5. Enhanced patients’ wellbeing?

It was hypothesised that the intervention would have a positive outcome and result in

quicker cannulation with fewer failed attempts (questions 1 and 2). It was also

hypothesised that massage would result in cannulation evoking less anxiety and being

less painful (questions 3 and 4). These hypotheses were tested through the conduct of

nonparametric statistical tests for comparison of two independent groups (Mann-Whitney


tests). Other tests were also conducted, notably the Chi-square which was utilised to

determine associations within the data. The results of this statistical testing are presented

in sections 4.7.1- 4.7.4. Section 4.8 considers the impact of massage on patients’

wellbeing more generally (answers the 5th research question). Factors other than

massage impacting on cannulation are presented in section 4.9.

4.7.1 Experience of pain

Data were collected both prior to, and following, cannulation to attain information on both

anticipated pain prior to the procedure and procedural pain arising as a result of it.

4.7.1.1 Anticipated pain

Participants scored ‘how much hurt’ they anticipated placement of the needle would cause,

prior to the procedure taking place, on a scale of 0 (no hurt) to 10 (worst possible hurt).

Although there was considerable variation, there was no statistically significant difference

between the two study groups (p > 0.05).

Non-parametric independent samples t-test (Mann Whitney) = z = -0.14, p = 0.45 (ns)

Typically, patients anticipated little pain prior to cannulation (mean 2.3, SD 2.2) (Table

4.5).

Table 4.5 Anticipated pain

Study group Anticipated pain

Mean (SD)

Range z-value p-value

Massage 2.3 (2.1) 0-9

Control 2.3 (2.3) 0-9

-0.14 0.45 (ns)

Patients’ in the massage group when asked about experiences of pain stated that they had

not known what to expect prior to having treatment for the first time. As one lady phrased

it: ‘The unknown…you don’t know what to expect, so you, you think the worst’ (022). In

the event it tended to be viewed as ‘acceptable’ and ‘bearable’. It became almost routine

to some. One gentleman expressed: ‘I suppose I gradually got more confident…in the fact

that it wasn’t going to hurt…before I knew what was involved, then I didn’t know whether


there’d be pain or not…But, soon, having experienced it, I realised that there wasn’t any

particular pain at all’ (003).

4.7.1.2 Procedural pain

In addition to anticipated pain, participants recorded the procedural pain associated with

cannulation. The same numeric rating scale was used, where 0 represented ‘no hurt’ and

10 ‘worst possible hurt’. As with anticipated pain, there was no difference between the two

study groups’ procedural pain following cannulation (p > 0.05).


These procedural pain scores were typically low (Table 4.6), although some individuals did

report feeling extreme pain (i.e. maximum value).

Table 4.6 Procedural pain following cannulation

Study group Pain following cannulation

Mean (SD)


Massage 2.2 (2.1) 0-9

Control 2.0 (2.2) 0-10

-1.39 0.08

(ns)

During interviews conducted with those in the massage group it became clear that

experience of pain was very variable. On one end of the scale, three people spoke of it as

only an uncomfortable ‘prick’ (010, 029, 031). A number of patients matched the pain to

previous experiences, such as that experienced when donating blood. One third of

patients expressed that in general they did not find cannulation particularly painful.

Nevertheless, these same people did recall and detail the ‘one time’ it went wrong. They

used words including ‘prodding’ (024), ‘ploughing’ and ‘poking’ (029) to describe what

occurred when a nurse had to ‘have several goes’ (023). One gentleman described how

on a couple of occasions the needle bent in his arm, but went on to express that he felt he

was ‘quite a strong bloke’ (038), suggesting that he had not been overly distressed by this.

Other patients expressed a clear dislike of needles, and explained that they always found

them uncomfortable and painful. One such lady described herself as being ‘a bit of a

coward when it comes to needles and things’ (046). For some patients the cannulation

process became more difficult with time, often requiring at least two attempts before the


cannula was successfully placed. One lady to whom this applied revealed: ‘it (the

cannulation process) did get worse (with time) …I didn’t really know how the chemo

worked but it just, it didn’t help - my veins were not really that good, so, it did cause me a

lot of pain’ (021). In all, seven of those interviewed reported having veins that were difficult

to cannulate and told of the discomfort associated with positioning the cannula. All of

these were female.

It was interesting to note that a small number of patients (27%) suggested that the level of

pain they felt varied according to the ‘experience’ of the nurse who cannulated.

The statistical analysis of the questionnaire data suggested that there was no difference in

the pain that was experienced following cannulation by those in the experimental and

control groups. This can be better understood when the interview data are reviewed.

Those in the intervention group explained that although the massage was pleasant, it did

not necessarily affect how painful the ensuing cannulation was. One lady summarised the

feelings of many of those interviewed: ‘I think no amount of massaging makes up for the

fact if the nurse isn’t skilful… (I) think that any human being would screw themselves

up…and, and wait for the needle…But as, as time, as I found the ones that were good at

it…the massaging helped and it didn’t go away. I didn’t screw myself up because I knew

she’d get it and that, it didn’t destroy the massaging’ (029).

4.7.2 Anxiety

Anxiety was measured on two occasions during the time patients were in the Day Unit for

treatment – before cannulation and immediately afterwards. These data were analysed

independently and results are presented in the following sections.

4.7.2.1 Before cannulation

Participants were requested to record their feelings of anxiety immediately prior to

cannulation. Thus, for those that had had massage this referred to their anxiety levels

once massage had been given. It was anticipated that massage would reduce anxiety;

and this reduction did near significance (p > 0.05).



Those in the massage group appeared to record lower anxiety levels prior to cannulation

(Table 4.7).

Table 4.7 Anxiety prior to cannulation

Study

group

Anxiety before cannulation

Mean (SD)


Massage 2.1 (2.5) 0-10

Control 2.5 (2.6) 0-10

-1.57 0.059 (ns)

The benefit afforded by massage in this situation was explored during the telephone

interviews. Some participants explained how pre-treatment, they were often just generally

stressed, ‘nervous anyway’ (023) and feeling ‘daunted’ (038) about what was to come.

However, they spoke of how massage often allowed them to settle and feel ready for

cannulation and treatment. Other patients similarly stated that they believed they benefited

greatly from arm massage (021, 028, 029, 031, 046, 048) because it helped them feel

positive and relaxed. This was especially true on the first visit to the Day Unit for treatment

(031 & 046). Reference was made by patients during the interviews to the way in which

massage helped to warm up the arm and veins, making them more visible (021, 028, 029,

031). It was also felt by two interviewees to help with cannulation (028, 046). One lady’s

views expressed those of many. She said: ‘It was very nice and relaxing...I really did enjoy

it.... it was a nice part to start with the chemotherapy I think… I had a chat and you

unwound before you had the treatment... and she (the therapist) always done both arms…

she always covered it up (arm she would have treatment in) to make sure that, you know, I

had plenty of veins that were good for taking blood, you know, for the needle to go in... I

mean I just found it quite a nice experience... It’s quite calming before um the other

treatment started” (048).

4.7.2.2 Following cannulation

Participants recorded their anxiety levels after chemotherapy had been administered. This

enabled the research team to determine whether massage prior to cannulation impacted

on their feelings of well-being after treatment was administered. Analysis of these data

revealed that there was little difference between the groups (p > 0.05).



Both groups did have reduced anxiety following administration of their treatment, and the

massage group scored marginally higher at this time (Table 4.8).

Table 4.8 Anxiety after treatment administration

Study

group

Anxiety after treatment

Mean (SD)


Massage 1.6 (1.9) 0-9

Control 1.4 (1.8) 0-8

-1.25 0.105 (ns)

Thus, the limited benefit afforded by massage appeared not to be sustained following

cannulation. Patients explained in the interviews that massage was delivered identically

during the study. It did not vary from one time to the next. But for some, massage

consistently afforded them little benefit during or after the procedure. These people

determined that this was because they were neither anxious nor uncomfortable about the

needle beforehand. Others felt that the massage, although it had been pleasant, was

unable to distract them from procedural pain and discomfort. Nonetheless, it was never felt

to have been negative. It could still make them feel ‘that little bit more comfortable’ (003).

One gentleman illustrated this well, he said: ‘It was nice. It was pleasing. I don’t think it

made one iota difference as regards to whether I felt the needle any more or less. It might

make a difference to someone who is frightened of needles. But, needles don’t in general

frighten me… Yep, it felt nice, calm, it felt like someone did care. Like you had been

personally taken care of. So that was very nice... I wouldn’t say it’s a waste of time, no”

(024).

4.7.3 Time taken to cannulate

Nurses cannulating the sample recorded how long the process took. Typically the process

was quick (mean 3.7 minutes, SD 5.1). On 44% of occasions it reportedly took less than

one minute, and on 64% of occasions cannulation was successfully accomplished in under

2 minutes. Analysis of the data revealed that the time taken to cannulate was not impacted

by massage (p > 0.05).



There was little difference between those receiving massage and those in the control

group (Table 4.9).

Table 4.9 Time taken to cannulate (minutes)

Study group Mean (SD) Range z-value p-value

Massage 3.7 (4.8) 0.5 - 35

Control 3.6 (5.4) 0.5 - 40

-0.67 0.251 (ns)

In some ways this was surprising as chi-square analysis suggested there were significant

differences in the condition of patients’ veins according to whether they received massage

(p < 0.05).

Chi-square test = 2χ (df2 ) = 7.2, p = 0.027*

Those that had massage appeared less likely to present with veins that were neither

visible or palpable following massage when compared to the control (Table 4.10). Half

the number of people (8%) in the intervention group when compared with the control

(16%) had veins that were classified by the cannulating nurse as neither visible nor

palpable. Forty –six percent of the massage group had veins that were somewhat visible

and palpable which compared with 34% in the control.

Table 4.10 Association between massage and vein palpability/visibility prior to

cannulation

Condition of vein Massage

N %

Control

N %

Total

N %

Neither visible nor palpable 10 (8) 21 (16) 31 (12)

Somewhat visible & palpable 64 (46) 44 (34) 108 (40)

Clearly visible & palpable 64 (46) 63 (50) 127 (48)

Total 138 (100) 128 (100) 266 (100)


4.7.4 Cannulation on first attempt

Although it appeared from the data that it generally took little time to cannulate, there were

occasions when the process was lengthy. Undoubtedly, it became lengthy when the

cannula was not successfully inserted on first attempt. On 25% of occasions cannulation

failed on first attempt, and one in every ten required three or more attempts. On one

occasion it took 7 attempts to place the cannula.

The number of failed attempts to cannulate appeared to differ little between the massage

and control groups. Individuals in both groups recorded on average two failed attempts

during the period they provided data. However, there was great variability. In the control

group there was an individual that reported 11 failed attempts to cannulate them over the 6

cycles they provided data. This compared with a maximum of 6 failed attempts across an

individual’s 6 treatment cycles in the massage group. Although there was some variability

in the number of unsuccessful cannulations between the massage and control groups,

these were not statistically significant.

On the 41 (18%) occasions when cannulation proved difficult, the nurses did use other

measures in attempt to dilate veins. In all but four of these they used warm water to

increase blood flow, and lumen volume.

Inability to cannulate on first attempt clearly has cost implications. Costs can be

considered in terms of patients’ pain and anxiety, nursing time as well as the tangible cost

of discarded cannulas. To determine whether factors, other than massage, impacted on

the cannulation process and thereby contributed to such costs, further statistical analyses

were undertaken. These are presented in section 4.9.

4.8 Attitudes towards, and perceptions of, massage

Data were collected on the 138 occasions when patients had massage to determine their

attitudes towards it. Responses recorded to questions regarding the intervention were

very positive. Almost all responses stated satisfaction with arm massage (95%); the other

5% of answers recorded feeling neutral about it.


On 93% of occasions, patients reported that massage had met their expectations,

although 7% of responses stated they had not known what to expect. This was referred to

in the interviews with stakeholders, where it emerged that for many people, massage

during the study had been their first experience of touch or other complementary

therapies.

From the interviews, it was gathered that whether or not patients believed massage aided

cannulation or relaxed them prior to it, they often looked forward to it and perceived it as a

‘positive’ aspect of the chemotherapy experience. All bar one of the interviewees spoke of

massage as being in some way comforting or relaxing. Massage was described as

‘luxurious’ (058), ‘pampering’ (022), and a ‘nice little treat!’ (021) that was ‘soothing’ (029).

One individual considered themselves ‘lucky’ through feeling ‘relaxed’ and ‘cared for’

through massage and reported that they ‘would recommend it (029)’to others. Another

had found it ‘relaxing’ and ‘reassuring’ (046). A further person found it a way of ‘passing

the time in a pleasant manner’ while waiting for treatment (003). Of the seven women that

repeatedly found cannulation problematic and painful, three specifically mentioned

massage as helping the process (007, 028, 031). Two further women suggested that it

might possibly have aided the process (010, 021).

Many interviewees found that not only was the massage positive but that the therapists

themselves made a very positive contribution. Familiarity was a key issue that arose.

Individuals enjoyed the familiarity, continuity and rapport they developed with the

therapist(s) they came into contact with (007, 010, 022, 038). It was viewed as ‘lovely to

have the same person’ (007, 023, 029, 031). One person explained, ‘you found yourself

sort of having a one-to-one conversation (with)…you were being looked after (by),

cosseted’ (029).

On 89% of occasions massage was perceived as a ‘very pleasant’ experience.

Descriptors commonly selected to describe feelings evoked by it included feeling relaxed

(98%), warm (62%), calm (61%) and sleepy (18%). Few negative responses were given

(Table 4.11)


Table 4.11 Feelings when massaged

(n = 133) Frequency %

Relaxed 131 98

Warm 83 62

Calm 81 61

Sleepy 24 18

Worried 2 2

Tickly 2 2

On most occasions, participants reported feeling very relaxed before massage

commenced (91%). However on almost 10% of occasions, participants felt some, or quite

a lot of, anxiety. They reported that they were not sceptical of the value of massage (98%

of occasions), and generally felt comforted during the process (81% of occasions), and

reported that it conveyed the feeling that they were being ‘treated as an individual’ (87% of

times) by ‘someone that had time to care’ (88% of times). After the massage they reported

feeling relaxed (89% of times), calm (87% of times) and reported on 75% of occasions that

it helped them cope with cannulation. This relatively low figure, when compared with other

feelings associated with massage, was explained during the interviews. Some individuals

articulated that whilst it was enjoyable, it did not make cannulation any less painful or

unpleasant. As one lady expressed: ‘The arm massage was lovely...And it was nice to

feel, you know that…being pampered a little bit…but, it didn’t really help...it didn’t take

away, the fear, you know...you’re going in and you’re going to have it’ (022). On 95% of

occasions individuals reported that, based on their experiences that day, they would

choose to have arm massage again if they had to have chemotherapy in future; 96%

would recommend it to others.

To determine whether there was any difference in perceptions of massage according to

gender or age, a series of chi-square tests were undertaken. These revealed no

difference according to age, but did identify differences associated with gender. It

appeared women were significantly more apprehensive than men before massage

commenced and responded more favourably to the process; they reported feeling

significantly more comforted, nurtured, relaxed, and calm. They also stated they felt

treated as an individual by someone with time to care significantly more than men (Table


4.12). However, they did not perceive that it helped them cope any better with cannulation

when compared with the men in the study.

Table 4.12 Feelings generated by massage according to gender

Feeling/perception Men

N %

Women

N %

2χ statistic p-value

Apprehension

before massage

Little/None

Some/much

44 (100)

0

77 (88)

11 (12)

6 0.016*

Comforted Little/None

Some/much

14 (35)

26 (65)

10 (11)

78 (89)

10.1 0.003**

Nurtured Little/None

Some/much

16 (44)

20 (56)

10 (11)

77 (89)

16.6 0.000**

Relaxed Little/None

Some/much

9 (20)

35 (80)

6 (7)

83 (93)

5.5 0.037*

Calm Little/None

Some/much

9 (23)

30 (77)

8 (9)

81 (91)

4.7 0.046*

Treated as

individual

Little/None

Some/much

12 (32)

25 (68)

4 (5)

84 (95)

18.1 0.000**

Someone had time

to care

Little/None

Some/much

12 (28)

31 (72)

4 (4)

85 (96)

14.9 0.000**

Helped to cope Little/None

Some/much

14 (33)

29 (67)

20 (22)

69 (78)

1.5 0.29

The findings presented above are exemplified by quotes attained during the telephone

interviews, where a difference in views towards the benefit of massage became evident.

The five males that were interviewed did not express specific anxiety prior to cannulation,

but found the massage to be pleasant. One man viewed it as ‘another aspect of it,

passing the time in a pleasant manner…I was fairly relaxed beforehand. But it was a

pleasant experience, rather than anything else’ (003). In general, the men tended to

suggest that others would benefit more from it than they had. One gentleman commented

‘I should imagine they’ll (massage therapists) be tremendous help to people that are

shaking…like are really quivering…and really down and wondering what’s going to happen

to their lives and that, and so I would think it would be very good for them indeed’ (058).

Thus, in general the men interviewed could see that massage may benefit others although

it had proved to offer them personally relatively little.


Conversely, females expressed stronger feelings about the effects of massage during

interviews. One lady brought together feelings expressed by other women that had found

cannulation problematic when she explained that massage was ‘very helpful because … it

puts you, especially the first time when you don’t know what, what, what’s going to

happen…the lady sort of does your arm … chats to you… puts (you in a) nice relaxed

mood, you know… brought the veins to, to the surface a bit more…it warms your

arm…and that brings your veins to the surface’.

4.9 Factors affecting cannulation

Initial analysis of the data revealed that although 25% of attempts to cannulate were

unsuccessful, these did not seem to be impacted by massage. Thus, further analysis was

undertaken in attempt to determine factors impacting on the cannulation process. These

are divided into factors that could vary on each visit such as the ease of the process or the

nurse that cannulated, and fixed demographic variables.

4.9.1 Variable factors

The variable independent factors that were investigated included the ease of cannulation,

the condition of patients’ veins, the nurse that cannulated and the cannula size. Each was

examined to determine whether they affected the time cannulation took, the pain

associated with the procedure and anxiety felt by individuals after cannulation.

4.9.1.1 Ease of cannulation

As would be expected it took less time to cannulate when it was perceived an easy

process (Table 5.13). On average (mean) it took 1.7 minutes (SD 1.4) to cannulate when

the process was straightforward and easy. When it was considered neither easy nor

difficult, time taken rose to 2.4 minutes (SD 1.9), and increased to 6.6 (SD 7.2) when

considered difficult. A Kruskal-Wallis test (a non-parametric one-way ANOVA) determined

these differences to be highly significant (p < 0.001).

Kruskall-Wallis (non-parametric One-Way ANOVA) = 2χ (df2 ) = 70.7, p = 0.000***


A Tukey’s post hoc test pointed out that it took significantly longer to cannulate when it

was ‘difficult’, than when it was felt to be neutral or easy. It is interesting to note that the

nurses recorded almost as many difficult cannulation episodes (n=98) as easy ones

(n=110) (Table 4.13).

Table 4.13 Effect of ease of cannulation on time taken

Ease of cannulation Number Mean time (mins) SD

Easy 110 1.7 1.4

Neutral 52 2.4 1.9

Difficult 98 6.6 7.2

The stakeholder interview that was conducted with the manager of the Day Unit provided

opportunity to discuss a view put forward by them that some individuals had ‘good veins’

that could be cannulated with ease, and in a timely fashion. This individual questioned

whether massage assisted cannulation and noted instead that in their experience the vein

palpability/visibility was an important factor. They elaborated: ‘I’m not sure if it (massage)

actually helps the, the nurses to cannulate…I think that where we ought to have had

difficulties we were still, we’ve still had them. So from a physical point of view…I can’t see

that it’s been, it hasn’t slapped me in the face to say: “Gosh, that vein has really come

up”…if you’re going to get very awkward hard veins to find, then they have remained so.

And I think, some of the times, we’ve had to go underneath hot water and all those things’.

The view above was supported by one patient who explained: ‘every single time it was

difficult to get a vein…I had the aromatherapy but I had to stand under hot water as well’

(007). Another lady revealed: ‘I had a hot water bottle, I used to take a hot water bottle with

me…and that helped as well…right from before they started anything…the nurse

suggested that and that helped as well. So the whole area was nice and warm. With the

massage it was even better to get the veins up.’ (029)

As would be expected, cannulation was felt by patients to be less painful when it was

perceived as an easy process (Table 4.14). On average (mean) pain was given a score of

1.3 (SD 1.5), on a 0-10 scale, when the process was straightforward and easy. When it

was considered neither easy nor difficult average pain scores rose to 2 (SD 1.9), and

increased to 3.03 (SD 2.5) when considered difficult. A Krukal-Wallis test determined

these differences to be highly significant (p < 0.001).


Kruskall-Wallis (non-parametric One-Way ANOVA) = 2χ (df2 )= 28.7, p = 0.000**

A Tukey’s post hoc test pointed out that cannulation was felt to be significantly more

painful when the process was ‘difficult’, than when it was felt to be ‘neutral’ or ‘easy’ (Table

4.14).

Table 4.14 Effect of ease of cannulation on procedural pain

Ease of cannulation Number Mean pain scores SD

Easy 106 1.3 1.5

Neutral 47 2.0 1.9


Cannulation caused patients less anxiety when it was perceived as an ‘easy’ process

(Table 4.15). On average (mean) anxiety was given a score of 1.1 (SD 1.8), on a 0-10

scale, when the process was straightforward and easy. When it was considered neither

easy nor difficult average anxiety scores rose to 1.5 (SD 1.6), and increased to 1.9 (SD

2.02) when considered difficult. A Krukal-Wallis test determined these differences to be

highly significant (p < 0.01).

Kruskall-Wallis (non-parametric One-Way ANOVA) = 2χ (df2 ) = 11.7, p = 0.003**

A Tukey’s post hoc test pointed out that cannulation caused significantly more anxiety

when it was ‘difficult’, than when it was felt to be ‘easy’ (Table 5.15).

Table 4.15 Effect of ease of cannulation on anxiety following cannulation

Ease of cannulation Number Mean anxiety scores SD

Easy 104 1.1 1.8

Neutral 51 1.5 1.6


Cannulation was quicker when it was perceived as an easy process (Table 4.16). On

average (mean) it took 1.7 (SD 1.4) minutes to cannulate when the process was


straightforward and easy. When it was considered neither easy nor difficult average the

time increased to 2.4 (SD 1.9) minutes, and increased to 6.6 (SD 7.2) minutes when

considered difficult. A Krukal-Wallis test determined these differences to be highly

significant (p < 0.001).


A Tukey’s post hoc test pointed out that cannulation took significantly longer when it was

‘difficult’, than when it was felt to neutral or easy (Table 4.16).

Table 4.16 Effect of ease of cannulation on time taken to cannulate

Ease of cannulation Number Mean time taken SD

Easy 110 1.7 1.4

Neutral 52 2.4 1.9


4.9.1.2 Vein palpability/visibility

Cannulation was felt by patients to be more painful in circumstances when the vein was

difficult to locate (Table 4.17). A Kruskal-Wallis test determined the differences between

the procedural pain scores, according to the vein condition, to be highly significant (p <

0.01).

Kruskall-Wallis (non-parametric One-Way ANOVA) = 2χ (df2 ) = 13.5, p = 0.001**

A Tukey’s post hoc test pointed out that cannulation was felt to be significantly less painful

when veins were ‘clearly visible & palpable’, than when veins were somewhat or neither

visible and/nor palpable (Table 4.17).

Table 4.17 Impact of vein visibility/palpability on procedural pain

Vein palpability/visibility Number Mean pain SD

Neither visible nor palpable 28 3.3 2.9

Somewhat visible & palpable 102 2.4 2.3

Clearly visible & palpable 122 1.5 1.6


Cannulation was associated with more anxiety in circumstances when the vein was difficult

to locate (Table 4.18). A Kruskal-Wallis test determined the differences between the

anxiety experienced, according to the vein condition, to be statistically significant (p <

0.05).

Kruskall-Wallis (non-parametric One-Way ANOVA) = 2χ (df2 ) = 6.7, p = 0.035*

A Tukey’s post hoc test identified that cannulation was associated with significantly less

anxiety when veins were ‘clearly visible & palpable’, than when veins were ‘neither visible

nor palpable’ (Table 4.18).

Table 4.18 Impact of vein visibility/palpability on anxiety

Vein palpability/visibility Number Mean anxiety SD




As would be expected, it took longer to cannulate in circumstances when the vein was

difficult to locate (Table 4.19). A Kruskal-Wallis test determined the differences between

the times taken to cannulate, according to the vein condition, to be highly significant (p <

0.001).


A Tukey’s post hoc test pointed out that it took significantly longer time to cannulate when

veins were ‘neither visible nor palpable’, than when somewhat or clearly visible and

palpable (Table 4.19).

Table 4.19 Impact of vein visibility/palpability on time taken to cannulate

Vein palpability/visibility Number Mean (time) SD





However, it is interesting to note that although massage appeared to make veins easier to

locate (section 4.7.3 – Table 4.10), this did not translate into those in the massage group

being easier to cannulate, or experiencing less pain (section 4.7.1.2 – Table 4.6) or anxiety

(section 4.7.2.2 – Table 4.8).

Once again, as would be expected, there were more successful cannulations on first

attempt when the vein was easy to locate (Table 4.20). A Chi-square test showed a

significant association between the ease with which a vein was located and the successful

placing of a cannula on first attempt (p < 0.001).

Chi-square test = 2χ (df2 ) = 16.7, p = 0.000***

71% of failures to cannulate on first attempt occurred when the vein was ‘somewhat’

difficult to locate or ‘neither visible nor palpable’ (Table 4.20).

Table 4.20 Association between vein palpability/visibility and cannulation on first

attempt

Vein palpability/visibility Didn’t Fail

N (%)

Failed attempt (s)

N (%)

Total

N (%)

Neither visible nor palpable 16 (9) 15 (23) 31 (12)

Somewhat visible & palpable 76 (38) 32 (48) 108 (41)

Clearly visible & palpable 106 (53) 19 (29) 125 (47)

Total 198 (100) 66 (100) 264 (100)

4.9.1.3 Nurse cannulating

The nurse cannulating appeared to be an important factor with respect to the time taken to

cannulate, and with regards to successful placing of cannulae on first attempt. This was

revealed when data from all cannulations performed by the individual nurses were

aggregated. Data were combined for those nurses that had performed less than 19

cannulations over the study period (Tables 4.21 to 4.24). Analysis of variance through

conduct of a Kruskal-Wallis test confirmed the differences between the nurses cannulating

were statistically significant (p < 0.001).



Table 4.21 confirms that some nurses took half as long as others to cannulate. There was

great variation in speed between the different nurses.

Table 4.21 Time taken to cannulate according to the nurse that cannulated

Nurse ID No. cannulations

performed

Mean time

(mins)

SD Range

(mins)

A 84 3.9 6.9 0.5 – 40

B 57 2.7 3.1 0.5 –15

C 54 2.4 3.9 0.5 – 25

D 29 6.5 3.6 1 – 15

E 19 3.6 5.2 0.5 – 23

Others: F, G, H & I 20 4.6 3.3 1 –15

A Tukey’s post hoc test identified that nurses B and C were significantly quicker at

cannulating when compared to the other nurses, while nurse D was significantly less swift

than the others.

Further chi-square analysis determined that there was a statistically significant difference

between the different nurses’ and their ability to cannulate successfully on first attempt (p <

0.05).

Chi-square test = 2χ (df5 ) = 13.8, p = 0.017*

Analysis of variance through conduct of a Kruskal-Wallis test found no statistically

significant difference between the nurse cannulating and the pain experienced by patients

following cannulation (p > 0.05).

Kruskall-Wallis (non-parametric One-Way ANOVA) = 2χ (df5 ) = 1.9, p = 0 .9 (ns)

Pain scores did not differ greatly according to the nurse cannulating (Table 4.22)


Table 4.22 Procedural pain according to the nurse that cannulated


performed

Mean pain SD

A 86 2.1 2.2

B 54 2.02 2.1

C 52 2.2 2.3

D 27 2.1 2.2

E 18 2.3 1.8

Others: F, G, H & I 15 1.7 2.3

Analysis of variance through conduct of a Kruskal-Wallis test found no statistically

significant difference between the nurse cannulating and the anxiety experienced by

patients following cannulation (p > 0.05).

Kruskall-Wallis (non-parametric One-Way ANOVA) = 2χ (df5 ) = 2.3, p = 0.8 (ns)

Anxiety scores did not differ greatly according to the nurse cannulating (Table 4.23)

Table 4.23 Anxiety following cannulation according to the nurse that cannulated


performed

Mean anxiety SD

A 85 1.5 1.9

B 52 1.5 1.7

C 54 1.7 2.2

D 29 1.2 1.8

E 18 1.3 1.3

Others: F, G, H & I 19 1.3 1.9

Table 4.24 below suggests that the nurses had differing levels of skill – unless particular

nurses always cannulated patients with difficult veins, and thus the findings reflect this

factor rather than the nurses’ skills.


Table 4.24 Failed cannulation according to the nurse that cannulated

Nurse ID No failed attempt

N (%)

Failed attempt(s)

N (%)

Total

N (%)

A 58 (67) 28 (33) 86 (100)

B 45 (79) 12 (21) 57 (100)

C 49 (92) 4 (8) 53 (100)

D 19 (66) 10 (34) 29 (100)

E 13 (68) 6 (32) 19 (100)

Others: F, G, H & I 14 (70) 6 (30) 20 (100)

Evidence in Tables 4.21 and 4.24 demonstrate that nurses referred to as Nurses B and C

were both more rapid and successful in their attempts to cannulate than others

undertaking this task. Findings from analysis of the stakeholder and patient interview data

suggest that nurses’ differing skill is an important factor. Both the patients themselves and

the nurse in charge of the Day Unit explained the importance of skill and experience.

The nurse in charge of the Day Unit was clear in outlining factors that aid successful

cannulation, and these included “definitely the experience of the nurse, her confidence.

Getting to know the patient, there’s definitely an aspect of that…you do get to know their

veins…So it’s the experience of the nurses, their confidence”.

When patients reported experiencing pain following cannulation, they often blamed it on

their veins and removed blame from the person cannulating. Nevertheless, 27% of those

interviewed commented that the level of pain they felt varied depending on the

‘experience’ of the nurse who cannulated: ‘some are absolutely brilliant, some, you know,

need a bit more practice basically. I mean, there’s nothing you can do about it. There’s no

substitute for experience’ (024). ‘Some people seem to do it…might do it easier that

others, and others have a problem with it…I think it’s more (problematic) when it’s the

experienced, inexperienced ones, but then they’ve got to learn, haven’t they?’ (010).

4.9.1.4 Cannula size

A Mann Whitney test found a statistically significant difference between the size of the

cannula used and the anxiety experienced by patients following cannulation (p < 0.05).


Non-parametric independent samples t-test (Mann Whitney) = z = -2.15, p = 0.032*

Typically, being cannulated with a 22 cannula was associated with more anxiety (Table

4.25).

Table 4.25 Effect of cannula size on anxiety

Study group Anxiety after cannulation

Mean (SD)


22 cannula 1.6 (1.8) 0-9

24 cannula 1.2 (1.9) 0-9

-2.15 0.032*

Furthermore, conduct of a Mann Whitney test found a statistically significant difference

between the size of cannula used and procedural pain experienced by patients following

cannulation (p < 0.001).

Non-parametric independent samples t-test (Mann Whitney) = z = -4.69, p = 0.000***

Typically, being cannulated with a 22 cannula was associated with more procedural pain

(Table 4.26).

Table 4.26 Effect of cannula size on procedural pain

Study group Procedural Pain

Mean (SD)


22 cannula 2.4 (2.1) 0-10

24 cannula 1.4 (2.1) 0-9

-4.69 0.000***

The fact that patients were more anxious and experienced more pain when cannulated

with a smaller needle is counterintuitive. In the main, women (78%) we cannulated using a

size 22 cannula. Therefore, it is possible that the anxiety and pain reported relates to the

fact that those cannulated with the smaller sized cannulas they were predominantly female

(See section 4.9.2.1).


Nevertheless, cannula size did not have an effect on the process itself, as neither he time

taken to cannulate was not impacted significantly by the size of cannula (Mann-Whitney

test, 2-tailed, p = 0.48), nor was failure to cannulate (Chi-square, p = 0.19).

4.9.2 Demographic factors affecting cannulation

The impact of specific demographic factors that were constant over time (including gender,

age and treatment regime) on the cannulation process was determined.

The following features of cannulation were included in the analysis: time taken to

cannulate, pain associated with the procedure, and anxiety following cannulation.

4.9.2.1 Gender

It was decided to look at the impact of gender in recognition that men and women may

react to stressful situations and medical procedures, including cannulation for

chemotherapy, differently.

Analysis of data relating to successful insertion of cannula at first attempt identified that

there were differences between men and women (p < 0.05).

Fisher exact test (Chi-square analysis) = 2χ (df1 ) = 5.82, p = 0.016*

Females failed to be cannulated on first attempt on 30% of occasions, while this failure

occurred on only 16% of occasions for males (Table 4.27).

Table 4.27 Association between gender and insertion of cannula on first attempt

Number of failed

attempts

Male

N %

Female

N %


None

One or more

74 (84)

14 (16)

124 (70)

52 (30)5.8 0.016*

Likewise, analysis of data relating to the time taken to cannulate men and women in the

sample identified that there did appear to be a gender difference (p < 0.001)


Non-parametric independent samples t-test (Mann Whitney) = z = -3.8, p=0.000***

Women took significantly longer to cannulate than men (Table 4.28)

Table 4.28 Time taken to cannulate (in mins) according to gender

Gender Mean (SD) Range z-value p-value

Male 2.3 (2.4) 0.5 – 14

Female 4.3 (5.9) 0.5 – 40

-3.8 0.000**

The relationship between gender and time taken to cannulate is further exemplified in

figure 4.3:

Figure 4.3 Time taken to cannulate according to gender

Time to cannulate

Above 5 minutes

2 to 5 minutes

1 to 2 minutes

1min and under

Cou

nt

70

60

50

40

30

20

10

0

Gender of patient

Male

Female


Data were then analysed to see whether the condition of men and women’s veins prior to

cannulation differed. This suggested that they did significantly (p < 0.001)


Outcome of this analysis suggested that women had veins that were significantly more

difficult to locate prior to the procedure than men (Table 4.29).

Table 4.29 Association between gender and vein palpability/visibility prior to

cannulation

Vein palpability/visibility Male

N %

Female

N %


Neither visible nor palpable

Somewhat visible & palpable

Clearly visible & palpable

1 (1)

16 (18)

72 (81)

30 (17)

92 (52)

55 (31)

60.4 0.000

The apparently greater difficulty with cannulating women was reflected in data relating to

pain following cannulation (p < 0.001)


However, women not only reported significantly greater pain than men, they also

experienced a greater range of pain (0-10) than men. Men reported relatively low levels of

pain associated with the procedure (0-3) (Table 4.30).

Table 4.30 Procedural pain following cannulation experienced according to gender

Study group P a i n f o l l o w i n g

cannulation

Mean (SD)


Male 0.86 (0.96) 0 – 3

Female 2.7 (2.3) 0 – 10

-6.75 0.000


Chi-square analyses were conducted on the data recording pain following cannulation.

These data were recoded to provide three classifications of pain (low, medium and high –

See section 3.12.1) (Table 4.31). These tests confirmed the statistically significant

association between gender and pain experienced following cannulation (p < 0.001).

Chi-square test = 2χ (df2 ) = 33.6, p = 0.000**

There was a clear difference between the groups with 1/3 of women reporting medium or

high levels of pain following cannulation. None of the men at any stage registered more

than a low level of pain (Table 4.31)

Table 4.31 Association between gender and level of pain following cannulation

Pain fo l lowing

cannulation

Men

N ( %)

Women

N (%)


Low pain

Medium pain

High pain

84 (100)

0 -

0 -

115 (68)

36 (21)

17 (11)

33.6 0.000

As previously reported, 70% of women interviewed reported having veins that were

problematic to cannulate, resulting in pain. One lady expressed during her interview: ‘They

had terrible problems trying to find my veins as well, which had added to the grief’ (021).

This differed markedly to the explanations provided by the men that were interviewed.

They revealed that in general they did not find cannulation painful. They appeared to

adapt to the cannulation process and associated discomfort – to them it became routine.

As one gentleman said, it was ‘not painful so I would cry out “ouch” or anything like

that...No, I mean, it’s mildly discomfortable. Uncomfortable. But I wouldn’t put it any higher

than that’ (003).

The apparently greater difficulty with cannulating women was further reflected in data

relating to anxiety after cannulation (p < 0.001).



Women not only reported significantly greater anxiety than men, they also experienced a

greater range of anxiety (0-9) than men. Men reported relatively low levels of anxiety

associated with the procedure (0-3) (Table 4.32).

Table 4.32 Anxiety following cannulation experienced according to gender

Study

group

Anxiety following cannulation

Mean (SD)


Male 0.5 (0.8) 0 – 3

Female 1.9 (2.01) 0 – 9

-6.6 0.000***

Chi-square analyses were conducted on the data recording anxiety following cannulation.

These data were recoded to provide three classifications of anxiety (low, medium and high

– See Table 5.31). These tests confirmed the statistically significant association between

gender and anxiety experienced following cannulation (p < 0.001).


There was a clear difference between the groups with 20% of women reporting medium or

high levels of anxiety following cannulation. None of the men at any stage registered over

low levels of anxiety (Table 4.33).

Table 4.33 Association between gender and anxiety following cannulation

Anxiety following

cannulation

Men

N ( %)

Women

N (%)


Low pain

Medium pain

High pain

85 (100)

0 -

0 -

138 (80)

27 (16)

7 (4)

19.4 0.000


4.9.2.2 Age

To determine whether age was a factor that impacted on the cannulation process, the age

data were coded into those under or over the age of 56. Analyses were then undertaken to

determine whether there were differences according to age with regards to time taken to

cannulate, successful cannulation on first attempt and on anxiety and pain associated with

the procedure.

Initial analysis was undertaken through conduct of Mann-Whitney and Chi-Square tests to

determine any differences between the two age groups with regards to time taken to

cannulate, or the success/failure rate in placing cannula on first attempt. These revealed

no statistically significant differences between age and successful insertion of cannula on

first attempt (p = 0.248), or between age and time taken to cannulate (p = 0.076).

The levels of pain reported by the sample were then analysed to determine whether there

were differences according to participants’ age. This was ascertained through conduct of

a Mann-Whitney test; a statistically significant difference was confirmed (p < 0.001).

Non-parametric independent samples t-test (Mann Whitney) = z = -7.51, p=0.000***

This analysis suggested that younger patients reported significantly greater pain following

cannulation than older patients (p < 0.001) (Table 4.34).

Table 4.34 Procedural pain following cannulation experienced according to age


Mean (SD)


24-55 yrs 3.5 (2.2) 0 – 8

56-79 yrs 1.5 (1.8) 0 – 10

-7.51 0.000***

When further chi-square analysis was undertaken this association became more evident (p

< 0.001).


It appears that only 12% of individuals aged 56 years and over experienced medium or

high levels of pain in comparison with over 40% of those in the younger age group (Table

4.35).


Table 4.35 Association between age and level of pain following cannulation

Pain following

cannulation

24-55 yrs

N %

56-79 yrs

N %


Low pain

Medium pain

High pain

45 (58)

21 (27)

11 (15)

154 (88)

15 (9)

6 (3)

28.4 0.000***

Similar tests were conducted on data recording patients’ levels of anxiety. This analysis

determined that younger patients also reported significantly greater anxiety following

cannulation than older patients (p < 0.001) (Table 4.36).

Table 4.36 Anxiety experienced after cannulation according to age

Study group Anxiety following cannulation

Mean (SD)


24-55 yrs 2.84 (2.1) 0 – 9

56-79 yrs 0.86 (1.3) 0 – 8

-8.05 0.000

Once again, chi-square analysis clarified the association between patients’ age and

anxiety experienced following cannulation (p < 0.001).


Nearly all those in the older age group reported low anxiety after the procedure (96%)

whereas 32% of younger patients reported feeling medium or high levels of anxiety

afterwards (Table 4.37).

Table 4.37 Association between age and anxiety experience after cannulation

Anxiety following

cannulation

24-55 yrs

N %

56-79 yrs

N %


Low anxiety

Medium anxiety

High anxiety

54 (68%)

21 (26%)

5 (6%)

169 (96%)

6 (3%)

2 (1%)

37.7 0.000***


Tests were also conducted on data recording the time taken to cannulate patients. This

analysis determined that there was not a statistically significant difference between the

time taken to cannulate younger patients when compared to older patients (p > 0.05)

(Table 4.38). However, the difference between the time taken to cannulate and age did

approach significance; older patients appeared to be cannulated quicker on average.

Table 4.38 Time taken to cannulate according to age

Study group Time to cannulate

Mean (SD)

Range

(mins)

z-value p-value

24-55 yrs 4.3 (5.2) 0.5 – 30

56-79 yrs 3.4 (5.01) 0.5 – 40

-1.8 0.08 (ns)

Chi-square analysis showed a lack of clear association between patients’ age and the time

taken to cannulate them (p > 0.05).

Chi-square test = 2χ (df3 )= 5.9, p = 0.1 (ns)

It is of interest to note that almost half of those in the older age group were cannulated in

under a minute (48%), when compared to the younger group (37%). Furthermore, _ of the

younger patients took more than 5 minutes to cannulate (Table 4.39).

Table 4.39 Association between age and time taken to cannulate

Time to cannulate 24-55 yrs

N %

56-79 yrs

N %


1 min and under

1 to 2 minutes

2 to 5 minutes

Above 5 minutes

30 (37%)

19 (23%)

12 (15%)

20 (25%)

87 (48%)

33 (18%)

35 (19%)

27 (15%)

5.9 0.1 (ns)

4.9.2.3 Nature of regime

The impact of treatment type on the cannulation process was investigated. This was

undertaken in realisation that the vesicant nature of chemotherapeutic agents often makes


repeated cannulation for the administration of treatment difficult. To do this, regimes were

classified as either vesicants or as irritants/non vesicants (Table 4.40).

Table 4.40 Chemotherapy regime classifications

Vesicants Irritants/Non vesicants

Cisplatin & Etoposide

CHOP

FEC

Epirubicin + Cyclophosphomide

ABVD

Single Epirubicin

Weekly 5FU +/- folinic acid

Carboplatin & Etoposide

Analysis was then undertaken to determine the impact of treatment classification on time

taken to cannulate, number of failed attempts when cannulating and on pain and anxiety

associated with the procedure.

Conduct of Chi-square tests determined that vesicant regimes were significantly

associated with failed cannulation attempts (p < 0.01) (Table 4.41).


Failure to cannulated occurred when the treatment was a vesicant drug regime in 29% of

cases, while failure only occurred in 15% of cases when the treatment was non-vesicant or

an irritant (Table 4.41)

Table 4.41 Association between nature of regime and insertion of cannula on first

attempt

Number of failed

attempts

Vesicant

N %

Other

N %


None

One or more

122 (71)

51 (29)

86 (85)

15 (15)

8.99 0.003**


Mirroring these findings, Mann-Whiney tests identified that vesicant regimes resulted in

cannulation being a significantly more lengthy procedure (p < 0.01) (Table 4.42).

Table 4.42 Time taken to cannulate (in mins) with vesicant and other regimes

Regime classification Mean (SD) Range z-value p-value

Vesicant 4.4 (6.0) 0.5 – 40

Other

(Irritants/non vesicants)

2.5 (2.7) 0.5 – 15

-2.8 0.005**

On average, cannulation for delivery of vesicant agents took twice as long as cannulation

for administration of other drugs. Indeed, with vesicant regimes, nearly _ of all

cannulations performed took over 5 minutes unlike other drugs where those taking over 5

minutes comprised only 10% of all cannulations.

Given the findings above, the association between the nature of the drug regime and

perceived difficulty on cannulating (easy, neutral or difficult) was investigated and found to

be statistically significant (p < 0.001).


Cannulation was ‘easy’ in 68% of cases when the drug regime was non-vesicant or irritant,

while it was ‘difficult’ in 51% of cases when the drug regime was vesicant (Table 4.43).

Table 4.43 Association between nature of regime and ease of cannulation

E a s e o f

cannulation

Vesicant

N %

Other

N %


Easy

Neutral

Difficult

42 (26)

38 (23)

83 (51)

68 (68)

14 (14)

18 (18)

46.6 0.000***

As can be seen from Tables 4.43 and 4.44, tests performed determined that vesicant

agents were not only significantly associated with greater perceived difficulty with

cannulating, but also significantly associated with and greater pain following cannulation.


Table 4.44 Procedural pain following cannulation experienced with vesicant and

other regimes


Mean (SD)


Vesicant 2.8 (2.3) 0-10

Other 0.9 (0.3) 0-9

-7.4 0.000**

When level of pain was classified into low, medium and high and crosstabulated by nature

of regime, this association between regime and pain following cannulation was highly

significant (p <0.001).


Nearly all those in receipt of non-vesicant drugs reported low pain following cannulation

whereas 1/3 of those prescribed vesicant ones reported medium or high pain (Table 4.45).

Table 4.45 Association between nature of regime and level of pain following

cannulation

E a s e o f

cannulation

Vesicant

N %

Other

N %


Low pain

Medium pain

High pain

108 (68)

34 (22)

16 (10)

91 (97)

3 (2)

1 (1)

28.7 0.000***

Tests performed determined that vesicant agents were significantly associated with

greater anxiety following cannulation (p < 0.001) (Table 4.46).


Table 4.46 Anxiety following cannulation experienced with vesicant and other

regimes

Study group Anxiety following cannulation

Mean (SD)


Vesicant 1.9 (1.9) 0-9

Other 0.7 (1.3) 0-8

-6.3 0.000***

A chi-square test further reinforced the previous findings; anxiety was classified into low,

medium and high and crosstabulated by nature of regime. This association between

regime and anxiety following cannulation was highly significant (p < 0.01).


It was found that nearly all those in receipt of non-vesicant or irritant drugs reported low

anxiety following cannulation whereas 19% of those prescribed vesicant ones reported

medium or high anxiety (Table 4.47).

Table 4.47 Association between nature of regime and anxiety following cannulation

Ease of cannulation Vesicant

N %

Other

N %


Low anxiety

Medium anxiety

High anxiety

130 (81)

25 (15)

6 (4)

93 (97)

2 (2)

1 (1)

13.7 0.001

4.9.3 Experience of first treatment

It was anticipated that patients could find their first ever cannulation for chemotherapy

more difficult and stressful than subsequent ones since they were uncertain of what to

expect, and many had been recently diagnosed. To determine whether this was the case,

the data recorded at first cycle were compared with two subsequent ones (Table 4.48)

through conducting Friedmann’s tests. The five variables analysed in this manner were:

the time taken to cannulate; and both the anticipated and procedural pain experienced by

participants. These determined that feelings recorded immediately prior to cannulation,

i.e. anxiety prior to cannulation and anticipated pain, for first treatment, were significantly


higher than those reported on subsequent cycles. This was not the case with procedural

pain, anxiety after cannulation or the time taken to cannulate. There were no statistically

significant differences in the latter variables over time.

Table 4.48 Trends in anxiety and anticipated pain over time

Mean Chi-square

statistic

DF p-value

Anxiety pr ior to 1st

chemotherapy cycle

2.49

Anxiety prior to 2nd

chemotherapy cycle

1.66

Anxiety pr ior to 3rd

chemotherapy cycle

1.85

7.73 2 0.021 *

Pain anticipated prior to 1st

chemotherapy cycle

2.30

Pain anticipated prior to 2nd

chemotherapy cycle

1.66

Pain anticipated prior to 3rd

chemotherapy cycle

2.04

10.9 2 0.004**

4.10 Models explaining factors impacting on cannulation

Regression models were constructed to ascertain factors that impacted on 5 key

dependant variables: Anxiety before and after cannulation, anticipated pain and actual

experienced pain, and time taken to cannulate.

A two-stage process was used to arrive at the models reported in this section:

1) Stage one: Inferential statistical tests (including Mann-Whitney and Chi-square

tests) were carried out involving the 5 dependant variables (presented in previous

sections).

2) Stage two: Various models were constructed to predict each of the 5 dependant

variables. More than one model was constructed to explain each one because the

number of possible contributing factors was too great to place in one model. A high


number of factors placed in a model can give rise to a large error value. This can

result in derivation of spurious results.

The modelling process used in step two entailed backwards stepwise elimination of non-

significant (and therefore non-impacting) main effects and 2-way interactions from the

models. Main effects are independent variables that impact on the dependent one. Two-

way interactions comprise the effect on the dependant variable created by two

independent factors interacting together. Main effects were only removed from the model

when all its interactions with other factors had been removed. Therefore in the results

presented within this section of the chapter, the reader will notice that non-significant main

effects remain in a model where they contribute to a significant interaction effect.

(Interaction effects are denoted by a §).

4.10.1 Model explaining anxiety prior to cannulation

In Table 4.49, the reader will note that factors in previous sections that appeared to impact

on anxiety prior to cannulation (age, gender, anticipated pain and massage group) were

incorporated into the model. Through backwards stepwise regression, it became apparent

that factors that did contribute to feelings of anxiety prior to cannulation were anticipated

pain, gender and the intervention group to which participants were allocated.

Table 4.49 Model of factors impacting on anxiety prior to cannulation

Dependant

variable

Factors Resulting factors

Anxiety prior to

cannulation

• Massage group

• Age group

• Gender

• Anticipated pain

(Covariate)

• Massage group (p = 0.02*)

• Gender (p = 0.002**)

• Anticipated pain

(p = 0.000***)

Patients were significantly more anxious prior to cannulation when they did not have

massage, were female, or anticipated experiencing high levels of pain following

cannulation (Appendix 10).


4.10.2 Model explaining anxiety following cannulation

Once again, factors identified from previous analyses as impacting on anxiety following

cannulation (age, gender, cannulating nurse, average pain following cannulation) were

incorporated into the model along with the intervention group people were allocated to

(Table 4.50). Through backwards stepwise regression, it became apparent that many

factors contributed to feelings of anxiety following cannulation. Significant main effects

included age, pain typically experienced following cannulation and the intervention group

individuals were randomised to. Furthermore, interactions between gender and massage

group, massage group and average cannulation pain, and the nurse cannulating and

average pain were statistically significant factors.

Table 4.50 Model of factors impacting on anxiety following cannulation

Dependant

Variable


Anxiety

Following

Cannulation

• Massage group

• Age group

• Gender

• Nurse ID

• Grouped average pain

scores following

cannulation


• Age group (p = 0.000***)

• Gender (p = 0.073) (§)

• Nurse ID (p = 0.083) (§)

• Average pain (p = 0.000***)

• Gender x Massage (p = 0.037*)

• Massage x Average pain

(p = 0.000***)

• Nurse ID x Average pain

(p = 0.039*)

§ No significant main effect but remain in the model as they contribute to a significant interaction with

another factor

From this model it appeared that individuals felt more anxiety after cannulation if they were

younger, typically found cannulation painful, and were not in receipt of massage prior to

the procedure. Furthermore, interaction effects suggested men that did not have massage

were susceptible to feeling anxious after cannulation, as were people that did not have

massage but typically experienced medium ranking (or more) pain. The model also

identified a statistically significant interaction effect between the cannulating nurse and the

pain typically experienced following cannulation. This final interaction effect suggests that

when particular nurses cannulated and the procedure was typically associated with


medium or higher pain, individuals were likely to feel greater anxiety afterwards (see

Appendix 11).

4.10.3 Model explaining anticipated pain prior to cannulation

Further modelling was undertaken to determine the main and interaction effects that gave

rise to the level of pain individuals anticipated they would experience following cannulation.

Based on previous analysis, the following independent factors were incorporated into the

model: age, cannulating nurse, anxiety prior to cannulation and intervention group people

were allocated to (Table 4.51). Factors were eliminated from the model as each of them

acted independently to give rise to anticipated pain prior to cannulation along with two

interaction effects. These interaction effects were age and the identity of the cannulating

nurse, and the identity of the nurse and the level of patients’ anxiety before cannulation.

Table 4.51 Model of factors impacting on anticipated pain prior to cannulation

Dependant

Variable


Anticipated pain

prior to

cannulation

• Massage group

• Age group

• Nurse ID

• Anxiety prior to

cannulation

(Covariate)


• Age group (p = 0.000***)

• Nurse ID (p = 0.006**)

• Anxiety prior to cannulation

(p = 0.000***)

• Age x Nurse ID (p = 0.001**)

• Nurse ID x Pre-anxiety

(p = 0.002**)

From this model it appeared patients anticipated greater pain when they were younger,

allocated to the intervention group, and cannulated by specific nurses.

Additionally, they anticipated more pain when they experienced high anxiety prior to

cannulation. Interaction effects were identified in the model and determined that younger

individuals when cannulated by particular nurses anticipated more pain than others did.

Another interaction effect identified in the model suggests that those with higher anxiety

prior to the procedure when cannulated by specific nurses also anticipated higher levels of

pain (Appendix 12).


4.10.4 Model explaining procedural pain

In order to determine factors that explained procedural pain, a model was tested that

incorporated factors that had been identified as statistically significant in previous testing.

These were age, gender, nature of chemotherapy (vesicant versus non vesicant or

irritant), pain experienced on initial cannulation, and anxiety prior to cannulation along with

the massage group individuals were randomised to (Table 4.52). Stepwise elimination of

non-significant factors resulted in three explanatory factors remaining in the model: the

nature of the chemotherapy given, the pain experienced on first cannulation and the level

of anxiety experienced prior to the procedure.

Table 4.52 Model of factors affecting patients’ pain following cannulation

Dependant

variable


Pain following

cannulation

• Massage group

• Age group

• Gender

• Chemotherapy regime

• Grouped pain scores

experienced on 1st

cannulation

• Anxiety prior to cannulation

(covariate)

• Chemotherapy

regime (p = 0.016*)

• Pain experienced on

1st cannulation

(p = 0.000***)

• Anxiety prior to

cannulation

(p = 0.000***)

This model confirms that patients experienced significantly more pain following cannulation

when treated with vesicant drugs, if they experienced high pain on their first cannulation

for chemotherapy, or were highly anxious prior to being cannulated (see Appendix 13).

4.10.5 Model explaining time taken to cannulate

A final model was constructed and tested. This one was developed to explain factors that

determined how long cannulation took. Factors included within the model were: age,

gender, nature of chemotherapy regime, identity of cannulating nurse, and both the pain

typically experienced during cannulation and the pain experienced on first ever cannulation

for chemotherapy. Stepwise elimination of non-significant factors left three main effects

and one interaction one. The main effects were age, chemotherapy type and identity of


the nurse. The interaction effect that was statistically significant within the model was one

between age and the identity of the nurse performing the procedure (Table 4.53).

Table 4.53 Model of factors affecting time taken to cannulate patients

Dependant

variable


Time taken to

cannulate

• Age group

• Gender


• Nurse ID

• Grouped pain scores

experienced on 1st

cannulation

• Average pain following

cannulation (Covariate)

• Age group (p = 0.032*)


(p = 0.025*)

• Nurse ID (p = 0.001**)

• Age x Nurse ID

(p = 0.01**)

This model determines that individuals take longer to cannulate when the procedure is

undertaken by particular nurse(s), and when patients are younger and in receipt of

vesicant treatments. An interaction effect evident in the model determined that when

younger patients were cannulated by specific nurse(s) the procedure took longer than at

other times (Appendix 14).

4.11 Impact of massage service on delivery of chemotherapy day care

Previous sections of this chapter reported on the impact of massage, and other influential

factors, on individual experience. We will now turn to consider the impact of the massage

service on the atmosphere within, and delivery of care by, the Day Unit itself. This was

alluded to particularly in the stakeholder interviews and therapist focus group.

The massage therapists themselves alluded to their contribution to care delivery on the

Day Unit under investigation during the focus group. They recognised that the nursing

staff were usually very busy, and that their perception of this ‘busyness’ distanced them

from those they were providing care to. The therapists perceived that they performed a

very specific role in the treatment suite. The group discussed how they might represent a

link between the staff and patients. They felt very much ‘part of the team’ and explained

‘we’ve all got a place in that team, and we do bridge gaps between the nurses and the


medical staff and the family’. The group also hoped that the massage service would help

chemotherapy be ‘a less stressful experience’, reduce anxiety, and have a generally

positive effect through helping patients relax.

The stakeholders spoke of their visions for the massage service before it was instituted.

They explained how they had felt it would be ‘hugely successful’ and ‘very beneficial’,

through providing ‘relaxation and stress release’. They envisaged it would be ‘therapeutic’

and anticipated it would be viewed positively by both patients and staff through providing

an ‘improved’ and ‘nice atmosphere’ within the treatment suite. It was also hoped that it

would facilitate nurses’ cannulation of patients. Although the effect of massage on

cannulation remained unanswered when the stakeholder interviews were conducted, it

became apparent that their other visions had come to fruition. Patients, therapists and

stakeholders alike considered the massage service successful. It was seen as very

beneficial and enhanced the atmosphere within the Unit as a whole.

One stakeholder spoke of a particular benefit for nurses following introduction of the

massage service. They explained ‘it helps the nurses’ and ‘buys them time’ in their

schedule of administering treatment; “I think it helps the nurses. In fact I know it does. I’d

like to see the service maintained and grow with time; grow with patients that we get. I

would hate not to have anything there. And I think we’d miss being able to not being able

to offer something important to us”. Therapists themselves talked of the benefit provided to

nurses through providing ‘more hands and less formality’. They explained in the focus

group that by providing massage they were able to use and fill the time that patients had to

wait before the nurse was ready to administer treatment. The nurses were said to feel a

kind gratitude towards the therapists for their voluntary presence and contribution. One

stakeholder discussed how the therapists adapted as they integrated into the daily

workings of the Day Unit. Clearly initial stages were difficult at times as it can be a

challenge ‘having strange people coming into the treatment suite.’ However, this eased

with time as staff and volunteers got to know and appreciate each other and liaised

increasingly over time.

4.12 Impact of massage service on cancer services

Comments made by patients, stakeholders and therapists referred to the high quality

service provided to patients by the cancer services team. They also referred to the

contribution made to this by the massage service. Patients perceived the massage

initiative as ‘first class’, a ‘luxury’ worthy of recommendation to others.


Most patients in the interviews spoke highly of the general environment within the Day

Unit. They expressed the importance of feeling ‘welcome’, ‘relaxed’, ‘calm’, ‘comfortable’

and ‘stress-free’. The received view was that the massage service enhanced this within

the Day Unit.

The therapists discussed a number of ways in which the massage service might expand in

future during the focus group discussion. A few therapists mentioned how positive they

thought it would be to offer massage to carers. The group also felt it would be ‘wonderful

to see it on all the wards…to have a therapist available usually’. In this way they surmised

the service might not ‘just be offered to patients, there are nurses too that could benefit’.

The focus group spent some considerable time discussing whether therapists should be

paid for their services. They stressed that with complementary therapies becoming more

recognised professions ‘especially with college diplomas, courses that are becoming

available now’, and with the cost of training to be a therapist that ‘the way forward…in

some future time…will be paid’ posts. They hoped that posts that were remunerated would

be provided with regular one-to-one supervision and support and a clear method of

appraisal. These were areas that were considered to be lacking somewhat at present.

Further, the group expressed awareness of the need for formalised guidelines. They

articulated that guidelines or protocols were needed to standardise procedures. They also

considered that guidelines might help the issue of ‘confidentiality’. There was discussion

over how therapists should go about passing on important information about the patient

‘for their well-being, for their comfort’ to appropriate staff. Most of the group felt that the

passing on of patient-related information to staff was down to ‘common sense’, although

others did question ‘how can we breach confidentiality when we’re actually within the work

environment?’ when ‘you’re acting in the patients’ best interest’. Members of the focus

group perceived this as a grey area, and one that could do with clarification. Similarly, the

stakeholders echoed concerns and considerations regarding patient confidentiality,

support and supervision of therapists, development and use of guidelines, and the desire

of therapists to have paid posts. Funding was a key factor in considering the expansion of

the service and institution of paid therapist posts.

When looking to the future, the stakeholders talked of four ways they hoped it could be

developed in future. First, they voiced the hope that the service might be expanded to

patients in their homes. They explained that at the present time patients could end up

‘feeling quite upset when they’ve finished treatment…and we just can’t accommodate that’.

Second, they explored the possibility of having paid therapist posts in the evening. This

would allow for additional service cover in future. Another key development would be


having dedicated space, ‘facilities’ where complementary therapies could be provided.

One individual explained that ‘it would be very nice to have a proper sort of therapy

area…a proper designated area’. The final aspect that stakeholders wished to improve

was the level of cover provided by therapists. This was variable during the study, and at

times therapists struggled to come into the Day Unit, and cover for other not able to work,

in order to provide arm massage to those in the study. The stakeholders talked of their

desire for the massage service to be available full-time and expanded to cover not only

patients but carers and staff within the hospital, and even patients at home in the

community.

4.13 Summary of results

The data provided by the various approaches to data collection provided an insightful

picture of the massage service and the benefit it afforded. The results from this study

suggest that massage can be beneficial in facilitating cannulation and certainly enhances

the environment in which chemotherapy is administered. It is one factor, along with a

number of others, which can influence the pain and anxiety that accompanies the

procedure. It appears, however, to impact less on the speed at which successful

cannulation is achieved. Rathermore, the skill of the cannulating nurse is fundamental in

this respect. The demographic characteristics of individual patients play an important part

with younger women appearing to find cannulation more problematic, painful and anxiety-

provoking. Further, certain chemotherapy treatments, notably those that are more

vesicant, are more commonly associated with pain. Patients having vesicant drugs

typically prove difficult and time-consuming to cannulate.


5 Discussion

5.1 Introduction

This chapter provides a discussion of outcomes associated with introducing a massage

service for patients undergoing cannulation prior to treatment in a Chemotherapy Day Unit.

The previous chapter pointed to the marginal statistically significant benefit afforded by

massage to those in the intervention group. However, it also provided colourful

descriptions from those that had had the massage intervention, suggesting that for some it

could provide a clinically significant effect. This chapter will explore this anomaly and

discuss the role massage may have in future delivery of cancer services. Following this,

the discussion turns to consideration of factors that are associated with difficult

cannulation. The chapter then concludes by detailing the study limitations and

recommendations for future research.

5.2 Massage and cannulation

The study aimed, through adopting a multi-method research approach incorporating an

RCT to determine:



More specifically it sought to answer whether the massage intervention

1. Reduced time taken for successful cannulation?

2. Reduced number of cannulas used?

3. Reduced pain associated with the procedure?

4. Reduced patients’ feelings of anxiety?

Results presented in the previous chapter suggested that massage had not impacted as

hypothesised. Rather, its measurable benefits were limited even though the qualitative

data strongly supported its use. The reasons for this are discussed below.


5.2.1 Massage and time taken to cannulate

Data from the Nurse Questionnaire suggested that arm massage was beneficial in

preparing patients’ veins for cannulation. A statistically significant association was

identified between massage and the vain palpabili prior to cannulation. Those massaged

had veins that were easier to locate both visually and on palpation. Twice as many in the

control group, when compared to the treatment group, had veins that the cannulating

nurses classified as ‘neither visible nor palpable’. These statistical findings were echoed in

the qualitative data. Seven women who had received massage reported that nurses found

their veins hard to locate at times. Of these, five alluded to the manner in which massage

benefited the cannulation procedure through making veins easier to access. Given this

finding, one could expect that this would be reflected in the time taken to cannulate. It

would seem logical that it would be quicker to insert a cannula into veins that are easily

located. However, this proved not to be the case in this study.

There are three plausible explanations for the above anomaly. First, it appeared that the

nurses were not accurate in their recording of time taken to cannulate. The intention was

that they recorded this time period on their own watches. However, feedback from the

nurses has indicated that in many instances they were only estimating the time taken and

thus it could be argued that the recorded time should be viewed only as a guide. Given

this, it would appear plausible that small, but important differences, in the time taken to

cannulate may have arisen but were not recorded due to the insensitivity/inaccuracy of

recording. This suggestion is lent support by the study conducted by Lenhardt et al. (29).

They determined that local warming halved cannula insertion time, but this difference

amounted to only around 20-30 seconds. If such a small difference had arisen in this

study also, it would not have been detected through the crude estimates of time that were

reported.

The second explanation for the anomaly relates to the lack of blinding in this study. The

nurses were not blind to the treatment arm patients were in. Due to lack of space, patients

received massage in the treatment suite where nurses were cannulating patients and

giving treatment. Further, there were often traces of oil on the arm that had been

massaged. Thus, it is possible that this realisation biased how they classified the condition

of patients’ veins prior to cannulation. Richardson (34) provides a discussion on the

complexities of using RCTs to evaluate complementary therapies. She, along with other


researchers including Anthony (35) suggest that blinding is often difficult to achieve in

studies of complementary therapies, as the therapist is an integral part of the intervention

and thus patients – and often others - will be aware of the group they are randomised to.

Further Richardson suggests that overemphasis on significance testing and inadequate

sample sizes often increase the probability of type 2 error and conclusions being

erroneously drawn that suggest the inefficacy of the intervention. To counteract this,

Kacperek (36) advocates incorporating patients’ views into the evaluation – the approach

used in this study.

Third, it could be argued that although patients’ veins may have been easier to locate in

those that had massage, it is possible that the residue of oil made the arm more slippery

and difficult to cannulate. If this were the case the benefit offered by massage may have

been counterbalanced by the difficulty imposed through the arm being slippery. This factor

was mentioned by one patient in their interview, and was a topic of informal discussion in

one of the steering group meetings. Thus, although this factor is worth bearing in mind, it

was not looked at specifically in this study.

5.2.2 Massage and cannula usage

Data relating to the success rate for insertion of cannulas suggested that 25% of cannulas

were not placed on first attempt. This figure supports the conduct of studies, such as this

one, that attempt to facilitate this process. Failed attempts are costly, embarrassing for the

nurse undertaking the procedure, and painful and anxiety provoking for those undergoing

it.

Analysis of data from the Nurses’ Questionnaire compared the success and failure rates

for cannulation between the two study groups. It had been hypothesised that when

massage was given there would be fewer unsuccessful attempts to cannulate. This was

not borne out in this study. Both groups reported a failure rate of around 25%; there was

failure to cannulate (with one or more attempts made before successful cannulation) in

26% of cannulations carried out within massage group, and 25% of those made within the

control group. This figure is in line with previous ones reporting failure to cannulate on first

attempt. Lenhardt et al. (29) studied the efficacy of local warming in aiding cannulation

and reported 28-30% of cannulas failed to be placed on first attempt in their control

groups. However, they determined that local warmth reduced these rates to 6%. Thus it

would appear from the current study that massage did little to reduce the number of

cannulas used, and proved less effective than local warming.


5.2.3 Massage and procedural pain

The third research question that this study sought to answer was whether arm massage

reduced the pain (both anticipated and actual) associated with cannulation. To determine

this, data were attained from the Patient Questionnaire and analysed to allow between-

group differences to be examined. These analyses suggested that both groups

anticipated similarly low pain prior to the procedure and found it relatively painless. There

were no statistically significant differences between the anticipated and procedural pain

experienced by the two study groups. The average anticipated pain (mean for both groups

2.3) was very similar to that actually experienced (mean massage group 2.2 and control

2.0). As may be expected, anticipated pain was highest prior to the first treatment cycle,

when patients had limited understanding of what they would experience, and fell with time.

It also appeared that with experience, patients learned what to expect. Over time their

anticipated and actual levels of pain became congruent.

It is worthy of note that the levels of anticipated and procedural pain reported in this study

were similar to those reported by a control group recruited to a study investigating the

efficacy of Tellington Touch in facilitating venipuncture (30). Whilst venipuncture is

different to cannulation, it is similar in so far as a needle of similar guage is inserted in to

the arm. Tellington Touch is another form of touch therapy entailing 5-minutes of gentle

physical touch. In the study by Wendler (30), a nurse trained in the procedure delivered

Telllington Touch to upper portions of participants’ shoulders, back and arms. The control

group in Wendler’s evaluation reported (on a similar scale of 0-10 with 0 being ‘no hurt’

and 10 ‘the worst possible hurt’) a mean value for anticipated pain prior to the procedure of

2.3 – the same as that reported by both study groups in the current study. As with the

current study, the control group in Wendler’s study (30) also reported low average actual

procedural pain (mean 1.4). Unlike the current study, their investigation reported on a

one-off venipuncture procedure. This might explain the discrepancies between actual and

anticipated pain that were not evident in the current study. Also, similar to the current

study, Tellington Touch appeared to impact little on the anxiety or pain associated with

gaining venous access.

Although the results of this study suggest that massage had little effect on either

anticipated or procedural pain, it is possible that a floor effect occurred with the numeric

rating scale questions. Participants generally recorded low levels of anxiety and pain and

it is possible that this floor in the response range created an instrument bias against


recording benefits of massage. If this were to be the case, improvements or benefits of

massage would be difficult to demonstrate given the low recordings typically reported.

However, the findings from the qualitative analysis provide further insight into the apparent

ineffectiveness of massage with regards to experiences of pain. It appeared that for the

relatively few individuals that found cannulation painful and stressful, massage acted as a

welcome distraction, and for some was perceived as a pampering process they looked

forward to. However, it seemed that these feelings and positive emotions were not of

sufficient strength or long lasting to influence the level of pain experienced.

Furthermore, it was apparent from the telephone interviews with patients that many of

them were not overly concerned about cannulation itself. They perceived cannulation as a

means to the end that for some was little more than inconvenient. If this was the case for

the majority of those recruited to the sample, any benefit afforded people that found the

procedure painful and anxiety-provoking would have been masked. Thus it would be

unsurprising that statistically significant results were not forthcoming and the hypotheses

put forward at the outset not supported.

5.2.4 Massage and feelings of anxiety

As with both actual and anticipated pain, patients in the study reported little anxiety in the

main, either before or after cannulation. The procedure was perceived as routine and an

aspect of treatment that they came to accept. Consequently, both study groups reported

low levels of anxiety both prior to, and after, cannulation. However, although anxiety was

low in both groups, it was 16% lower in the massage group prior to cannulation. Although

this difference was not statistically significant, it neared significance (p = 0.059). Certainly,

the comments made during telephone interviews were positive and suggested that it

helped individuals feel less daunted, and better prepared for needle insertion and ensuing

treatment.

Previous research has established that anxiety causes venous constriction. Given this

association, it would seem plausible that reduction of anxiety through whatever means,

including massage, may be reflected in veins becoming easier to access. The data from

this study lend support to this. Not only was there a trend for anxiety to be lower prior to

cannulation in the massage group, the massage group also had veins that were

significantly more visible and palpable.

Unfortunately any trends in relaxation induced by massage were negated on cannulation.

Following the procedure anxiety was similar in the two study groups. What is unclear from


this study is whether anxiety would have remained low had massage continued in some

form throughout the procedure. Further, it is unclear whether the benefits with respect to

venous access and pre-cannulation anxiety would have occurred had massage been

delivered to other areas of the body.

5.3 Massage and well being

This study suggests that there is a complex relationship between arm massage and

cannulation outcomes. It appears that for some individuals massage can aid cannulation

and make attendance for chemotherapy less stressful and more palatable. These people

stereotypically are young and female. However, there are many confounding factors other

than age and gender. It appears that the nurse undertaking the procedure and the type of

drug being administered also have a bearing on the experience and individuals’ perceived

wellbeing. Their previous experiences impact on how they anticipate and experience

future cannulation and treatment. Thus, it appears that individuals’ response to having

chemotherapy and to receiving massage is individualistic and highly complex.

Previous research and a systematic review of aromatherapy published in 2000 (37)

support the belief that massage can help to reduce anxiety in the short term, is pleasant

and acts as a mild anxiolytic in stressful situations. However, like this study the findings

do not suggest that the relaxing effects induced are sufficient to recommend that massage

be used to treat anxiety. As recognised by Cooke and Ernst (37), it appears that massage

has no lasting effects, either good or bad.

However, counter arguments would suggest that many studies, including the current one,

were sufficiently flawed to prevent more firm conclusions being drawn. Conducting

methodologically rigorous research in complementary and alternative medicine is difficult

(34, 38). Study designs can be compromised through lack of funding, difficulty in

measuring outcomes of concern to patients (like quality of life or existential meaning), and

inability to maintain blinding (38). Further, studies can be compromised when the required

sample is not attained; for example symptomatically ill patients may be unwilling to

participate in an RCT (38). In the current study, the sampling method precluded

recruitment of only those people that found cannulation stressful.

If methodologically rigorous experimental or quasi-experimental designs are not possible

to implement in evaluation of certain complementary therapies like massage, it would be

logical to propose researchers use other methodological approaches to understand its

holistic process and outcomes. Indeed, a number of qualitative studies have been


conducted in an attempt to understand how people respond to massage. In some cases it

appears to help individuals open up, recognise and express emotions, and come to terms

with changed self-image (39). Research by Bredin (39) described how a body-centred

intervention for women following mastectomy, that incorporated massage, helped

participants come to terms with some of their innermost private experiences. Thus, the

therapeutic effects of massage and engagement in open and meaningful dialogue can be

far reaching; it may be difficult to capture such benefits with standard psychometric

measures.

The channel through which massage can allow patients to build a positive and valued

relationship with the masseuse was a theme identified in both the patient interviews and

the therapist focus group. Patients felt privileged to have the treatment and those

providing it likewise referred to being privileged. Billhult and Dahlberg (21) refer to the

relief brought about by massage given to patients with cancer as ‘meaningful relief’ (p.

180); it allows them to ‘get away’ from physical, social and psychological suffering and

enables them to ‘feel good’. Once again, these very personal yet desired feelings and

emotions may be difficult to capture in instruments that tend to deconstruct feelings of

wellbeing and quality of life.

There is some debate over how much of an impact gender may have in response to

massage. The current study suggests that men are more stoical than women, and may

find benefits of massage more elusive. However, previous research conducted by

Weinrich and Weinrich (25) would not support this. In the latter study men with cancer

achieved more relief from pain through massage than women. The affects of gender and

other variables also appear to impact on the cannulation process itself. These are

discussed in the next section.

5.4 Factors affecting cannulation

Previous research has documented that certain individuals are more difficult to cannulate

than others. Infants, children, the obese, and black patients, along with IV drug users,

have been identified as groups in whom gaining venous access through cannulation can

prove difficult (29). However, the sample in this study did not include children or infants,

and included few obese people or patients that were not Caucasian and so we are unable

to comment on this. However, it did suggest that certain groups were more vulnerable

with regards to failed or difficult attempts to cannulate. Women, younger individuals, and

those receiving vesicant drugs were statistically more likely to undergo unsuccessful or


problematic cannulation. It is becoming more usual for women with breast cancer to be

given high doses of anthracyclines. These are associated with pain on their administration,

which can persist after the treatment is given. It would appear logical that such people

would be particularly vulnerable to the pain and anxiety that the women in this study

alluded to.

5.5 Study limitations

The findings from any study should be considered in the light of limitations in its design or

conduct. This study utilised a multi-method design in attempt to minimise weakness in the

study design. However, statistical data attained through the RCT element were likely to be

compromised. Blinding is a hallmark of a quality RCT, but this was not achieved in this

study. Some authors would suggest that this shortfall would not undermine the study.

Richardson (34) proposes that it is neither essential nor possible in many trials of

complementary therapies. Either way, it is likely that the current study was compromised

through lack of blinding. This proved unavoidable in so far that insufficient space in the

clinical area and residue of oil on patients’ arms alerted those cannulating to the study

group people were allocated. It is possible that this biased their perceptions and recording

of the cannulation process. Further, patients themselves were aware of the study group to

which they belonged and this may also have influenced their views of the process.

A further limitation relates to the documentation of time. The RCT element required

nurses to time and document the period it took to cannulate patients. This proved to be

inaccurate with nurses documenting an estimate on many occasions. This hampered the

accurate documentation of these data and may have prevented real differences between

the study groups from being identified.

The questionnaires that were used in the study were developed by the research team and

have not been subject to psychometric testing. Thus their validity and reliability cannot be

assured. However, they did follow the same approaches to those used successfully in

previous evaluations of massage and other interventions for cannulation (23, 29, 30).

Furthermore, data from the qualitative elements triangulated with that recorded in the

questionnaires suggesting that the questionnaires were valid and accurately captured the

experiences of both cannulating and cannulation.

Finally, the massage was intended to be a standard intervention but it is possible that

there was some variation in how the treatment was given. Such variation can affect the

efficacy of the approach, and contribute to experimental error. The research team


attempted to counteract this through ensuring that all therapists underwent the same

protocol-directed training. The apparent success of this was referred to in data attained

from the interviews with patients and from the therapist focus group. These data

suggested that the massage varied little within or between therapists over time. However,

this cannot be assured.

5.6 Recommendations for practice

The results from this study are not sufficiently favourable to suggest that cancer services

establish an NHS resourced massage service to enhance delivery of chemotherapy.

However, given the way in which it contributed to the general atmosphere in the Day Unit,

making the environment less stressful, and clinical, it is evident that the massage service

was a welcomed and valued initiative within the Unit itself and Acute Trust at large. On

many occasions, patients, therapists and stakeholders talked of feeling privileged at

having the facility. To this end, it should be maintained if possible and it would seem that

this would be achievable if massage is financed through voluntary contribution and fund

raising, or given on a volunteer basis. It could be argued that if provided on a volunteer

basis, this will only work in the long term if volunteers receive some recompense for their

contribution. Recompense can come in the form of gaining valuable training, skills and

experience in working with patients with cancer. The NICE guidance states that those who

work with patients with cancer, including therapists that do so on a voluntary basis, should

receive sufficient training to allow them to be familiar with, and adhere to, Network policies

designed to ensure best practice (32). Further the National Guidelines for the use of

Complementary Therapies in Supportive and Palliative Care suggest that the educational

and training needs of therapists vary according to skills and experience but should be

assessed and planned for (33). It may be that newly qualified therapists could offer to

work within the service before moving on to paid employment. The environment in this

case should be considered a learning one for the therapists, and they would require

guidance, support and supervision to facilitate this. Implementation of action learning sets

where therapists would meet as a group and discuss their challenges, experiences and

ways of working might be valuable in this context.

It is evident from the current study that space was at a premium within the Day Unit. The

therapists lacked space and privacy in which to provide the therapy. This is one area that

needs addressing. A massage service would benefit from having dedicated space.

Without this the service is likely to be compromised. This need not be away from the point


where the treatment is delivered. In fact their presence within the Unit was felt to enhance

the atmosphere within it. An alternative approach would be to train nurses in this skill.

However, the advantages and disadvantages of nurses providing massage as oppose to

massage therapists have yet to be explored. Further we don’t know how feasible it is,

given the time pressures that many nurses that give chemotherapy operate under.

However, it could be possible to provide massage whilst assessing the patient prior to

cannulation.

The findings from this study also raise issues about the training of nursing staff to

cannulate. Cannulation is a skill that nurses and patients alike realise varies between

those that perform the procedure. The findings from this study confirm those found

previously (40) which suggests practice enhances skill. However, this may not always be

the case and it is important that attempts are made to accelerate the learning process.

Typically, nurses undergo one-off training in cannulation for chemotherapy. This study

suggests that whilst this provides a basis for their practice, some nurses are more

competent than others. It is possible that ‘top-up’ training could be beneficial. Reference

is made in the literature to different instruction methods to teach theoretical and clinical

cannulation skills, and to enable individuals to gain practise in the procedure (41-43).

Institution of ongoing and innovative approaches to cannulation training, including self-

directed training, could serve to optimise skills in this area of nursing practice. What is

clear from the current findings is that a failure rate of around 25% is not unusual. This

could serve as a benchmark for future audit of practice. In this manner, those that find

cannulation difficult could be identified and supported.

5.7 Recommendations for future research

The findings from this study suggest that cannulation can prove very difficult and stressful

to vulnerable individuals. It would appear that women, and notably young women, are

difficult to cannulate and can find the experience both painful and stressful. Those with

only one arm available for cannulation, most often those having treatment for breast

cancer, may be at particular risk of damage to their veins along with people receiving

vesicant drugs. It remains unanswered from the current study whether these individuals

would benefit from massage prior to cannulation, but it does suggest that this would be a

valuable area to research in future. The sampling criteria in any future research evaluating

the efficacy of massage prior to cannulation for chemotherapy might usefully be refined to


focus on patients who are problematic to cannulate and find the process painful and

stressful.

Further research also needs to be undertaken to understand gender differences in both

the giving and receiving of massage. Typically, the men in the study were less effusive

and complimentary about massage. This may be because massage requires a closeness

that may not be welcome by all. Further, in this study all volunteer massage therapists

were women. This may have altered the men’s perception of, and receptiveness to, it.

Unfortunately, the gender of the therapists was not discussed during the telephone

interviews and thus needs further consideration in future. It is also important to note that

there may have been an age effect operating. The men in this study were of an age

(mean age for men was 65years (SD=12), Females: 57 year (SD=13)) where they may

have felt that massage was inappropriate. Future research should try to explore some of

these issues further.

Mention was made in the previous section of different ways that nurses’ competence in

cannulating patients could be enhanced through education and training. However, the

relative efficacy of these different approaches has yet to be determined. This could be a

fruitful area for research that would greatly inform our understanding of ways in which

clinical skill such as these can be taught, enhanced and maintained.

During the interviews and focus groups, mention was made of extending the massage

service to both carers and to patients in their homes. This is an area that has not been

studied before and may be worthy of both service development and subsequent evaluation

in future.

Whatever the group that is massaged in future research, the design adopted for its

evaluation should be considered carefully. Where possible, if an RCT is conducted,

individuals (those both receiving the intervention and documenting outcomes) should be

blind to the treatment. This was not the case in the current study, and this may have

biased the findings. Alternatively, a pre-test post-test design, with or without an equivalent

control, may be a better alternative. Such designs are frequently used when random

selection or assignment is impracticable. However, such quasi-experimental approaches

are less robust than RCTs as extraneous factors are less easy to control.

Further, whilst an RCT is the gold-standard for evaluations, researchers would be wise not

to overly deconstruct the experience of having massage. It is a holistic treatment, and it is

possible that through looking at the minutiae, or small treatment effects such as its impact

on cannulation, its wider benefits may not be addressed. Through adopting a multi-

method approach, these shortcomings may be overcome.


6 References

1. Cancer Research UK. CancerStats: Incidence - UK. 2004. http://www.cancerresearchuk.org/statistics/ (Accessed 3 September 2004)

2. Department of Health. The NHS Cancer Plan: A plan for investment. A plan for reform. London: HMSO; 2000.

3. Bremnes RM. Experience with and attitudes to chemotherapy among newly employed nurses in oncological and surgical departments: A longitudinal study. Supportive Care in Cancer 1999;7(1):11-16.

4. Coates A, Abraham S, Kaye SB, Sowerbutts T, Frewin C, Fox RM, et al. On the Receiving End- Patient Perception of theSide-effects of Cancer Chemotherapy. European Journal of Cancer and Clinical Oncology 1983;19:209-220.

5. Liu G, Franssen E, Fitch MI, Warner E. Patient Preferences for Oral Versus Intravenous Palliative Chemotherapy. Journal of Clinical Oncology 1997;15(1):110-115.

6. Rhodes VA, McDaniel RW, Hanson B, Markway E, Johnson M. Sensory perception of patients on selected antineoplastic chemotherapy protocols. Cancer Nursing 1994;17(1):45-51.

7. McDaniel RW, Rhodes VA. Development of a preparatory sensory information videotape for women receiving chemotherapy for prest cancer. Cancer Nursing 1998;21(2):143-148.

8. Ream E, Richarson A, Alexandre-Dann C. Patients' sensory experiences before, during and immediately following the administration of intravenous chemotherapy. Journal of Cancer Nursing 1997;1(1):25-31.

9. Rees R, Feigel I, Vickers A, Zollman C, McGurk R, Smith C, et al. Use of complementary therapies by women with breast cancer in the South Thames region: Research Council for Complementary Medicine (RCCM); 1999.

10. Ferrell-Torry AT, Glick OJ. The use of therapeutic massage as a nursing intervention to modify anxiety and the perception of cancer pain. Cancer Nursing 1993;16(2):93-101.

11. Ahles TA, Tope DM, Pinkson B, Walch S, Hann D, Whedon M, et al. Massage Therapy for Patients UndergoingAutologous Bone Marrow Transplantation. Journal of Pain and Symptom Management 1999;18(3):157-163.

12. Fellowes D, Barnes K, Wilkinson S. Aromatherapy and massage for symptom relief in patients with cancer (Cochrane Review). Chichester, UK: John Wiley & Sons, Ltd; 2004.

13. Smith MC, Kemp J, Hemphill L, Vojir CP. Outcomes of therapeutic Massage for Hospitalized Cancer Patients. Journal of Nursing Scholarship 2002;34(3):257-262.

14. Corner J, Cawley N, Hildebrand S. An evaluation of the use of massage and essential oils on the wellbeing of cancer patients. International Journal of Palliative Nursing 1995;1(2):67-73.

15. Buckley J. Massage and aromatherapy massage: Nursing art and science. International Journal of Palliative Nursing 2002;8(6):276-280.

16. Trevelyan J. Complementary Options. Nursing Times 1998 April 1:28-29.17. Wilkes E. Complementary Therapy in Hospice and Palliative Care. Sheffiled: Trent

Palliative Care Centre and the Executive of Help the Hopsices; 1992.


18. Kohn M. Complementary Therapies in Cancer Care: Abridged report of a study produced for Macmillan Cancer Relief: Macmillan Cancer Relief; 1999 June 1999.

19. Wilkie DJ, Kampbell J, Cutshall S, Halabisky H, Harmon H, Johnson LP, et al. Effects of massage on pain intensity, analgesics and quality of life in patients with cancer pain: A pilot study of a randomised clinical trial conducted within hospice care delivery. The Hospice Journal 2000;15(3):31-53.

20. Grealish L, Lomasney A, Whiteman B. Foot Massage: A nursing intervention to modify the distressing symptoms of pain and nausea in patients hospitalised with cancer. Cancer Nursing 2000;23(3):237-243.

21. Billhult A, Dahlberg K. A Meaningful Relief From Suffering.Experiences of Massage in Cancer Care. Cancer Nursing 2001;24(3):180-184.

22. Evans B. An audit into the effects of aromatherapy massage and the cancer patient in palliative and terminal care. Complementary Therapies in Medicine 1995;3:239-241.

23. Wilkinson S, Aldridge J, Salmon I, Cain E, Wilson B. An evaluation of aromatherapymassage in palliative care. Palliative Medicine 1999;13(5):409-417.

24. Stephenson NLN, Weinrich SP, Tavakoli AS. The effects of foot reflexology on anxiety and pain in patients with breast and lung cancer. Oncology Nursing Forum 2000;27(1):67-72.

25. Weinrich SP, Weinrich MC. The effect of massage on pain in cancer patients. Applied Nursing Research 1990;3(4):140-145.

26. Hadfield N. The role of aromatherapy massage in reducing anxiety in patients with malignant brain tumours. International Journal of Palliative Nursing 2001;7(6):279-285.

27. Dunwoody L. Cancer patients' experiences and evaluations of aromatherapy massage in palliative care. International Journal of Palliative Nursing 2002;8(10):497-504.

28. Cassileth BR. Evaluating Complementary and AlternativeTherapies for Cancer Patients. Ca: A Cancer Journal for Clinicians 1999;49(6):362-375.

29. Lenhardt R, Seybold T, Kimberger O, Stoiser B, Sessler DI. Local warming and insertion of peripheral venous cannulas: single blinded prospective randomised controlled trial and single blinded crossover trial. British Medical Journal 2002;325(24 August):409-412.

30. Wendler MC. Effects of Tellington Touch in healthy adults awaiting venipuncture. Research in Nursing and Health 2003;26:40-52.

31. Harrington KJ, Kelly SA, Pandha HS, Jackson JE, Hollyer JS, McKenzie CG. An audit of Hickman catheter use in patients with solid tumours. Clinical Oncology 1994;6(5):288-293.

32. NICE. Guidance on Cancer Services: Improving Supportive and Palliative Care for Adults with Cancer. The Manual. London: National Institute for Clinical Excellence; 2004 March 2004.

33. NCHSPCS. National Guidelines for the Use of Complementary Therapies in Supportive and Palliative Care. London: National Council for Hospice and SpecialistPalliative Care Services; 2003.

34. Richardson J. The use of randomized control trials in complementary therapies: exploring the issues. Journal of Advanced Nursing 2000;32(2):398-406.

35. Anthony HM. Clinical research: Questions to ask and the benefits of asking them. In: Lewith GT, Aldridge D, editors. Clinical Research Methodology for Complementary Therapies. London: Hodder & Stoughton; 1993.


36. Kacperek L. Patients' views on the factors which influence the use of an aromatherpy massage outpatient service. Complementary Therapies in Nursing & Midwifery 1997;3:51-57.

37. Cooke B, Ernst E. Aromatherapy: a systematic review. British Journal of General Practice 2002;50(455):493-496.

38. Pan CX, Morrison S, Ness J, Fugh-Berman A, Leipzig RM. Complementary and Alternative Medicine in the Management of Pain, Dyspnea, and Nausea and Vomiting Near the End of Life: A Systematic Review. Journal of Pain and Symptom Management 2000;20(5):374-387.

39. Bredin M. Mastectomy, body image and therapeutic massage: a qualitative study of women's experience. Journal of Advanced Nursing 1999;29(5):1113-1120.

40. Ung L, Cook S, Edwards B, Hocking L, Osmond F, Buttergieg H. Peripheral Intravenous Cannulation in Nursing. Journal of Infusion Nursing 2002;25(3):189-200.

41. Hewitt J, Roberts CM. Evaluating the practice outcomes of a venepuncture and intravenous cannulation. Nurse Education in Practice 2003;4(1):77-79.

42. Chang KK-P, Chung JW-Y, Wong TK-S. Learning intravenous cannulation: A comparison of the conventional method and the CathSim Intravenous Training System. Journal of Clinical Nursing 2002;11(1):73-78.

43. Snelling PC. Developing self-directed training for intravenous cannulation. Professional Nurse 2002;18(3):137-139, 141-142.


7 Appendices

Appendix 1

Appendix 2

Appendix 3

Appendix 4

Appendix 5

Appendix 6

Appendix 7

Appendix 8

Appendix 9

Appendix 10

Appendix 11

Appendix 12

Appendix 13

Appendix 14

Arm massage protocol

Patient information sheet

Patient consent form

Therapist information sheet

Patient questionnaire

Nurse questionnaire

Patient interview schedule

Stakeholder interview schedule

Focus group guide

Model explaining anxiety prior to cannulation (SPSS output)

Model explaining anxiety following cannulation (SPSS output)

Model explaining anticipation of pain prior to cannulation (SPSS output)

Model explaining procedural pain (SPSS output)

Model explaining time taken to cannulate (SPSS output)


Appendix 1: Arm massage protocol

PROCEDURE

* Ask patient if they wish to use the toilet facilities prior to commencing the massage,

as cannulation should take place directly following this.

* Ensure patient is comfortable and place a pillow covered with a clean towel on the

patient’s lap.

* Please ask the patient if they have an allergy to sunflower oil before applying this.

* The patient’s sleeves should be rolled up the arms, well away from the potential risk

of staining with carrier oil, and jewellery wherever possible should be removed.

* Establish which arm is likely to be cannulated. This is particularly so in breast

cancer patients. If axillary lymph nodes have been removed - using the arm for

cannulation is generally avoided and especially if lymphoedema is present.

The following technique should last for approximately 10 minutes if possible.

* Place your hands over the patient’s to establish contact, then proceed to apply oil

over the arms and hands using effleurage movements.

* Cover one arm with an edge of the towel to maintain warmth.

* Warm up the arm with effleurage massage.

* Gently petrissage over the top of the forearm, working up and down the arm.

* Effleurage the forearm 2 or 3 times more before moving to the hand.


* Lightly pettrisage the top of the hand and fingers, then turn the hand over and

massage the palms.

* Finish with effleurage of the forearm and hand, stroking down the arm to finish.

* Cover this arm and repeat the sequence on the other arm if appropriate.

* To finish, keep the arms covered with the towel to maintain warmth, laying your

hands on the arms or hands to signify the end of treatment to the patient. Inform the staff

nurse and of course offer the patient a drink.

Note

Do not massage the arms if lymphoedema is present, nor over inflammed, hot or tender

areas.


Appendix 2: Patient information sheet

PATIENT INFORMATION SHEET

Study title: A study investigating the effects of arm massage prior to chemotherapy

Introduction

You are being invited to take part in a research study. Before you decide whether or not

to, it is important for you to understand why the research is being done and what it will

involve. Please take time to read the following information carefully and discuss it with

others if you wish. Ask us if there is anything that is not clear or if you would like more

information. Take time to decide whether or not you wish to take part.

Thank you for reading this.

Purpose of the study

This study is being conducted over a period of a year. It aims to find out the impact of arm

massage prior to chemotherapy. Arm massage has been used on Chartwell Unit for some

months now. It appears that it may help to relax people and make the nurses’ insertion of

the needle (cannula) required for chemotherapy more easy. Because of this observation,

a team of researchers has decided to formally study its effectiveness. The study will look

at the discomfort associated with the needle (cannula) being placed in the arm before

chemotherapy is given. It will look at the emotions felt prior to, and after, chemotherapy is

given and investigate the views of people about the impact of arm massage .

The researchers will also be asking nurses and the massage therapists for their views of

the massage service.

Through looking at these factors the researchers will find out




Why you have been chosen

You are being asked if you would like to take part in this study because you are about to

begin chemotherapy that will be given to you via a form of needle (cannula). All patients

like you, who have not previously had chemotherapy this way, and are being treated on

Chartwell Unit are being invited to take part. We are aiming to involve 50 patients in this

research study.

Do you have to take part?

It is up to you to decide whether or not to take part. If you do decide to take part you will

be given this information sheet to keep and be asked to sign a consent form. If you decide

to take part you are still free to withdraw at any time without giving a reason. This will not

affect the standard of care you receive now or in the future.

What will happen if you take part?

The research tem will be collecting data on Chartwell Unit for a 6-month period.

To find out whether arm massage assists in the giving of chemotherapy, those that take

part

in the study will be divided into 2 groups. The first group will be given the arm massage in

addition to their usual care. The second group will not have the massage but will have the

routine care offered to patients whilst undergoing chemotherapy. Patients will be placed in

the relevant group by chance. You will be informed of the group you will be in by the

nurses caring for you. If allocated to the massage group your chemotherapy treatment will

normally be booked between the hours of 1130 and 1600.

Whichever group you are in (with-massage or without-massage) you will be asked to

complete a booklet of questions immediately before and after each chemotherapy

treatment is given to you. This will ask about the level of pain and anxiety you

experienced on that occasion, and

the time taken for treatment. Those that have the massage will be asked about their

experiences of, and satisfaction with, arm massage. A small number of those in the

massage group (fifteen people) will additionally be asked to take part in a recorded


telephone interview that will last around 20 minutes. This will provide an opportunity to

discuss experiences in greater depth. Again, these people will be selected by chance.

The research team will send you a letter at a later date if you are chosen for this part of the

study.

What do I have to do?

Having the arm massage will not have any implications for what you can or cannot do in

your daily life; you will be able to use other types of complementary therapies if you wish.

Through participating in the study you will have to complete a questionnaire each time you

attend the unit for your chemotherapy. You will be required to answer questions

immediately before and after you have had your treatment. A small group of people,

fifteen individuals, will be invited to take part in a short interview to talk about their

experiences of chemotherapy and arm massage once the study is complete. Again, you

will be informed by letter sent by the research team if you are selected to take part in this

aspect of the study.

What is the drug or procedure that is being tested?

What is being tested is a gentle 10-minute arm massage with basic carrier oil.

What are the alternatives for treatment?

Those that do not have the massage treatment will have the usual care provided to

patients prior to cannualtion for chemotherapy.

What are the side effects of any treatment received when taking part?

None are expected.


What are the possible disadvantages and risks of taking part?

Gentle arm massage, the treatment being given in attempt to make cannulation easier, is

not physically invasive but does require a physical closeness and type of touch that some

patients may find unpleasant. However, it is anticipated that in general people will find the

treatment relaxing and beneficial to them.

What are the possible benefits of taking part?

We hope that the arm massage will help those who receive it. However, this cannot be

guaranteed. The information we get from this study may help us to understand the

potential of arm massage and indicate how the process of giving chemotherapy may be

improved in future.

Those that do not receive the arm massage may enjoy being part of a study that could

improve the care for patients undergoing chemotherapy in future.

What if new information becomes available?

Sometimes during the course of a research project, new information becomes available

about the treatment that is being studied. If this happens, the research team will tell you

about it and discuss with you whether you want to continue in the study. If you decide to

withdraw, your research doctor will make arrangements for your care to continue. If you

decide to continue in the study you will be asked to sign an updated consent form.

What happens when the research study stops?

In the past, arm massage has been offered to patients treated in Chartwell Unit on an ad

hoc basis. During data collection for this study, it will only be available to those in the

experimental group, or those not taking part in the research. On completion of the study,

and dependant on the results, the massage service will return to being offered on an ad

hoc basis.


What if something goes wrong?

The principal investigator is indemnified through the general King’s College London

Liability Insurance, with the principle of ‘No Fault’ compensation in operation for subjects of

clinical research. Liability for damages/compensation claims by human research subjects

for bodily injury from participation in clinical trial or healthy volunteer studies conducted by

King’s. The basis for damages or compensation will be in accordance with ABPI

guidelines irrespective of fault on the College’s part.

Will my taking part in this study be kept confidential?

All responses you give will be anonymous. Any information about you, which leaves the

hospital, will have your name and address removed so that you cannot be recognised from

it. All study information will be stored in accordance with the Data Protection Act (1998) in

a locked filing cabinet to which only the researchers will have access.

Any information you provide during an interview may be presented in quotes in future

research articles or presentations. However, if this is the case you will be given a different

name so you will not be identifiable from your comments.

What will happen to the results of the research study?

The researchers intend to circulate the findings locally, nationally and internationally. The

research team will return to Chartwell Unit and talk through the findings with the staff at a

suitable opportunity. They will also be provided with a written report of the findings. If you

would like such a copy of the findings, please let the staff on Chartwell Unit know.

The principal researcher, Dr Emma Ream, has been invited to present about interim

findings at a symposium during the European Cancer Conference (ECCO 12) to be held in

Copenhagen in September 2003. Furthermore, one of the conditions of accepting the

grant was that the researchers would publish their findings in a European cancer journal.

In this way the findings will reach both a national and international audience.


The researchers will also seek opportunities to publish in a journal of complementary

medicine to reach an audience wider than a nursing one.

Who is organising and funding the research?

Nurses on Chartwell Unit are undertaking this study alongside nurse researchers from

King’s College, London University.

The European Oncology nursing Society has provided funding for the study. This covers

the necessary researchers’ expenses.

Who has reviewed the study?

The European Oncology Nursing Society and Bromley Local Research Ethics Committee

have reviewed the study.

Contact for Further Information

Please contact Helen Hannon in the Treatment Suite on Chartwell Unit if you would like to

discuss the study further, phone number 01689 863155

Thank you for taking part in this study.

Please keep this copy of the information sheet alongside your copy of the consent form.

30.04.2003 Patient Information Sheet Version 1


Appendix 3: Patient Consent form

Centre Number:Study Number:Patient Identification Number for this trial:

CONSENT FORM FOR PATIENTS

Title of Project: An exploratory trial of the efficacy of arm massage in facilitating intravenous cannulation foradministration of cytotoxic chemotherapy

Name of Researcher: Dr Emma Ream

1. I confirm that I have read and understand the information sheet dated 30.04.2003 (version 1) for the above study and have had the opportunity

to ask questions

2. I understand that my participation is voluntary and that I am free towithdraw at any time, without giving any reason, without mymedical care or legal rights being affected.

3. I understand that sections of any of my medical notes may be looked at byresponsible individuals from the research team or from regulatoryauthorities where it is relevant to my taking part in research. I givepermission for these individuals to have access to my records.

4. I understand that I may be requested to take part in a taped telephoneinterview.

5. I agree to take part in the above study.

________________________ ________________ ____________________Name of Patient Signature Date

_________________________ ________________ _______________Name of Person taking consent Signature Date(if different from researcher)

_________________________ ________________ ____________________Researcher Signature Date


Appendix 4: Therapist information sheet

THERAPISTS INFORMATION SHEET

Study title: A study investigating the effects of arm massage prior to chemotherapy

Introduction

You are being invited to take part in a research study. Before you decide whether or not

to, it is important for you to understand why the research is being done and what it will

involve. Please take time to read the following information carefully and discuss it with

others if you wish. Ask us if there is anything that is not clear or if you would like more

information. Take time to decide whether or not you wish to take part.

Thank you for reading this.

Purpose of the study

This study is being conducted over a period of a year. It aims to find out the impact of arm

massage prior to chemotherapy. Arm massage has been used on Chartwell Unit for some

months now. It appears that it may help to relax people and make the nurses’ insertion of

the (needle) cannula required for chemotherapy more easy. Because of this observation,

a team of researchers has decided to formally study its effectiveness. The study will look

at the discomfort associated with the (needle) cannula being placed in the arm before

chemotherapy is given. It will look at the emotions felt prior to, and after, chemotherapy is

given and investigate the views of people about the impact of arm massage.

The researchers will also be asking patients and the nurses placing the needle (cannula)

in the patients arm for their views of the massage service.

Through looking at these factors the researchers will find out




Why you have been chosen

You are being asked if you would like to take part in this study because you are regularly

massaging patients arms before their chemotherapy treatment. All patients who have not

previously had chemotherapy and are being treated on Chartwell Unit are being invited to

take part. We are aiming to involve 50 patients in this research study.

Do you have to take part?

It is up to you to decide whether or not to take part. If you do decide to take part you will

be given this information sheet to keep and be asked to sign a consent form. If you decide

to take part you are still free to withdraw at any time without giving a reason.

What will happen if you take part?

The research team will be collecting data on Chartwell Unit for a 6-month period.

Information regarding arm massage prior to cannulation will be gathered from the

therapists performing arm massage, the patients receiving arm massage and the nurses

performing the cannulation.

To find out whether arm massage assists in the giving of chemotherapy, those patients

that take part in the study will be divided into 2 groups. The first group will be given the

arm massage in addition to their usual care. The second group will not have the massage

but will have the routine care offered to patients whilst undergoing chemotherapy. Patients

will be placed in the relevant group by chance. The nurse will inform the patient of the

group they will be in. If allocated to the massage group the patient's chemotherapy

treatment will be booked between the hours of 1130 and 1430.

Whichever group the patient is in (with-massage or without-massage) they will be asked to

complete a booklet of questions immediately before and after each chemotherapy

treatment is given to them. This will ask about the level of pain and anxiety they

experienced on that occasion, and the time taken for treatment. Those that have the

massage will be asked about their experiences of, and satisfaction with, arm massage. A

small number of those in the massage group (fifteen people) will additionally be asked to


take part in a recorded telephone interview that will last around 20 minutes. This will

provide an opportunity to discuss experiences in greater depth. Again, these people will

be selected by chance and the nurses looking after them on Chartwell Unit will tell them if

you have been chosen for this part of the study.

The nurses will complete a brief questionnaire for each needle (cannula) they insert on a

patient participating in the study. This will allow data to be collected from nurses

cannulating the patients on the 100 episodes that will be evaluated in this study. It will

allow data to be collected on the state of patients’ veins prior to the procedure, time taken

for successful cannulation, number of cannulation attempts, degree of difficulty

encountered in the process and other methods used to achieve cannulation (e.g.

application of heat). These data will allow differences in ease of cannulation between the

two groups to be determined and described statistically.

What do I have to do?

The study aims to determine whether gentle arm massage:

1. Enhances patients’ wellbeing.

You will be invited on completion of the study to share your views on arm massage during

a one-off focus group anticipated to last approximately 1 hour. It will be facilitated and

recorded by 2 members of the research team (those outside the institution where data will

be collected).

A focus group is an informal discussion between 6-10 people, focusing on a particular

experience which all those taking part can talk about. This focus group is about the

experience of providing arm massage before cannulation. In particular your perceptions on

how patients responded to the massage and to reflect on factors that both impeded and

facilitated the process. You will also be encouraged to consider patient characteristics that

may influence outcomes of the treatment.

What is the drug or procedure that is being tested?

What is being tested is a gentle 10-minute arm massage with basic carrier oil.


What are the alternatives for treatment?

Those that do not have the massage treatment will have the usual care provided to

patients prior to cannualtion for chemotherapy.

What are the side effects of any treatment received for the patient taking part?

None are expected.

What are the possible disadvantages and risks of taking part?

Your time is required to attend the focus group

What are the possible benefits of taking part?

We hope that the arm massage will help those who receive it. However, this cannot be

guaranteed. The information we get from this study may help us to understand the

potential or arm massage and indicate how the process of giving chemotherapy may be

improved in future.

Those that do not receive the arm massage may enjoy being part of a study that could

improve the care for patients undergoing chemotherapy in future.

What if new information becomes available?

Sometimes during the course of a research project, new information becomes available

about the treatment that is being studied. If this happens, the research team will tell you

about it and discuss with you whether you want to continue in the study. If you decide to

continue in the study you will be asked to sign an updated consent form.


What happens when the research study stops?

In the past, arm massage has been offered to patients treated in Chartwell Unit on an ad

hoc basis. During data collection for this study, it will only be available to those in the

experimental group. On completion of the study, and dependant on the results, the

massage service will return to being offered on an ad hoc basis.

What if something goes wrong?

The principal investigator is indemnified through the general King’s College London

Liability Insurance, with the principle of ‘No Fault’ compensation in operation for subjects of

clinical research. Liability for damages/compensation claims by human research subjects

for bodily injury from participation in clinical trial or healthy volunteer studies conducted by

King’s. The basis for damages or compensation will be in accordance with ABPI

guidelines irrespective of fault on the College’s part.

Will my taking part in this study be kept confidential?

All responses you give will be anonymous. Any information about you, which leaves the

hospital, will have any personal details, such as your name removed so that you cannot be

recognised from it. All study information will be stored in accordance with the Data

Protection Act (1998) in a locked filing cabinet to which only the researchers will have

access.

What will happen to the results of the research study?

The researchers intend to circulate the findings locally, nationally and internationally. The

research team will return to Chartwell Unit and talk through the findings with the staff at a

suitable opportunity. They will also be provided with a written report of the findings. If you

would like such a copy of the findings, please let the Manager of the Chartwell Unit know.


The principal researcher, Dr Emma Ream, has been invited to present about interim

findings at a symposium during the European Cancer Conference (ECCO 12) to be held in

Copenhagen in September 2003. Furthermore, one of the conditions of accepting the

grant was that the researchers would publish their findings in a European cancer journal.

In this way the findings will reach both a national and international audience. The

researchers will also seek opportunities to publish in a journal of complementary medicine

to reach an audience wider than a nursing one.

Who is organising and funding the research?

Nurses on Chartwell Unit are undertaking this study alongside nurse researchers from

King’s College, London University.

The European Oncology nursing Society has provided funding for the study. This covers

the necessary researchers’ expenses.

Who has reviewed the study?

The European Oncology Nursing Society and Bromley Local Research Ethics Committee

have reviewed the study.

Contact for Further Information

Please contact Helen Hannon in the Treatment Suite on Chartwell Unit if you would like to

discuss the study further, phone number 01689 863155

Thank you for taking part in this study.

Please keep this copy of the information sheet alongside your copy of the consent form.

30.04.2003 Therapist Information Sheet Version 1


Appendix 5: Patient Questionnaire


Appendix 6: Nurse Questionnaire


Next…


Appendix 7: Patient Interview schedule

PATIENT INTERVIEW GUIDE

1. How did you find the experience of attending the unit for chemotherapy?

2. How had you anticipated it would be before you started the treatment?

3. Did your feelings towards it change over time?

4. In general how anxious did you feel when you attended the unit?

5. What factors affected how you felt?

6. Did anything in particular improve the experience for you?

7. How would you describe any feelings of pain or discomfort that you felt when the

cannula was placed in your arm?

8. In general how bad (intense/severe) would you say that this feeling was?

9. How did you find the arm massage?

10. How many times did you have it?

11. In what ways did the arm massage affect how you felt (for good or bad)?

12. What factors impacted on the process?

a. Environmental

b. Situational

c. Interpersonal

13. On what occasions (if any) was the massage helpful?

14. In what ways was it helpful?

15. On what occasions (if any) was the massage unhelpful?

16. In what ways was it unhelpful?

17. How in your opinion could the massage service be improved?

THANK YOU


Appendix 8: Stakeholder interview schedule

NURSE/THERAPIST MANAGER (STAKEHOLDERS) INTERVIEW GUIDE

Service related issues

1. What vision did you have for the service?

a. Role or function?

b. What had you hoped to achieve by it?

2. How successful do you believe it has been?

a. What aspects of the service are working well/not so well?

3. How has it evolved over time?

4. Thinking back to when the service was being set up:

a. What challenges did you encounter in setting up the service?

5. What challenges have impacted on its daily delivery?

a. Administrative

b. Manning

c. Housing – space

6. How did you deal with these?

7. Based on these service-related issues, what is key for its smooth running?

Patient related issues – if either delivered massage or cannulated during process of study

8. What do you see as the benefits (if any) for patients?

9. Did any patients benefit particularly?

a. If so who were they?

b. What was this benefit?

c. Why do you think this was the case?

10. Did any patients seem to find it unhelpful?

a. If so who were they?

b. In what way did it seem unhelpful?



Considering the therapists themselves

11. In your view what are key criteria for therapists recruited to the post?

a. What specific experience should they have if any?

12. What specific attributes/characteristics should they have, if any?

13. What ongoing support/supervision do the therapists need? (Therapy manager only)

14. What training issues, if any, have arisen? (Therapy manager only)

15. How has individual performance been reviewed? (Therapy manager only)

Looking to the future for the massage service

16. How could the service be improved?

a. What potential would you like to see realised in future?

17. What might stop this from happening?

18. How could these challenges be overcome?

Looking to the future as regards successful cannulation for chemotherapy

19. What other than massage would you consider instituting to improve future

chemotherapy/cannulation?

20. What other thoughts comments would you like to add regarding cannulation for

chemotherapy, and the role of massage?

THANK YOU


Appendix 9: Focus group guide

FOCUS GROUP GUIDE

1. Welcome

2. Refreshments- whilst waiting for all participants to arrive

3. Ask participants to complete short questionnaire, to collect demographic data

4. Completion of consent forms with Primary Researcher (two copies signed)

Introduction

Welcome participants to group introduce primary and secondary researchers. Open group

discussion by reaffirming confidentiality of group and guidelines/rules, including level of

group confidentiality and right to withdraw at any time.

Questioning Route

Opening Question (ice breaker to each individual & act as voice identifier for transcription)

1. Can you begin by telling us your name and one thing that you are looking forward to this

year?

Introductory Question

2. How do you think patients find attending Chartwell Unit for chemotherapy?

Transition Questions

3. What difference does it make providing patients in places like Chartwell with massage?

4. How do you think it impacted on the people in this study?

5. What do you see as the benefits (if any) for patients?


6. What factors impacted on the process?

a. Environmental

b. Situational

c. Interpersonal

7. Did any people seem to derive particular benefit?

a. If so whom were they?

b. What was this benefit?


8. In what situations, if any, was it less beneficial?

9. Did any people seem to find it unhelpful?

a. If so whom were they?

b. In what way did it seem unhelpful?


Process questions

10. How did you find the process of providing arm massage for the patients in the study?

11. Was it as you had anticipated?

12. How sufficient was your training to prepare you for the work you have been doing on

Chartwell?

13. Were there any occasions when you were unable to give provide massage?

a. Perhaps due to pain/discomfort/lymphoedema

b. Other reasons

14. What challenges are there with regards to providing massage to patients in a unit like

Chartwell?

15. What concerns do you have about the service?

Concluding questions

16. How could the arm massage service be improved?

17. Anything else to add?

THANK YOU


Appendix 10: Model explaining anxiety prior to cannulation (SPSS output)

Tests of Between-Subjects Effects

Dependent Variable: Anxiety prior to cannulation

11.280 1 5.447 .020

20.442 1 9.871 .002

873.812 1 421.958 .000

542.563 262

1705.538 265

SourceMASSAGE

GENDER

ANTHURT

Error

Corrected Total

Type III Sumof Squares df F Sig.

Massage group


1.994a .127 1.743 2.245

2.406a .131 2.148 2.664

Massage groupHad massage

Didn't have massage

Mean Std. Error Lower Bound Upper Bound

95% Confidence Interval

Evaluated at covariates appeared in the model: Anticipated pain = 2.32.a.

Gender of patient


1.884a .160 1.568 2.200

2.516a .111 2.298 2.735

Gender of patientMale

Female



Evaluated at covariates appeared in the model: Anticipated pain =2.32.

a.

Parameter Estimates


.898 .044 20.542 .000 .812 .984ParameterANTHURT

B Std. Error t Sig. Lower Bound Upper Bound



Appendix 11: Model explaining anxiety following cannulation (SPSS output)


Dependent Variable: Anxiety after cannulation

5.676 1 3.244 .073

10.725 1 6.129 .014

32.847 1 18.771 .000

17.275 5 1.974 .083

131.713 2 37.635 .000

7.722 1 4.413 .037

26.523 1 15.157 .000

26.458 7 2.160 .039

414.719 237

874.086 256

SourceGENDER

MASSAGE

AGE (2 groups)

RNURSEID

RAVACTHR

GENDER * MASSAGE

MASSAGE * RAVACTHR

RNURSEID * RAVACTHR

Error

Corrected Total


1. Gender of patient


2.197a .215 1.773 2.622

2.603a .142 2.324 2.882


Female



Based on modified population marginal mean.a.

2. Massage group


2.326a .191 1.950 2.702

2.493a .203 2.094 2.893


Didn't have massage




3. Age of patient (2 groups)


2.868a .203 2.468 3.268

1.933a .169 1.599 2.266

Age of patient (2groups)Aged 24-55

Aged 56-79





4. Nurse ID


3.476a

.514 2.463 4.489

2.403a .273 1.864 2.941

2.177a .241 1.702 2.653

2.024a .509 1.022 3.026

2.123a .284 1.564 2.682

2.284a .237 1.816 2.751

Nurse IDAll other: 506, 509,514, 911

508

510

511

512

513




5. Average throughout all cycles (per individual) of Pain on cannulation


1.070 .134 .806 1.333

3.336 .275 2.794 3.878

3.980a .536 2.924 5.037

Average throughoutall cyclesLow Pain

Medium Pain

High Pain




6. Gender of patient * Massage group


1.940a .282 1.385 2.496

2.519a .293 1.941 3.097

2.711a .175 2.367 3.056

2.468a .193 2.088 2.849


Didn't have massage

Had massage

Didn't have massage


Female




7. Massage group * Average throughout all cycles (per individual) of Pain on cannulation


1.224 .152 .925 1.524

2.600 .335 1.941 3.260

3.980a .536 2.924 5.037

.915a .182 .557 1.273

4.072a .355 3.372 4.772

.b . . .


Medium Pain

High Pain

Low Pain

Medium Pain

High Pain


Didn't have massage




This level combination of factors is not observed, thus the corresponding population marginalmean is not estimable.

b.


8. Average throughout all cycles (per individual) of Pain on cannulation * Nurse ID


1.134 .329 .485 1.783

1.006 .219 .575 1.438

1.237 .225 .794 1.680

1.228 .370 .500 1.956

.794 .302 .198 1.390

1.019 .183 .657 1.380

5.818 .965 3.917 7.719

2.927 .432 2.076 3.778

2.133 .380 1.384 2.882

2.820 .941 .967 4.673

3.452 .480 2.506 4.399

2.867 .303 2.270 3.464

.a

. . .

4.147b .950 2.274 6.019

4.147b .782 2.606 5.688

.a . . .

.a . . .

3.647b .950 1.774 5.519


508

510

511

512

513

All other: 506, 509,514, 911

508

510

511

512

513

All other: 506, 509,514, 911

508

510

511

512

513


Medium Pain

High Pain



This level combination of factors is not observed, thus the corresponding population marginalmean is not estimable.

a.

Based on modified population marginal mean.b.


Appendix 12: Model explaining anticipation of pain prior to cannulation (SPSSoutput)


Dependent Variable: Anticipated pain

7.706 1 5.773 .017

16.676 1 12.493 .000

22.514 5 3.373 .006

315.498 1 236.354 .000

27.763 5 4.160 .001

26.736 5 4.006 .002

329.709 247

1256.195 265

SourceMASSAGE

AGE (2 groups)

RNURSEID

PREANX

AGE (2g)*NURSEID

RNURSEID * PREANX

Error

Corrected Total


1. Massage group


2.744a .155 2.439 3.050

2.374a .161 2.056 2.692


Didn't have massage



Evaluated at covariates appeared in the model: Anxiety prior tocannulation = 2.30.

a.

2. Age of patient (2 groups)


3.050a .260 2.538 3.562

2.069a .096 1.880 2.257


Aged 56-79




a.

3. Nurse ID


1.831a

.410 1.024 2.638

2.193a .163 1.872 2.515

2.275a .165 1.949 2.601

3.274a .613 2.068 4.481

3.127a .273 2.590 3.664

2.655a .133 2.394 2.917


508

510

511

512

513




a.


4. Parameter Estimates - Anxiety prior to cannulation


.802 .058 13.733 .000 .687 .917ParameterPREANX



5. Age of patient (2 groups) * Nurse ID


1.270a

.734 -.175 2.716

2.453a .282 1.897 3.010

2.600a .284 2.039 3.160

4.366a 1.204 1.995 6.736

4.576a .505 3.582 5.571

3.035a .229 2.583 3.486

2.392a

.294 1.814 2.970

1.933a .193 1.553 2.313

1.950a .212 1.532 2.368

2.183a .282 1.628 2.738

1.677a .246 1.192 2.162

2.276a .161 1.958 2.593


508

510

511

512

513

All other: 506, 509,514, 911

508

510

511

512

513


Aged 56-79



Evaluated at covariates appeared in the model: Anxiety prior to cannulation = 2.30.a.

6. Parameter Estimates - Nurse ID*Anxiety prior to cannulation


-.231 .159 -1.449 .149 -.544 8.289E-02

-.199 .084 -2.371 .019 -.365 -3.373E-02

-.188 .091 -2.063 .040 -.367 -8.506E-03

-.129 .134 -.960 .338 -.393 .136

-.451 .103 -4.375 .000 -.655 -.248

0a

. . . . .

Parameter[RNURSEID=100] *PREANX

[RNURSEID=508] *PREANX







This parameter is set to zero because it is redundant.a.


Appendix 13: Model explaining procedural pain (SPSS output)


Dependent Variable: Pain on cannulation

17.737 1 5.883 .016

52.177 2 8.653 .000

92.815 1 30.786 .000

615.021 204

965.100 208

SourceRCHEMO

RACTHUR1

PREANX

Error

Corrected Total


1.Treatment given


3.697a .440 2.829 4.566

3.005a

.491 2.038 3.972

Treatment givenVesicant Drugs

Irritant Or Non VesicantDrugs



Evaluated at covariates appeared in the model: Anxiety prior to cannulation =2.55.

a.

2. Pain on cannulation - Cycle 1 data


1.730a .145 1.444 2.017

2.822a .293 2.243 3.400

5.502a 1.265 3.007 7.997

Pain on cannulation -Cycle 1 dataLow Pain

Medium Pain

High Pain



Evaluated at covariates appeared in the model: Anxiety prior to cannulation =2.55.

a.

Parameter Estimates


.303 .055 5.549 .000 .195 .411ParameterPREANX




Appendix 14: Model explaining time taken to cannulate (SPSS output)

Age of patient (2 groups)

Dependent Variable: Time taken to cannulate

6.564 1.171 4.255 8.873

3.848 .471 2.920 4.777


Aged 56-79





137.960 1 5.099 .025

126.038 1 4.658 .032

626.345 5 4.630 .001

423.708 5 3.132 .010

5411.290 200

6443.432 212

SourceCHEMO

AGE (2 Groups)

NURSEID

AGE (2g)*NURSEID

Error

Corrected Total


Treatment given


6.175 .655 4.885 7.466

4.237 .861 2.539 5.935

Treatment givenVesicant Drugs

Irritant Or Non VesicantDrugs



Nurse ID


3.735 1.637 .506 6.964

2.693 .872 .975 4.412

1.878 .807 .287 3.469

12.015 2.701 6.690 17.341

6.785 1.282 4.256 9.314

4.130 .693 2.763 5.497


508

510

511

512

513




Age of patient (2 groups) * Nurse ID


1.677 3.007 -4.252 7.605

2.700 1.424 -.107 5.508

1.715 1.268 -.786 4.216

22.031 5.219 11.739 32.323

6.697 2.166 2.425 10.969

4.563 1.066 2.462 6.665

5.793 1.328 3.175 8.412

2.686 1.001 .712 4.661

2.041 .943 .183 3.900

2.000 1.390 -.741 4.741

6.873 1.346 4.219 9.527

3.697 .832 2.055 5.338


508

510

511

512

513

All other: 506, 509,514, 911

508

510

511

512

513


Aged 56-79



an exploration of the efficacy of ... - king's college london · dr emma ream, senior lecturer...

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