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NURS 5366 Research Article Appraisal Part Two.
Research Article Appraisal Part Two
Tamara Vasquez
The University of Texas at Arlington
NURS 5366 – Principles of Nursing Research
Michelle Hampton PhD, RN, NEA-BC
November 21, 2020
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NURS 5366 Research Article Appraisal Part Two.
Research Article Appraisal Part Two
Tamara Vasquez
The University of Texas at Arlington
NURS 5366 – Principles of Nursing Research
Michelle Hampton PhD, RN, NEA-BC
November 21, 2020
NURS 5366 Research Article Appraisal Part Two.
Research Article Appraisal Part Two
The article that will be appraised in this paper will be: “Effect of a scheduled nurse
intervention on thirst and dry mouth in intensive care patients” (Vonstein et al., 2019). The
topics that will be discussed in this paper include population, sample, setting, legal and ethical
issues, measurement, data collection, data analysis, interpretation of finding, and evaluation of
the article.
Population, Sample, and Setting
The setting for the research article was WellSpan York Hospital and their 2 medical ICUs.
The two units were separated into the scheduled intervention unit and the usual care unit. No
medical diagnoses were ruled out for the study. The participants were picked by stratified
random sampling as the researchers had certain criteria for the participants to meet prior to
addition into the study. These included age of at least18 years old, English speaking, ability to
provide informed consent, an ICU stay of 12 hours or more, had a score of -1, 0, or +1 on the
Richmond Agitation-Sedation Scale, and had a baseline thirst intensity or thirst distress score of
3 or greater (Vonstein et al., 2019). Participants were prohibited for: a history of dementia, open
lesions or desquamation on the mouth or lips, or medical condition such as oral surgery that
contraindicated the intervention (Vonstein et al., 2019). The study employed five research nurses
who were trained to enroll patients and collect the data. The quasi experimental design leads to
sample bias as it does not allow for randomization. Selection bias is evident in the study as the
candidates were chosen from only 2 ICUs located in the same hospital, this provided easy access
data. Observer bias, with the use of 5 different research nurses there is a possibility of
unintentionally influencing patients projecting their expectations onto the patients. Gray et al.
(2017) define a bias as something that “occurs if there is any influence or action in a study that
NURS 5366 Research Article Appraisal Part Two.
al., 2017, p. 672). Participants in each group were not aware of each other therefore providing
privacy to all patients.
Measurement
The Pearson χ² test and the Fisher exact test was used to evaluate the dependent variables
of sex, ventilator status, and nothing by mouth and are considered nominal data. Age differences
was determined using an independent samples t test, this is also was a nominal data. The
outcome variables of number of ice water swabs used and number of times lip moisturizer with
menthol was used, thirst intensity scores, thirst distress scores and dry mouth scores were
examined to assess assumptions for parametric testing (Vonstein et al., 2019). Vonstein et al.
(2019) state “the study violated the assumptions of normality (kurtosis ≥ 1.0; Shapiro Wilk test
<.05), so nonparametric analyses was used” (p.44). The Wilcoxon signed rank test
differentiated between before and after scores related to the interventions. The Mann-Whitney
test detected differences in the mean use of ice water swabs and lip moisturizer with menthol.
Statistical significance was established as P less than .05 (Vonstein et al., 2017). The Wilcoxon
and the Mann-Whitney tests are ordinal levels of measurement within this study.
Construct validity of the NRS was established through factor analysis. Concurrent
validity was supported by strong correlations between NRS and scores on a visual analog scale,
current pain intensity word scales, and simple descriptive scales (Vonstein et al., 2019). The
study collected data using the NRS over a visual analog scale as patients are more accustomed to
the 0 to 10 NRS. The authors reference Puntillo et al. (2014) utilizing the visual analog scale
within their study. Mirroring of the Puntillo et al. (2014) study is clear in determining dry
mouth, thirst intensity, and thirst distress scoring 0 (none) to 10 (worst possible). For those
patients that were not able to verbalize due to endotracheal intubation, a paper copy of the NRS
was shown
NURS 5366 Research Article Appraisal Part Two.
and they were asked to point to the number that corresponded to their feeling, or to nod when the
research nurse pointed to the numbers which was done in a previous study (Vonstein et al.,
The article examines comparisons with a study conducted by Wang et al. (2015) who
also used the visual analog scale to measure thirst and dry mouth. The mean value located within
the Wang et al. (2015) study was 5.789 (P=.04), indicating that thirst and dry mouth were
significant predictors of discomfort in patient with mechanical ventilation. Puntillo et al. (2014)
used the 0 to 10 NRS scale for thirst intensity and distress but utilized a dichotomous (yes-no)
scale for dry mouth (Vonstein et al., 2019). The preintervention findings by Vonstein et al.
(2019) were higher for thirst intensity and distress over Puntillo et al. (2014).
Data Collection
Gray et al., (2017) describe data collection as unique to each study as the process of
choosing subjects and collecting data from them with the actual data collection measures and
relies on both research design and measurement methods. (p. 493). A numeric rating scale (NRS)
of 0 through 10 was used to determine thirst distress, thirst intensity, and dry mouth of the
patients participating in the study. The authors make use of five research nurses in their study
who are stated to have been trained to enroll and collect data regarding the patients. Vonstein et
al. (2019) “these nurses used a researcher-developed data collection tool to ensure precision in
collection” (p. 43). The authors do not detail the extent of the training or the data collection
process that the nurses were trained on, therefore the consistency and reliability of the data
collected could be challenged. Data was collected over a period from February through
September 2017.
NURS 5366 Research Article Appraisal Part Two.
intensity, 5.46 (SD 3.1) thirst distress, and 6.68 (SD 2.7) dry mouth were calculated (Vonstein et
al., 2019). As projected, the mean use of ice water oral swabs and lip, moisturizer with menthol
was much bigger in the scheduled intervention group over the usual care group: oral swabs 5.
vs 1.7 (P <.001); lip moisturizer with menthol 4.4 vs 0.5 (P <.001) (Vonstein et al., 2019). The
preintervention scores obtained in both groups within 1 hour of the study beginning did not
fluctuate drastically; thirst intensity (P = .22), thirst distress (P = .22), or dry mouth (P = .68)
(Vonstein et al., 2019). The intervention group had markedly greater differences in the three
outcomes over the usual care group. Vonstein et al. (2019) report findings as thirst intensity (-
2.84 vs -1.68, U = 941.5, Z = -2.24, P = .02) and dry mouth (-3.15 vs -1.56, U = 877.5, Z = -
P = .008) (p. 45). The authors revealed that these are clinically significant with a medium-effect
size for thirst intensity (Cohen d=0.4) and dry mouth (Cohen d=0.5) (Vonstein et al., 2017). For
the independent samples t test, Cohen’s d is determined by calculating the mean difference
between two groups, then dividing the result by the pooled standard deviation (Stangroom,
2020). The priori power analysis conducted at the beginning of the study for the paired t test
yielded an α of .05.
The authors defined the findings using several visual aids. A flowchart was assembled to
validate the breakdown of participant enrollment in the study. Three tables are built in the
article. Table 1 is group demographics with the breakdown of the two groups and to P value for
each indicator. Table 2 represents the NRS for each group along with the Wilcoxon signed rank
test, the table also incorporates the Z score and P values obtained. Table 3 is the breakdown of
the Mann-Whitney test comparing the mean difference in scores of the three outcomes. The use
of the visual aids is beneficial to condense and succinctly place the information for the reader to
immediately perceive and understand.
NURS 5366 Research Article Appraisal Part Two.
Researcher Interpretation of Findings
The hypothesis stated in the article is “providing patients with regularly scheduled
applications of ice water oral swabs and lip moisturizer with menthol would decrease the
patients’ perception of thirst intensity, thirst distress, and dry mouth more than would providing
these interventions upon patients’ request” (p. 42). The objective of this study was to develop and
test a protocol that involved scheduled nursing interventions of providing ice water oral swabs
and lip moisturizer with menthol to patients in the ICU (Vonstein et al., 2019). The outcomes
realized that by executing a scheduled intervention of providing patients with ice water oral
swabs and lip moisturizer with menthol reduces indicators of thirst and dry mouth. This modest
intervention can reduce patient irritation associated with dry mouth, thirst distress, and thirst
intensity. The authors provide a clear description of the study findings using visual aids
(flowchart and tables) along with the narrative explanation within the article. They included non-
statistical findings of the number of patients that declined participation and those not meeting
inclusion criteria. An unexpected finding could be that thirst distress between the two groups did
not differ (P=.07) (Vonstein et al., 2019). The research findings validated the hypothesis that if a
patient receives scheduled interventions that foster hydration then dry mouth, thirst distress, and
thirst intensity should decrease for the patient.
The theoretical framework for this study was not stated by the authors and the model was
not provided. The authors describe limitations of their study as being staffing challenges and
patient enrollment which did not meet the sample size outlined of sixty-six for each group
determined by the priori power analysis (Vonstein et al., 2019). They determined that the power
was sufficient to detect a significant difference for thirst intensity and dry mouth in both groups,
the lack of difference for thirst distress could be a type II error related to insufficient power
NURS 5366 Research Article Appraisal Part Two.
determined using a priori power analysis and the study was limited to two ICUs in a single
hospital. This weakness could have been corrected by extending the length of the study to reach
the recommended sample size, including patients with a baseline score of 2 or greater, and
including more patients with mechanical ventilation. Another weakness is the use of quasi-
experiment design which is that randomization is not allowed limiting the study's ability to
conclude a causal association between an intervention and an outcome (Gray et al., 2017, p.
The study determines that patients in the scheduled intervention group have sizable
enhancement of the symptoms of dry mouth, thirst distress, and thirst intensity. While the
population size was not adequate to meet the recommended sample size, the results still provide
confidence in the findings. However, the findings are not able to be generalized to other patient
populations outside of the ICU. The article describes there were limited number of patients
included in the study that were receiving mechanical ventilation as did the Puntillo et al. (2014)
study. This could limit the credibility of the study. Vonstein et al. (2019) infer “further research
with larger sample sizes is needed to generalize our findings to other populations of patients” (p.
NURS 5366 Research Article Appraisal Part Two.
References
Gray, J., Grove, S. K., Sutherland, S., & Burns, N. (2017). Burns and Grove's the practice of
nursing research: appraisal, synthesis, and generation of evidence (8th ed.). Elsevier.
Hargrave, M. (2020, September 19). Standard deviation.
Investopedia.
https://www.investopedia.com/terms/s/standarddeviation.asp.
Kjeldsen, C. L., Hansen, M. S., Jensen, K., Holm, A., Haahr, A., & Dreyer, P. (2017). Patients'
experience of thirst while being conscious and mechanically ventilated in the intensive care
unit. Nursing in Critical Care , 23 (2), 75–81. https://doi.org/10.1111/nicc.
Puntillo, K., Arai, S. R., Cooper, B. A., Stotts, N. A., & Nelson, J. E. (2014). A randomized
clinical trial of an intervention to relieve thirst and dry mouth in intensive care unit
patients. Intensive Care Medicine , 40 (9), 1295–1302.
https://doi.org/10.1007/s00134- 014-3339-z
Stangroom, J. (2020). Effect size calculator for T-Test. Effect Size Calculator (Cohen's D) for T-
Test. https://www.socscistatistics.com/effectsize/default3.aspx.
Vonstein, M., Buchko, B. L., Millen, C., Lampo, D., Bell, T., & Woods, A. B. (2019). Effect of
a scheduled nurse intervention on thirst and dry mouth in intensive Care Patients.
American Journal of Critical Care , 28 (1), 41–46. https://doi.org/10.4037/ajcc
Wang, Y., Li, H., Zou, H., & Li, Y. (2015). Analysis of complaints from patients during
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