Puntillo Research Critique | Homework Market Help

Research Article:

Puntillo, K., Morris, A., Thompson, C., Stanik-Hutt, J., White, C., Wild, L., (2004).Pain

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behaviors observed during six common procedures: Results from Thunder Project II.

Critical Care Medicine, 32(2):421-427.

Critique of Research Article Form

  1. 1.      In your words, what was the purpose of the study? List any research questions or hypotheses (if you use direct quote remember to properly cite).         

The objective of the study by Puntillo et al (2004) was to identify the particular pain-related factors and behaviors that can be used in predicting the level of behavioral reactions during the six medical procedures, which included femoral sheath removal, tracheal suctioning, wound care, wound drain removal, and central venous catheter insertion. In order to achieve this objective, Puntillo et al (2004) used the following research questions: (a) what behaviors are exhibited frequently at the baseline and when undergoing the specified procedures among patients with and those without pain? (b) What is the probability of an increase in behaviors from baseline in patients with versus patients without pain? (c) Does the level of behavioral reaction exhibited by patients undergoing the specified procedures differ among patients with and those without procedural pain? (d) What is the relationship between the level of the reported pain intensity and the level of behavioral reaction exhibited by patients who are undergoing the specified procedures? (e) What are the factors that determine the degree of the patient’s behavioral reactions in the course of a medical procedure?

  1. 2.      What was the independent variable(s)?                                                     

The independent variables in Puntillo et al (2004) were procedural pain and lack of procedural pain among patients.

  1. 3.      What were the dependent variables?         

The dependent variables in this study included the behavioral responses during the selected procedures such as  eyes closed, verbal complaint, moaning, clinched fists, wince, rigid and grimace.

  1. 4.                  How were the dependent variables measured (what instrument/tools were used)?

The dependent variables were measured using the behavior observation tool, which contained the operational definitions of each behavioral response. The data collectors were supposed to checkmark each behavior exhibited by the by the patient during the procedures. Facial responses comprises of grimace, frown, wince, eyes closed, eyes wide open with eye brows raised, looking away in the opposite direction away from the direction of pain, smile, mouth wide open to expose the tongue and teeth, clenched teeth exposing a slightly open mouth, and none. The verbal responses included moaning, verbal complaints associated with pain, protest words, crying, whimpering, screaming, none, and inability to assess. The body movements included lack of movement, rigid, guarding, pushing, defensive grabbing, restlessness, touching site, flailing, shaking, clenched fists, none, and inability to assess.

  1. 5.      Were reliability and validity of the measures described?

            Fully described for all / partially described / not described          

Puntillo et al (2004) fully described the validity of the measures they used in their study. For instance, the validity of the behavior observation tool for usability and completeness was affirmed through a review by an expert advisory group, after which it was pre-tested in 7 hospitals before the actual study. In aIDition, the data collection nurses received took part in educational training sessions offered by the site coordinator in order to guarantee the consistency and accuracy of the procedures.

  1. 6.      What type of study methods was used? (mark relevant box and then delete rest of boxes)     


Non-equivalent control group__?___

(pretest-post test or post test only)




Phenomenological __?__

  1. 7.      Describe the sample size and characteristics.                                             

The sample size for the study was 5,957 and was conducted in 169 sites. The male participants comprised of 59.4 percent and female participants comprised of 41.6 percent. In terms of ethnicity composition, 75.7 percent were white, 7.8 percent black, and 16.5 percent other.

  1. 8.      What statistical tests were used to analyze study data?                            

Puntillo et al (2004) deployed a number of statistical tests to analyze the study data. Frequencies were deployed to analyze the prevalence of behavioral responses during the baseline and during the procedure and to make comparisons regarding the behavioral responses exhibited during the two test times. Cramer’s V and Chi-square analyses were deployed to test the relationship between an increase in behavioral response during the baseline test and during the procedure. Other tests used by Puntillo et al (2004) included the Mann-Whitney test and the T-test to analyze the difference between the behaviors exhibited patients without and those without procedural pain. In aIDition, the study used Pearson-product moment and multiple regressions for data analysis.

  1. 9.      For each dependent variable, list and interpret the results?                    

Puntillo et al (2004) reported that patients who lacked either procedural pain or background pain showed significantly less signs if pain-related behaviors compared to the patients who had pain. Thus, patients with pain tend to respond more behaviorally when compared to patients without pain. Puntillo et al (2004) also reported specific behaviors exhibited more frequently among patients with and those without procedural pain. The behaviors associated with procedural pain include verbal complaints, eyes closed, wince, rigidity and grimace. In aIDition, patients with procedural pain exhibited no movement less frequent when compared to postoperative patients. Puntillo et al (2004) also affirmed that there is a relationship between the expression of behavior and experience of procedural pain.

  1. 10.  Were there methodologic problems, which potentially underminethe internal validity (quality of study) of the study procedures or external validity (generalizability) of the results?                                                                
Internal validity Threat Present Rationale
History N The duration between pre-test and post-test was relatively small
Maturation N The study observed patients on one instance and it was not a long-term experiment


Inadequate protocol Control   The researchers deployed all measures to ensure that the participants and the data collectors observed the study protocol
Attrition mortality N There were no cases of participant dropouts during the study, neither were instances associated with participants dying during the procedures.
Testing (repeated) Y Pain was assessed on three instances, which increases the likelihood that the participants would opt to modify the manner through which they respond to pain.
Hawthore effect Y There is a chance that the participants could have reacted differently if they were aware they were being studied; for instance, some participants could have refrained from showing signs of pain in order to create a perception that they are strong and can withstand pain during the procedures
Selection bias    
Sample size power N The sample size was relatively large


External validity Threat present Rationale
Study sample

Match your patients?

N The participants were actual patients undergoing actual medical procedures
Study site/practice


Match your


N The study was conducted in a real hospital setting; that is, all the situational specifics such as the treatment administration, conditions of treatment and others are similar to a hospital setting
Would it be feasible

implement the study

intervention in

the real world

(costs, complexity,

personnel, time, etc.)?

N The study can be replicated in a real world setting, in fact, the study was conducted in a real world setting, which implies that there are no limitations regarding the replication of the study in a real world context.
  1. 11.  In one sentence and using your own words, what is the “take home message” from this study?         

The findings by Puntillo et al (2004) are important in the healthcare context and that the findings can be generalized.

  1. 12.  Based on your answers above, should these results be applied in practice.(yes or no)  

            Why or why not? And if yes with whom?

Yes, the results of the study can be applied in practice. This is because the study has few threats to internal validity and no threats to external validity, which implies that the results of the study can be generalized and applied to other people and situations in a healthcare setting. The study can be applied in practice by healthcare professionals, particularly those who are involved in conducting medical procedures such as surgeons and dentists among others.




















Puntillo, K., Morris, A., Thompson, C., Stanik-Hutt, J., White, C., Wild, L., (2004). Pain   behaviors observed during six common procedures: Results from Thunder Project II.    Critical Care Medicine, 32(2):421-427.


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