JUNE 3/VOLUME 12/NUMBER 37/1998

RESEARCH

Mac Gabhann L (1996) A comparison of two depot injection techniques. Nursing Standard.
12, 37, 39-41.

A comparison of two depot injection techniques

In the study reported in this article, the researchers attempted to raise awareness among
practitioners of the importance of intramuscular drug administration technique in reducing
injection site complications following antipsychotic depot injections. They also aimed to
improve and expand the scope of present practice by comparing the effect of two accepted
techniques, the 'air bubble' and 'Z-track' on these complications, and demonstrate that the air
bubble technique is more effective in reducing seepage and causes less discomfort. A 'within
subjects' design was used, and Likert scales for scoring subjective and objective assessment
of complications were established and scored at each injection. The study showed that there
was no significant difference between the effects of either technique

Date of acceptance: February 25 1998.

L'am Mac Gabhann RMN, BSc(Hons), was a practice research nurse, Bracton Centre,
Specialist Mental Health Service, Oxleas NHS Trust, at the time of writing this article, and is
now Senior Nurse, Practice Research, Bromley Mental Health Services, Oxleas NHS Trust,
Bexley, Kent.

KEY WORDS
MENTAL HEALTH NURSING
INJECTIONS

These key words are based upon work undertaken by the RCN Library.

Antipsychotic medication has been used for the treatment of mental illness since the 1950s
(Frankenburg 1994), increasingly in the form of intramuscular (IM) depot injections (Day et al
1995). As large numbers of patients have been discharged from institutional care, their mental
health has been maintained, by IM injection, in the community. Health professionals have
been able to monitor more effectively compliance with treatment and assess patients' mental
state against administered medication (Barnes and Curson 1994).

Complications can occur at the site of the injection following IM drug administration, such as:
seepage of the injection solution and/or bleeding from the injection site onto the skin; pain;
irritation; and even skin lesions. Such complications are widely recognised and have been
investigated (Hay 1995, Murphy 1991).

One cause of complications noted in these investigations is some degree of fault in the IM
injection administration technique itself. However, there is little evidence in the literature of
studies comparing different techniques or examining the effect of particular techniques on
local site complications. This gives cause for concern because most mental health nurses will,
at some stage of their career, be involved in administering IM depot injections.

A literature review by staff at the Bracton Centre, Specialist Mental Health Service, identified
only two studies which compared the effects of different techniques on local site
complications (Keen 1986, Quartermaine 1995). There is extensive literature highlighting one
or other technique as best practice to avoid complications but, as Middlemiss and Beeber
(1989) pointed out, there has been no investigation as to whether one technique was more
effective than another, or why one is chosen over another.
As part of an evaluation of nursing practice and clinical effectiveness, staff at the Bracton
Centre decided to carry out a study comparing depot injection administration techniques. The
aims of the study were to:

• Raise awareness among health practitioners of the importance of technique,

especially in reducing local site complications
• Evaluate ongoing practice and initiate improvements if necessary.

The centre's consultants approved the study as did the local research ethics committee.

The study compared the effect of the Z-track and air bubble techniques, and sought to prove
the hypothesis that the air bubble technique was more effective in reducing seepage and
discomfort at the injection site.

STUDY METHODS
Study design Sixteen residents at the centre agreed to participate in the study, each giving
written consent following a written and verbal explanation of what the study entailed. A total of
148 injections administered during the period of the study met the criteria for inclusion
specified in the study protocol.

The independent variable was that subjects received their IM depot injection medication by
the air bubble or Z-track techniques. Both techniques were standardised for the study. The
dependent variables were the:

• Incidence and degree of medication seepage at injection site

• Incidence and degree of blood seepage at injection site
• Incidence of skin lesions at injection site
• Incidence and degree of pain experienced at injection site
• Incidence and degree of irritation experienced at injection site.

The equipment used for each injection was:

• 2ml syringe
• Green 21 gauge, 1.5 inch needle
• Alcohol swab
• Needle for drawing up drug solution
• Gauze swab
• A small plaster.

Posters with guidelines for the standardised techniques were developed and displayed in
clinical areas where the study was taking place. Any deviation from the standard technique or
equipment resulted in that particular injection being discounted from the results.

A data sheet was devised which used Likert-type scoring scales to measure the data (Robson
1993). A step-by-step guide to the study and a staff training pack were distributed to each
clinical area.

Before the study started, nurses likely to be administering injections were trained in the
practice of standardised techniques and the purpose of the study was explained to them.
Demonstrations were given and the researcher spent time in the clinical areas familiarising
staff and patients with what was expected of them during the study.

Procedure Each time a resident was due his or her prescribed injection, it was administered
using one or other of the standardised techniques, with each technique being alternated. The
techniques were similar in preparation and procedure, but differed in the specific features of
the air bubble or Z-track method.

In the case of the air bubble technique (Pritchard and Mallett 1992, Taylor et al 1993), the
person administering the injection stretches the skin of the chosen site for injection between
the thumb and forefinger and plunges the needle into this taut skin at a right angle,
penetrating to the muscle. The plunger is then pulled back gently to ensure that a blood
vessel has not been punctured, in which case blood appears in the syringe, the needle is
withdrawn and the procedure started again. The medication is then injected slowly into the
muscle. The needle is withdrawn and the taut skin is released. A small amount of air is also
drawn up into the syringe before the medication is injected. This air will also be injected into
the muscle following the medication and should form an air lock in the muscle depot
preventing the medication from seeping out along the needle track into other subcutaneous
tissue or onto the skin.

With the Z-track technique (Belanger 1985), the person administering the injection places the
ulnar side of his or her non-dominant hand distal to the chosen injection site. The skin is then
drawn away from the site and held taut. The needle is plunged into the skin at the original site
while the skin is still held taut, aspirated to check that a blood vessel has not been punctured
and the medication injected slowly. After a few seconds the needle is withdrawn quickly and
the taut skin released. By initially drawing the skin away from the injection site, the skin and
subcutaneous tissues are moved away from the muscle which remains static. When skin and
subcutaneous tissue are released after the injection they return to their original position over
the muscle. This return has the effect of breaking the needle track into the muscle because
the track in the skin and subcutaneous layers move away from the muscle as the taut tissues
return to the original position. The medication should then be locked in the muscle depot.

Each time an injection was given a data sheet was completed. The administering nurse
recorded objective scores for seepage, bleeding and lesions and the resident's subjective
scores for pain and irritation. At the next injection the resident was also asked to score
whether he or she had experienced pain at the injection site at any time following the previous
injection.

Inter-rater reliability for drug administration and Likert scale completion was tested for 10 per
cent of staff participants. The researcher was present at one injection for each of the selected
staff members, and scored a separate but identical data sheet for comparison with the
standardised technique.

The study was carried out over five months, after which time the data sheets were collected
and patient names removed, leaving only an identity number and the tabulated results from
the data.

DATA ANALYSIS
Data were measured at ordinal level for related samples and the level of significance was
chosen as p<0.05. The Wilcoxon signed-rank non-parametric test for related samples was
used to analyse results. In view of a perceived association between scores for pain with the
Z-track technique and bleeding with the same technique, the Spearman's correlation
coefficient non-parametric test for ordinal data was carried out (Coolican 1994).

RESULTS
The results for each dependent variable were tabulated, though only pain, seepage and
bleeding occurred with sufficient frequency to warrant analysis. The results seemed to show a
conflicting pattern, where there was more medication seepage with the air bubble technique,
but more bleeding and pain with the Z-track technique. However, on analysis there was no
significant difference between the effects of either technique on these complications. There
was also no significant correlation between pain and bleeding using the Z-track technique.
The results suggest that complications still occur even when exercising 'best practice' while
administering injections. They also extend the scope for increasing the parameters of
practice, in suggesting that both the air bubble and Z-track are equally effective techniques for
the administration of IM depot injections.

DISCUSSION
Although the hypothesis in this study was rejected, the implications for nursing practice are
positive, in that the results suggest a wider scope of practice and heightened awareness of
the importance of technique in reducing complications. The process of implementing the
study questioned staff practice, previous training and perceptions of what was acceptable
practice. It also demonstrated an initial reluctance to change 'safe habits' when administering
injections, but later, enthusiasm to adopt the standardised techniques once the evidence of
their benefits were accepted.

Prior to the study, the majority of staff had never used an air bubble in injections. In fact there
was almost a unanimous experience of staff being told in their training never to allow air to
remain in the syringe. Despite the non-existence of literature to support this belief, it was
instilled deeply, and it took some time and practice for staff to accept this technique. Although
the air bubble technique is normal practice in North America (Taylor et al 1993), it is not used
frequently in the UK where variants of the Z-track technique tend to prevail. The period of
training for staff during the study highlighted disparate knowledge and practice of injection
techniques. There was no working policy or procedure on administering injections to which
staff could refer. Anecdotal evidence suggested that generally the standard or a variant of the
Z-track technique was used at the clinic.

As awareness of technique and the relationship to complications increased, some staff

realised that their chosen techniques were not substantiated by research evidence. Some
were even contrary to accepted good practice, such as administering larger than acceptable
volumes of medication in one injection site.

The process of implementing this study became an appraisal of present nursing practice and,
given a framework for best practice, individual and general improvements in practice
prevailed.

As noted, complications did occur despite using evidence-based techniques. There may be
several reasons for this: staff were unused to the techniques or self-conscious of being part of
a study; staff were reluctant to commit fully to the idiosyncrasies of each technique; the
techniques themselves may not be perfect; the fact that this was 'real world' research carried
out in the normal clinical environment; and an expectation that with such an invasive
procedure, one might expect at least some minor complication.

The strengths of this study lie in the fact that it was carried out in a normal clinical
environment. By using a within subjects design, potential variables which may have affected
the accuracy of the study were kept to a minimum. On the other hand, the involvement of
many staff with the expectation that they would adhere to standardised techniques,
regardless of reliability testing and allowance for individual's subjective scoring of pain and
irritation, may well defeat this advantage. Human nature and individual intervention can hardly
be standardised which again may affect the accuracy of results.

Two previous studies reported that the Z-track technique resulted in more pain at injection site
(Keen 1986) and that there was less seepage of medication with the air bubble technique
(Quartermaine 1995). The pattern of results in this study seemed to support both these
studies. The final sample size was small in this case and the pattern emerging may have
become significant if it was larger or the study longer. Although the hypothesis was rejected,
the impact of the study on nursing was positive, in that the scope of practice could now be
broadened within the range of technique. This demonstrates the importance of research as a
tool for development rather than simply to achieve a particular result.
CONCLUSION
This study was carried out in order to enhance client care at the centre and develop nursing
practice. It has achieved this by applying specifically to the chosen client and staff group
under normal intervention conditions, as it was in this area that the study aimed to raise
awareness of injection technique.

Although the study can be replicated perhaps more accurately in any clinical area treating
people with depot injections, the results may only apply to this client group. The process of
implementing the study, ensured the development and a broadening of the scope of nursing
practice. For the Bracton Centre, the study culminated in a comprehensive policy for
administering depot injections, gleaned not just from a book, but also developed by residents
and staff, tailored to their environment, yet founded on research-based evidence. For nursing
generally, it may begin to make up for the lack of research in the area of injection technique
and the relationship to local site complications.

REFERENCES
Barnes TR, Curson DA (1994) Long term antipsychotics. A risk benefit assessment. Drug
Safety. 10, 6, 464-479.

Belanger MC (1985) Long acting neuroleptics: technique for intramuscular injection. Canadian
Nurse. 81, 8, 41-44.

Coolican H (1994) Research Methods and Statistics in Psychology. Second edition. London,
Hodder & Stoughton.

Day J, Henderson B, Butterworth T (1995) Shaping up the depot. Nursing Times. 91, 44, 51-
54.

Frankenburg FR (1994) History of the development of

antipsychotic medication. Psychiatric Clinics Of North America. 17, 3, 531-540.

Hay J (1995) Complications at site of injection of depot

neuroleptics. British Medical Journal. 311, 421.

Keen MK (1986) Comparison of intramuscular injection

techniques to reduce site

discomfort and lesions. Nursing Research. 35, 4, 207-210.

Middlemiss MA, Beeber LS (1989) Issues in the use of depot antipsychotics. Journal of
Psychosocial Nursing. 27, 6, 36-37.

Murphy JI (1991) Reducing the pain of intramuscular (IM)

injections. Clinical Care. July/August, 35.

Pritchard AP, Mallett J (1992) The Royal Marsden Hospital Manual of Clinical Nursing
Procedures. Third edition. London, Blackwell Scientific.

Quartermaine S (1995) A comparative study of depot injection techniques. Nursing Times. 91,
30, 36-39.
Robson C (1993) Real World Research: A Resource for Social Scientists and Practitioner-
Researchers. Oxford, Blackwell.

Taylor C, Lillis C, Le Mone P (1993) Fundamentals of Nursing: The Art and Science of
Nursing Care. Second edition. Philadelphia PA, JB Lippincott.