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Running Head: NURS 611 PICOT PAPER
PICOT Paper
Rebecca Pettis
University of New Hampshire
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Title:
In patients postoperative from CABG surgery, how does the use of music therapy as an
adjunct with medication for pain management compare to the use medication alone within the
length of their hospitalization?
Abstract
The use of music therapy as an adjunct for pain management in patients postoperative from
coronary artery bypass graft surgery (CABG) was the focus of this research summarization. The
question sought to be answered in this scholarly paper was as follows: Does the use of music
therapy decrease the patient’s pain when utilized with analgesic pain medications? Three
databases (PubMed, Cumulative Index to Nursing and Allied Health Literature [CINAHL], and
Medline) were searched extensively for preexisting literature on the topic published within the
last fourteen years. A total of five applicable studies were found and utilized in this appraisal of
evidence regarding music therapy and postoperative open heart surgery patients. After reviewing
all of the data and evidence presented in the research articles, it can be concluded that music
therapy is a useful and cost-efficient method to help manage pain when used with analgesic
medications in patients following a CABG.
Background and Rationale:
It is estimated that over eight-hundred thousand CABG procedures are performed worldwide
each year. A concern associated with such a traumatic surgery is the level of pain that patients
experience postoperatively. Pain is clearly defined as an “unpleasant sensory and emotional
experience associated with actual or potential tissue damage”, and can cause much discomfort
(Özer, Karaman Özlṻ, Arslan, and Gṻnes, 2008, p.20). When inadequately managed,
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postoperative-related pain can lead to severe consequences. These can include decreased quality
of life, physiological changes as evidenced through vital signs, and deep vein thrombosis or
pulmonary embolism (Özer et al., 2008). Most patients report moderate to severe pain following
a CABG and their pain is an issue which has been addressed in research many times. The priority
intervention used to manage postoperative pain is analgesic medications, which have been found
to help considerably. However, other adjuncts need to be explored for their effectiveness
regarding pain management in postoperative CABG patients. Even after pain medication, many
patients still report experiencing pain, and many report breakthrough pain. Finding different
methods, such as music therapy, to help control patients’ pain would increase patients’ comfort
significantly.
Music therapy has been found to be an effective way to help manage patients’ pain as an
adjunct to analgesic medications. Music therapy is defined as “the use of music in the
accomplishment of therapeutic aims: the restoration, maintenance, and improvement of mental
and physical health” in persons suffering from some sort of distress (Jose, Verma, and Arora,
2012, p.198). Music acts as a distraction from the pain itself which is part of what allows music
therapy to be so effective. The use of a calming, culturally-appropriate music allows the patient
to be soothed and relaxed. Music therapy is also useful because it is an easy intervention for
nurses to perform that has no known adverse effects and is cost-efficient. However, before music
therapy can be implemented as a nursing intervention, there has to be evidence to support the
inclusion of this adjunct. Evidence-based practice is crucial for a nurse to perform in their
practice, because it allows for the highest-quality care to be given to patients. Evidence-based
practice ensures that the care being provided is safe and efficient. Without any evidence to
support the use of music therapy, there would be no knowledge about the potential risks of using
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music therapy, or even if the therapy is beneficial. This compilation of articles in PICOT format
sets out to summarize the research evidence to show that using music therapy as an adjunct to
analgesic medications in the management of pain for patients who are postoperative from CABG
surgery is a beneficial and useful tool for nurses to implement.
Search Methods:
Databases searched include the CINAHL, PubMed and Medline. The search engines used in
all of these databases varied from basic search to advanced search. Typically, the process started
through using basic search, and then progressed to using the advanced search settings to narrow
down results to find articles most applicable to the topic.
Key words searched in CINAHL included: music, pain, heart surgery, music therapy, heart,
cardiac and CABG. Key words searched in PubMed included: music therapy, CABG, music
heart surgery, CABG patients, and pain. Key words searched in Medline included: music
therapy, pain, heart surgery, cardiac surgery, cardiac, heart, and CABG.
Limits used in CINAHL included: abstract available, publish date 2000-2014, English
language, human subjects, references available, full text available, and age group: all adult.
Limits used in PubMed included: abstract available and human species. Limits in Medline
included: linked full text, published 2009-2014, abstract available, English language, human, and
all adults: nineteen years or older. Resulting from this extensive database search, five articles
were carefully selected to be included. General inclusion criteria for all articles consisted of
music therapy as an adjunct intervention, and the patient could only be postoperative of a CABG
surgery. Exclusion criteria for this scholarly paper were the use of music therapy as the main
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pain management technique, pain unrelated to CABG surgery (i.e. depression), and the patient
being postoperative from other types of surgeries (i.e. abdominal).
Clinical Appraisal of the Evidence:
When analyzing the importance of the evidence found through the databases, the researcher
must address the design of the study, the results found, and the strengths and limitations
illustrated by the author. In the article written by Özer et al. (2008), the study performed was a
quasiexperimental, and included a convenience sample of ninety people. There was a control
group and an experimental group. The control group was instructed to stay in their bed while the
experimental group was exposed to music for thirty minutes. The researchers collected data
regarding pain intensity via verbal report both before and after the intervention. What they found
was that the experimental group had a statistically significantly lower amount of pain after the
intervention of music therapy (p=.001). This study had strength in its sample size of nearly one
hundred patients, and range in age of participants (eighteen through seventy eight). However, it
did have limitations regarding the fact that data was obtained from only one hospital in one area
of Turkey. Another limitation was that the authors created the study and gathered the data,
meaning that they were not blinded to the groups. Also important to be noted is that patients
were obtained through convenience sampling and were not randomized at all. As illustrated
above, this study has a significant number of limitations compared to the strengths. Therefore,
the results and recommendations set forth by this study should be approached carefully, and
other supplemental resources should be used in addition to just this study alone.
In the article written by Voss, Good, Yates, Baun, Thompson, and Hertzog (2004), the study
was set up as a randomized clinical trial. It consisted of an adult population postoperative from
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open heart surgery and it included sixty one people. The population was divided into three
groups which included being exposed to sedating music for thirty minutes (nineteen people), a
scheduled period of rest for thirty minutes (twenty-one people), or standard postoperative care
for thirty minutes (twenty-one people). The pain assessments were given before and after sitting
in a chair for the first time following surgery. All of the patients were on postoperative day one.
The scale used for pain was the visual analogue scale, which is rated zero through one-hundred
with zero being no pain and one-hundred being severe pain. Results for this study showed that
the only group who reported pain as mild after sitting in the chair was the group who listened to
music. The two remaining groups reported their pain as moderate or severe. The researchers also
found that the music group’s level of pain was significantly less compared to the other groups
(p<.017). Strengths of this study included looking at three different variables, using the visual
analogue scale which has been well-tested previous to use, and many more resources compared
to the other published literature. Limitations of this study included the fact that all of the data
was collected at one rural hospital, the sample size was relatively small, it was published in
2004, and the researchers remained in the room during the thirty minute intervention for each
group to observe. This could have led to inaccurate responses by the patients. This study has
some significant detail and credibility behind it, being cited in many other articles that were
found through the search process. However, the fact that the research is over ten years old is
concerning. Also the small sample size and lack of geographic diversity makes this article
difficult to rely on by itself. Other articles would need to be included as a reference before any
guidelines could be put into place.
In the article written by Cutshall, Anderson, Prinsen, Wentworth, Olney, Messner, Brekke,
Li, Sundt, Kelly and Bauer (2011), the study completed was a randomized control trial. There
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were one-hundred patients split into two groups. The experimental group participated in music
therapy two times a day for twenty minutes on postoperative days two through four (forty-nine
people), while the control group experienced standard postoperative care two times a day for
twenty minutes on postoperative days two through four (fifty-one people). The pain was
evaluated and recorded via a verbal pain scale before and after each intervention. Researchers
found that there was a significant decrease in the mean pain scores after two sessions of music
therapy on the second postoperative day (p=.001). Strengths of this study included a large sample
size, reporting of pain on a previously-validated scale, the study is current from 2011, and
looking at pain over a number of days. Limitations of this study include that the music options all
consisted of nature sounds; it may have been more effective to allow patients to choose their own
music. Another limitation was that all of the data was obtained at one hospital. This article seems
to be relatively current compared to some of the other articles which increased its credibility. It
also utilized professional statisticians, research coordinators and consultants as authors as
opposed to solely nurses as some of the other articles did. This study has some significance due
to its credibility because it has considerably extensive analyses sections and graphs, as well as
being published in a peer-reviewed journal. This makes the results of this study applicable and
able to be referenced in future studies that will be performed regarding the topic.
In the article written by Jose et al. (2012), the experimental study followed a pretest/posttest
design. There were sixty participants above the age of eighteen, randomly put into the
experimental or control group through the use of a computer. The experimental group consisted
of thirty participants having music therapy for twenty minutes followed by a rest period of ten
minutes. The control group consisted of thirty participants having a period of rest for thirty
minutes. The participants were all within three days of being postoperative of cardiac surgeries.
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The patients’ pain was assessed before and after the intervention via a numerical rating scale.
Upon the analysis of the collected data, researchers found that there was a significant decrease in
the amount of pain (p=.05) for those in the experimental group compared to the control group.
Strengths of this study include no conflict of interest or biases due to the randomization process,
the data is credible and current from 2012, and the study has been published in an international,
peer-reviewed journal. This study also included the work of a statistician and results were
illustrated in an organized, effective method. Limitations of this study included visiting only one
hospital in New Delhi, using a numerical scale that has not been previously tested for efficiency,
and only including sixty participants. Despite the limitations of this study which may seem
distracting, this study and its results should still be held with high regard due to its publication in
a credible journal, its process of randomization, and lack of conflict of interest.
In the article written by Sendelbach, Halm, Doran, Hogan Miller, and Gaillard (2006), a
randomized control trial was performed using eighty-six patients. Fifty patients were in the
experimental group, and were exposed to twenty minutes of music. Thirty-six patients were in
the control group and were exposed to twenty minutes of bed rest. Pain was assessed pre and
post intervention on postoperative days one through three using a numerical zero to ten scale.
Researchers found that there was a significant decrease in pain for the experimental group after
being exposed to music (p=.009). Strengths of this study include the size of the population, and
the fact that the researchers looked at pain over a number of days instead of just at one instant.
The study also included a literature review prior to the collection of data which shows its
reliability. Other strengths of the study include that it was randomized, utilized a professional
statistician to help interpret the results, and was performed in three different hospitals.
Limitations of this study include that the participants were interrupted during their music
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therapy/bed rest time by staff members accidentally. Another limitation of the study is that it is
from 2006, and is missing some data values. Missing data values were due to patient refusal after
the beginning of the study which is thought to be attributed to the burden of recovering from
cardiac surgery. The results of this article should be applied and referenced carefully due to the
year in which the study was performed, and the limitation of missing data. However, it still has
some merit due to its multiple strengths.
Evidence Synthesis:
Throughout all of the articles addressed in this PICOT paper, all studies assessed pain pre
and post intervention .In each study, statistically significant findings were established that
illustrated the use of music therapy as a useful adjunct with analgesic medications for patients
following CABG surgeries. The findings, as evidenced by the data collected, suggest that an
alternative, non-pharmacological pain management method such as music therapy can be helpful
to patients when medication does not take away all of their pain. In most cases, the pain score
dropped one or two points when compared to the control groups. Although the limitations
brought forth in the study need to be recognized, they are not crucial as to whether or not the
intervention is performed. This is because the intervention will not likely cause harm to the
patient, and there are no known adverse effects. Another benefit is that the music therapy is very
inexpensive. The body of evidence that has emerged from the analysis of all of the articles
discussed relates directly to the PICOT question; the use of music therapy as an adjunct to
pharmacological interventions can help to decrease the pain more effectively than the use of
pharmacological interventions alone.
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Clinical and Research Recommendations:
Based on the evidence appraisal which has been completed regarding five different studies, a
clear message has been brought to attention: Music therapy is an effective, non-pharmacological
adjunct with analgesic medications in pain management for patients postoperative from CABG
surgeries. This indicates that music therapy can and should be utilized in the clinical setting by
nurses who are caring for patients in the recovery stage from a CABG surgery. Further research
which needs to be done is regarding the specifics of the music therapy. Upcoming research needs
to entail the frequency, as well as the length of music therapy. For example, how many sessions
are most beneficial to the patient regarding pain management? How many minutes/hours should
the sessions last to be most helpful to patients regarding their pain? These are both questions that
still need to be answered by future research. The answers to these questions are key to providing
the most effective and efficient pain management through the use of the non-pharmacological
intervention of music therapy in patients postoperative from a CABG surgery during their
hospital stay.
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References:
Cutshall, S., Anderson, P., Prinsen, S., Wentworth, L., Olney, T., Messner, P., Brekke, K., Li, Z.,
Sundt, T., Kelly, R., & Bauer, B. (2011). Effect of the combination of music and nature
sounds on pain and anxiety in cardiac surgical patients: a randomized study. Alternative
Therapies In Health & Medicine,17(4), 16-23.
Jose, J., Verma, M., & Arora, S. (2012). An Experimental Study to assess the Effectiveness of
Music Therapy on the Post Operative Pain Perception of Patients Following Cardiac
Surgery in a Selected Hospital of New Delhi. International Journal Of Nursing
Education, 4(2), 198-201.
Ozer, N., Karaman Ozlu, Z., Arslan, S., & Gunes, N. (2013). Effect of Music on Postoperative
Pain and Physiologic Parameters of Patients after Open Heart Surgery. Pain Management
Nursing, 14(1), 20-28. Retrieved December 5, 2014, from Cumulative Index to Nursing
and Allied Health.
Sendelbach, S., Halm, M., Doran, K., Miller, E., & Gaillard, P. (2006). Effects of Music Therapy
on Physiological and Psychological Outcomes for Patients Undergoing Cardiac
Surgery. The Journal of Cardiovascular Nursing, 21(3), 194-200. Retrieved December 5,
2014, from PubMed.
Voss, J., Good, M., Yates, B., Baun, M., Thompson, A., & Hertzog, M. (2004). Sedative Music
Reduces Anxiety And Pain During Chair Rest After Open-heart Surgery. Pain, 112, 197203. Retrieved December 5, 2014, from Cumulative Index to Nursing and Allied Health.