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Abstract of thesis entitled
“Evidence based practice on Use of Music Therapy to Reduce Postoperative Pain
for Patients Undergone Cardiac Surgery”
Submitted by
YUEN LOK KAN
For the Degree of Master of Nursing
at the University of Hong Kong
in July 2016
i
Introduction: In the department of cardiothoracic unit, unrelieved postoperative pain
is the main complaint by patients who undergone cardiac surgery. Postoperative
complications would be the negative outcome of under-managed pain. Nurses, as a
healthcare professional, are capable of playing a more active role in facilitating patients
to tackle postoperative pain besides administering medications only. Non-
pharmacological pain control strategy such as music therapy, is studied in this
dissertation to explore its usage as an adjunct to optimized patients’ pain control after
cardiac surgery.
Objectives: This dissertation is to (1) systematically review and critically appraise
studies which assess the therapeutic effect of music therapy in reducing postoperative
pain for patients who undergone cardiac surgery; (2) to design an evidence-based
guideline for nurses to implement music therapy in clinical practice and (3) to establish
an implementation and evaluation plan for the evidence-based guideline.
Methods: A comprehensive literature search on the effect of music therapy to reduce
postoperative pain for patients undergone cardiac surgery was completed with
electronic database namely PubMed and ProQuest via ProQuest Medical Library in the
span from November 14 to December 4 in 2015. Quality of literature was assessed with
the methodological checklist of Scottish Intercollegiate Guidelines Network (SIGN) of
controlled trial studies. The transferability, feasibility and cost-benefit ratio of the
ii
evidence-based practice guideline were discussed so as to address the implementation
potential
Results: Five studies were selected and all of them were randomized controlled trials.
Two studies were graded with high quality, 1 study was graded with acceptable quality
and the remaining 2 were graded with low quality with high risk of bias. The highly
qualified studies consistently showed significant effect of reducing postoperative pain
for patients undergone cardiac surgery. The music therapy is transferable and feasible
in the clinical setting.
Conclusion: Evidence has shown that music therapy is effective of reducing
postoperative pain for patients undergone cardiac surgery. It is anticipated that patients,
healthcare professionals and health system would be benefited from the proposed
evidence-based guideline.
Evidence based practice on Use of Music Therapy to Reduce Postoperative Pain
for Patients Undergone Cardiac Surgery
by
YUEN LOK KAN
BNurs. (CUHK); RN
A thesis submitted in partial fulfillment of the requirements for
the Degree of Master of Nursing
at the University of Hong Kong
July 2016
iii
Declaration
I declare that this dissertation represents my own work, except where due
acknowledgement is made, and that is has been previously included in a thesis, dissertation
or report submitted to this University or to any other institution for a degree, diploma or
other qualifications.
Signed ………………………..
Yuen Lok Kan
iv
Acknowledgement
I would like to express my deepest, heartfelt gratitude to my dissertation supervisors
Dr. Kelvin Wang and Dr. Janet Wong from the School of Nursing of The University
of Hong Kong, for their expert advice on my dissertation and their clear guidance and
infinite patience over these two years. Last but not least, I would like to deliver my
gratitude and express my love to my parents, friends and colleagues for their support
and encouragement throughout my studies of the degree of Master of Nursing.
v
Table of Content
Abstract………………………………………………………………………………i-ii
Declaration…………………………………………………………………………....iii
Acknowledgement…………………………………………………………………….vi
Table of Content………………………………………………………………….....v-vi
List of Appendices and Illustrations………………………………………………….vii
Chapter 1: Introduction
1.1 Background……………………………………………………………………...1-2
1.2 Affirming Needs…………………………………………………………………2-6
1.3 Objectives and Significance……………………………………………………..6-7
Chapter 2: Critical Appraisal
2.1 Search and Appraisal Strategies……………………………………………………8
2.1.1 Inclusion and exclusion criteria……………………………………………8
2.1.2 Search Strategy……………………………………………………..….8-10
2.1.3 Appraisal Strategy………………………………………………………..11
2.2 Results…………………………………………………………………………....11
2.2.1 Report of Search Results……………………………….......................11-13
2.2.2 Summary of Appraisal Results……………………………………….13-16
2.3 Summary and Synthesis…………………………………………………………..16
2.3.1 Summary of Findings…………………………………………….…..16-17
2.3.2 Synthesis of Findings…………………………………………………….17
2.3.2.1 Music Delivery………………………………………………17-18
2.3.2.2 Music Type………………………………………………..…18-20
2.3.2.3 Duration of Music Therapy……………………………………...20
2.3.2.4 Dose and Date of Music Therapy…………………………….20-21
2.3.2.5 Comparisons…………………………………………………21-23
2.3.2.6 Outcome Measurement………………………………………….23
2.3.2.7 Preparation before Intervention……………………………...23-24
2.3.2.8 Effect Size…………………………………………………...24-26
Chapter 3: Translation and Application
3.1 Transferability……………………………………………………………………27
3.1.1 Target Audience……………………………………………………...27-29
3.1.2 Target Setting………………………………………………………...29-30
3.1.3 Philosophy of Care…………………………………………………...30-31
vi
3.2 Feasibility………………………………………………………………………...31
3.2.1 Freedom of Use…………………………………………………………..31
3.2.2 Adjustment on Routine for Intervention……………………...………31-32
3.2.3 Administrative Support……………………………………………… 32-33
3.2.4 Consensus………………………………………………………………..33
3.2.5 Availability of Staff and Resources…………………………………..33-34
3.2.6 Evaluation Tools…………………………………………………………35
3.3 Cost-benefit Ratio………………………………………………………………...35
3.3.1 Potential Risks………………………………………………………..35-36
3.3.2 Potential Benefits……………………………………………………..36-37
3.3.3 Costs………………………………………………………………….37-38
3.4 Evidence-based Practice Guideline……………………………………………….38
Chapter 4: Implementation Plan
4.1 Communication Plan……………………………………………………………...39
4.1.1 Stakeholders…………………………………...…………………......39-40
4.1.2 Communication Strategy……………………………………………..40-41
4.1.2.1 Forming a Communication Team………………………………..41
4.1.2.2 High-rank Nursing Support………………………………….41-42
4.1.2.3 Introducing a Change………………………………………...42-43
4.1.2.4 Sustaining a change……………………………………………...43
4.2 Pilot Study Plan…………………………………………………………………...43
4.2.1 Pilot Test Procedure…………………………………………………..43-44
4.2.2 Pilot Test Evaluation……………………………………………….....44-45
4.3 Evaluation Plan………………………………………………………………..45-46
4.3.1 Patient Outcomes………………………………………………………...46
4.3.2 Healthcare Providers’ Outcomes……………………………………..46-47
4.3.3 System Outcome……………………………………………………...47-48
4.3.4 Sample Size Calculation……………………………………………........48
4.3.5 Data Analysis…………………………………………………………48-49
4.4 Basis for Implementation………………………………………………….......49-50
Chapter 5: Conclusion………………………………………………………………51
Appendices……………………………………………………………………….52-83
Reference…………………………………………………………………………84-91
vii
List of Appendices and Illustrations
Diagram 1: PRISMA 2009 Flow Diagram……………………………………………10
Table 1: Table of Search Strategies…………………………………………………...13
Table 2: Level of Evidence of Each Article…………………………………………..14
Appendix 1: Table showing keys to evidence statements and grades of
recommendations by SIGN……………………………………………52
Appendix 2: Excluded Studies……………………………………………………….53
Appendix 3: Table of Evidence…………………………………………………..54-59
Appendix 4: Appraisal Checklists (SIGN, 2014)……………………………...…60-69
Appendix 5: Estimated Cost for Music Intervention……………………………..70-71
Appendix 6: Grade of Recommendations (SIGN, 2014)…………………………….72
Appendix 7: Evidence-based Practice Guideline………………………………….73-78
Appendix 8: Gantt Chart for Music Intervention Implementation in a 50-week
Period………………………………………………………………….79
Appendix 9: Questionnaire for Frontline Nurses on Their Perspectives on
Postoperative Pain Control…………………………………………….80
Appendix 10: Questionnaires for Nurses after Workshop……………………………81
Appendix 11: Questionnaire for Nurses Concerning Their Views of Innovation……82
Appendix 12: Questionnaire for Patients after Music Intervention………………….83
1
CHAPTER 1
INTRODUCTION
1.1 Background
Pain after surgery is a predictable experience. By the International Association
for the Study of Pain (IASP, 2014), pain is defined as “an unpleasant sensory and
emotional experience associated with actual or potential tissue damage, or described in
terms of such damage.” Patients after cardiac surgeries have no exemption of
postoperative pain. Tissue retraction, incisions and chest tube insertion after surgery are
expected (Mueller et al., 2000). More than 80% of patients experience moderate to
severe postoperative pain (Allred, Byers & Sole, 2010). Poor control over postoperative
pain is the culprit of undesirable physiological outcome including stiffness, immobility,
atelectasis, myocardial ischemia, deep venous thrombosis, pneumonia, depression,
anxiety and chronic pain (Nett, 2010). These complications impose heavy economic
burden to health care system, common medical implications consist of extended length
of stay and patient dissatisfaction (Apfelbaum et al., 2003).
Music is one of the cognitive-behavioral interventions for pain management
recommended by the Agency for Healthcare Research and Quality (AHRQ, 2001), and
has been proved to improve pain control and reduce use of pain medication (Bradt &
Dileo, 2009). Nurses, as a primary health care professional and extensively spend more
2
time with patients in postoperative pain, are therefore an ideal person to provide non-
pharmacological pain control methods and pain-relieving strategies to complement
currently prescribed analgesics (Dunn, 2004).
1.2 Affirming Needs
Based on my personal working experience in a Cardiac-Thoracic Surgical Unit
(CTSU) of a public hospital under the Hospital Authority (HA) in Hong Kong,
suboptimal and inadequate postoperative pain control after cardiac surgery is
commonly seen. Common cardiac surgical procedures in my department are as follow,
Coronary Artery Bypass Grafting (CABG), valve replacement and valve repair. In early
postoperative stage after patients’ sedation was weaned and extubated, by general
observation, the chief complaint of patients was postoperative pain when being asked
what bothered them most at the moment and a quarter of them reported pain score rating
at least 4 out of 10. Patients were attended upon discharge and they reported static
postoperative pain in general and some even claimed dissatisfaction over pain control.
CABG and valve surgery are two of the commonest cardiac procedures in Hong
Kong, composed of 51% and 28% of total cardiac procedures respectively from 2006
to 2011 in Prince of Wales Hospital (Underwood, 2012). Meanwhile, CABG
contributed 33% of cardiac interventions from 2010 to 2011 in Queen Mary Hospital,
while valve surgery contributed 30% (Hospital Authority, 2011).
3
CABG is one of the surgical procedures with nerve injury pain which leads to
hypersensitivity of outside stimulus such as light touch and amplified response to a
noxious stimulus (Kelhet, Jensen & Woolf, 2006). Knowing that more and more
cardiac surgeries have been proceeded and more studies concerning pain management
are available, patients still complain of considerable pain after surgery (Engwall &
Duppils, 2009). Particularly regarding patients who have undergone cardiac surgery
and postoperatively cared in ICU, more than 75% of them reported moderate and
severe pain during ICU stay (Gelinas, 2007). With poor postoperative pain
management of nerve damage, chronic pain is possible outcome. Minimizing or
relieving acute pain by early treatment was effective to prevent chronic pain, as
suggested by a research on pain management for patients after CABG (Watt-Watson
& Stevens, 1998). A study concerning estimated incidence of chronic pain after
CABG in US was done, 30-50% of subjects reported chronic pain and 5-10% even
reported severe chronic pain, rating their pain score at least 5 out of 10 (Kelhet et al.,
2006).
Pain is one of the undesirable outcomes which contributes to co-morbidities such
as postoperative arrhythmias due to sympathetic response of pain triggers. Imbalance
between sympathetic and parasympathetic activity is achieved and sympathetic outflow
is induced during pain distress which produces atrial ectopic beats and hence triggesr
4
postoperative atrial fibrillation (POAF) (Jiang et al., 2009).
Patients undergone cardiac surgery are prone to postoperative atrial fibrillation.
An incidence rate of 16-46% has been reported after cardiac surgery based on the extent
of postoperative monitoring strategies used and particular surgical interventions
(Hossein et al., 1997, Aranki et al., 1996, Auer et al., 2005, Fuller et al., 1989 & Pires
et al., 1995). Local tissue trauma on pericardium due to mechanical manipulation of
heart and local inflammatory response may both lead to POAF. POAF may occur when
myocardial sympathetic nerve fibers have been directly injured, for example, CABG
and valve surgery, which may influence the autonomic modulation of atrial myocardial
cells, producing arrhythmias (Ahna et al., 2005). Hemodynamic derangement
associated with POAF such as postoperative stroke, perioperative myocardial infarction,
heart failure and ventricular arrhythmias may be resulted even though POAF could be
self-limiting after cardiac surgery (Echahidi et al., 2008 & Kaireviciute, Aidietis & Lip,
2009).
In Hong Kong, a Nurse-coordinated CABG Clinical Pathway Resulting in
Shortening of Hospital Length of Stay and Improvement in Clinical Outcome was
conducted from 29th June, 2010 to 31st December, 2013 in Queen Mary Hospital (Lau,
2014). 362 cases of elective CABG were studied. Incidence rate of POAF was 3.9%
which was the second most only fewer than leg wound infection (4.7%). Meanwhile,
5
there is a growing demand of cardiac surgical service as heart disease is the third leading
cause of deaths in Hong Kong. There were 5,834 deaths caused by heart disease in 2013
and had increased to 6,405 deaths in 2014. In 2013, around 75,000 patients were
hospitalized with diagnosis of heart disease. Coronary heart disease contributed 68.7%
of heart disease deaths which was the dominant component of heart disease mortality
(Centre for Heath Protection, 2015). CABG is one of the surgical procedures of
coronary heart disease. However, a gross under-provision of cardiac surgery for Hong
Kong local population was noted when compared with the United Kingdom (UK), there
were around 400 coronary revascularization operations (CABG) per million
populations per annum. Hong Kong had a number of only 86 cases per million
populations per year while the coronary risk profile was similar with UK (Underwood,
2012).
Although growing demand for cardiac procedures service is anticipated, frontline
health care professionals like nurses would continue to provide holistic care during
patients’ experience of cardiac procedures. As a primary care provider, nurses would
endeavor to facilitate patient outcome by evidence-based practice. Enhancing patients’
efficacy of postoperative pain control after cardiac surgery is one of our nursing
objectives. On top of prescribed pharmacological interventions, promoting use of
nonpharmacological strategies of pain management is the area nurses should focus on.
6
Music therapy, which is relatively cheap and simple to use, serves as a non-invasive
technique to tackle postoperative pain. Use of music therapy causes little or even no
risk of adverse effect to patients which need to be explored by nurses in order to achieve
a better coping of pain by patients in postoperative stage.
Music listening is considered to induce endorphin release and alter catecholamine
levels which facilitate pain relief and improve physiological parameters such as
lowering blood pressure and heart rate (Guzzetta, 1989; Chlan, 1998 & Wong et al.,
2001). Previous studies have demonstrated an increase in relaxation level and a
distraction from pain with the use of music (Byers & Smyth, 1997; McCaffrey & Good,
2000 & McCaffrey & Locsin, 2002). Soothing and familiar music would occupy
patients’ mind and allow them to escape into their own world where is pleasant and
encouraging. Therefore, patients’ attention would be shifted away from negative pain
stimuli by a distractor, music (Nilsson, 2008). Good and colleagues (2005) have
conducted a randomized clinical trial showing music therapy results in a less post-test
pain in patients undergone intestinal surgery. A literature review has demonstrated the
effectiveness of music therapy to reduce pain intensity for gynecological patients
(Chow & Sin, 2015). However, there has not been a systematic review on the effect of
music therapy in alleviating postoperative pain after cardiac surgery.
1.3 Objectives and Significance
7
Hole and colleagues (2015) supported the use of music as an aid for postoperative
recovery, such as reducing postoperative pain, for adults in their systematic review and
meta-analysis. An evidence-based guideline of music interventions in clinical setting
would further improve the outcome of current care for patients experiencing
postoperative pain after cardiac surgery. However, there is no existing relevant
evidence-based protocol concerning postoperative pain with the use of music therapy
in Hong Kong. Therefore, by using the translational research method, this dissertation
aims to reduce postoperative pain in patients after cardiac surgery by the use of music.
Meanwhile, an evidence-based protocol intervention plan would be suggested.
The followings are the 3 objectives in this dissertation.
1. To systematic review and critically appraise the effect of music intervention on
postoperative pain alleviation after cardiac surgery;
2. To produce a nurse-led evidence-based guideline concerning the use of music in
patients who have undergone cardiac surgery for postoperative pain control;
3. To assess feasibility and transferability of music intervention for pain management
after cardiac surgery;
4. To establish a plan for implementation and evaluation of the proposed guideline to
be used on tacking postoperative pain after cardiac surgery.
8
CHAPTER 2
CRITICAL APPRAISAL
2.1 Search and Appraisal Strategies
2.1.1 Inclusion and exclusion criteria
Studies were included if
1. Patients aged 18 or over
2. Non-intubated patients undergone elective cardiac surgery
3. Use of music only given in postoperative period
4. Pain included in study outcome
5. Randomized controlled trials (RCT)
Studies were excluded if
1. Patients undergone emergency cardiac surgery
2. Patients undergone cardiothoracic surgery or thoracic surgery
3. Patients had hearing problem and cognitive and behavioral disorder
4. Mixed use of other complementary alternative medical therapies with music therapy
5. Music therapy was given either pre-operative period or intra-operative period or
both
2.1.2 Search strategy
The following keywords were used to conduct an electronic databases for studies
9
related to my topic. They were divided into three groups.
1. Music OR Music therapy
2. Postoperative pain
3. Cardiac surgery OR open-heart surgery OR CABG
The search was conducted from the middle of November to the beginning of
December in 2015. Two electronic databases were used in search process, they were
PubMed and ProQuest. Every single search result was screened with titles and abstracts
of the articles if they were suitable and relevant to my topic. Then, duplicated studies
were eliminated. Afterwards, studies in English using only RCT design and full text
published from 2000 to 2015 were selected. Lastly, in order to enrich the search result,
manual search over the reference lists of selected literatures was conducted.
10
PRISMA 2009 Flow Diagram (Diagram 1)
Records identified through
database searching
(n = 533)
Screen
ing
Inclu
ded
E
lig
ibil
ity
Id
en
tifi
cati
on
Additional records identified
through other sources
(n = 0)
Records after duplicates removed
(n =527)
Records screened
(n = 527)
Records excluded
(n = 520)
Full-text articles
assessed for eligibility
(n = 7)
Full-text articles
excluded, with
reasons
(n = 2)
(Appendix
Studies included in
qualitative synthesis
(n = 5)
11
2.1.3 Appraisal Strategy
Critical appraisal was conducted with the checklist developed by the Scottish
Intercollegiate Guidelines Network (SIGN, 2014). It composes of two parts, internal
validity and overall assessment of the study. Appraisal was then performed in terms of
clarity of research question, randomization, concealment method, blinding strategy,
similarities between intervention and control group, outcome measurement, drop-out
rate and intention to treat analysis, multiplicity of study. The study would then be
graded with 4 levels regarding the extent of minimizing bias, High quality (++),
Acceptable (+), Low quality (-), Unacceptable (0). Level of evidence of a study is also
graded according to SIGN Grading System (2012) shown in Appendix 1.
Table of evidence of each selected study was constructed after critical appraisal.
Relevant data of the study was systematically categorized into a table in terms of
bibliographic citation, study design, level of evidence, sample characteristics,
intervention, comparison, length of follow up, outcomes and effect size.
2.2 Results
2.2.1 Report of Search Results
All the searches were performed from the November 14 to December 4 in 2015
through electronic databases PubMed and ProQuest via ProQuest Medical Library.
With the keywords search, a total of 533 relevant studies was singled out, 26 from
12
PubMed and 507 from ProQuest respectively. After limiting search result to full text
published between the beginning of 2000 to December 2015, 478 studies were found.
To further screen the title and abstract of studies and eliminate duplication, only seven
studies fulfilled the inclusion and exclusion criteria. Finally, five out of seven studies
were RCT designs and were therefore identified to be reviewed. Search strategies and
flowchart are demonstrated in detail in table 1 and figure 1 as follows:
13
Table 1: Table of Search Strategies
Search Items Electronic Database
PubMed ProQuest via
ProQuest Medical
Library
Search Date 14/11/15 4/12/15
(1) Music OR Music Therapy 18,721 30,292
(2) Postoperative pain 76,056 77,351
(3)Cardiac Surgery OR Open-
heart Surgery OR CABG
372,375 142,313
(1) + (2) + (3) 26 507
Limit to full text 22 456
Published between Jan 2000 and
Dec 2015
20 418
Inclusion & Exclusion criteria
met after screening title and
abstract
6 2
Articles after removal of
duplication
7
Limit to RCT 5
2.2.2 Summary of Appraisal Results
Among 5 selected articles, all of them were RCT designs. 3 of 5 studies took
place in the United State (US) (Voss, et al., 2004, Sendelbach, et al., 2006 & Cutshall,
et al., 2011). One of them was from Sweden (Nilsson, 2009) and the remaining was
14
from Iran (Jafari, et al., 2012). According to SIGN grading framework, “1++” was
graded for the quality of 2 studies (Voss, et al., 2004 & Jafari, et al., 2012). One was
graded with “1+” (Nilsson, 2009). The remaining 2 were graded with “1-” (Sendelbach,
et al., 2006 & Cutshall, et al., 2011).
Table 2: Level of Evidence of Each Article
Studies Design Grading
Voss et al. (2004). Sedative music reduces anxiety
and pain during chair rest after open-heart surgery.
Pain, 112, 197-203.
RCT 1++
Sendelbach et al. (2006). Effect of Music Therapy
on Physiological and Psychological Outcomes for
Patients Undergoing Cardiac Surgery. Journal of
Cardiovascular Nursing, 21(3), 194-200.
RCT 1-
Nilsson, U. (2009). The effect of music intervention
in stress response to cardiac surgery in a randomized
clinical trial. Heart & Lung, 38(3), 201-207.
RCT 1+
Cutshall et al. (2011). Effect of the Combination of
Music and Nature Sounds on Pain and Anxiety in
Cardiac Surgical Patients: A Randomized Study.
Alternative Therapies, 17(4), 16-23.
RCT 1-
Jafari et al. (2012). The effects of listening to
preferred music on pain intensity after open heart
surgery. Iranian Journal of Nursing and
Midwifery Research, 17(1), 1-6.
RCT 1++
All studies have set their target group to patients who majorly undergone CABG
or valve surgery or both. Three of five studies were carried out in ICU settings (Voss
et al., 2004, Cutshall et al., 2011 & Jafari et al., 2012). Nurse to patient ratio is different
between ICU and general ward setting. Nurses attend patients’ needs more promptly in
15
ICU while more environmental disturbance such as noise and more crowded setting are
anticipated in general ward. There is no large discrepancy in subjects’ age in five studies,
ranged from 57 to 67 years and the sample size varied from 60 to 100 patients which is
an acceptable range.
All studies have addressed an appropriate and focused question on the effect of
music therapy over postoperative pain control. All studies have adopted randomization
method namely coin flipping, computer-generated randomization while Cutshall and
colleagues (2011) used stratified randomization based on pain score of 4 less or greater.
Subjects were acquired their pain score before random sampling that they may
exaggerate their score for intervention. Meanwhile, no intention-to-treat analysis was
performed in this study which may affect outcome.
Single-blinding to outcome investigator nurse was adopted in three studies (Voss
et al., 2004, Cutshall et al., 2011 & Jafari et al., 2012) which minimize bias when nurses
collecting data after intervention. On contrary, data collectors in other two studies may
exert extra effort or pressure on subjects when acquiring pain score and conducting
questionnaire.
No significant difference was manifested between groups in terms of
demographics, analgesics used and cardiac procedures in all studies.
Drop-out rates were less than or equal to 5% in four studies except Sendelbach
16
and colleagues’ (2006), prevalent drop-out were reported in postoperative day two to
three due to refusal of intervention and data collection therefore there was no repeated-
measure analysis for data collected beyond postoperative day two.
For the intervention and control, all studies demonstrated comparison between
treatment and control group. Voss and colleagues’ (2004) study was also the only one
mentioned intention-to-treat analysis.
2.3 Summary & Synthesis
2.3.1 Summary of Findings
All five selected studies were randomized control trials and have made a
conclusion suggesting giving music after open heart surgery will reduce postoperative
pain.
Voss and colleagues (2004) adopted a three-group design while settling subjects
for chair rest and receive intervention namely a thirty-minute music, scheduled rest and
usual care. Pain sensation and pain distress decreased after music intervention.
Sendelbach and colleagues (2006) conducted music intervention twice per day
for three consecutive days after surgery and concluded that mean pain intensity
decreased from three to two after intervention while control remained three throughout.
Nilsson’s (2009) study primarily focused on the stress response after music
intervention but also collected data of subjects’ pain score. It did not show a significant
17
reduction of pain score between intervention and control group with the mean
difference was 1.4 and 1.3 respectively.
Similar to the study of Sendelbach and colleagues’, Cutshall et al (2011)
conducted music intervention twice per day for three consecutive days starting at
postoperative day (POD) two. It highlighted the most significant decrease in mean pain
score by 1.4 after the second music session on POD two while a 0.4 decrease was
documented for the control.
Jafari and collagues (2012) studied the mean pain intensity before and multiple
score after intervention by the Numerous Rating Scale, showing a significant reduction
from 5.8 to 3.1 immediately after music intervention and the score decreased over time
as further data was collected thirty minutes and one hour after intervention. In contrast,
there was no difference in mean pain intensity between pretest and posttest, furthermore,
the score increased over time.
2.3.2 Synthesis of Findings
2.3.2.1 Music Delivery
Voss (2004), Sendelbach (2006), Jafari (2012) and their colleagues delivered
music via headphones while Nilsson (2009) and Cutshall and colleagues (2011) used
music pillow and Compact Disc player respectively. Subjects who did not use
headphones were prone to noise and surrounding sounds and hence were more easily
18
disturbed during music intervention. All studies except Jafari and colleagues (2012)
delivered music in private room. Interruption by visitors and healthcare personnel was
minimized as a sign was posted to indicate music intervention was in progress.
2.3.2.2 Music Type
All studies addressed the music delivered was chosen by patients within a list
of recommended music except Nilsson’s study (2009) that only 1 type of music was
offered. Music intervention which was prescribed or preferred by patients was
suggested to critically influence the effect of music therapy (Lesiuk, 2008). It is
suggested (Ebneshahidi & Mohseni, 2008) that patients feel more comfortable and
relaxed like at home instead of in an unfamiliar environment with their familiar type of
self-selected music because mind distraction and pain reduction could be facilitated.
Prior to patients’ selection of music, Voss (2004) and Jafari (2012) and their
colleagues reported they allowed patients to listen to a 30-second to 1-minute pieces of
each selections or in which patients interested. Therefore, subjects were able to select
their most desired music piece from the list in an attempt to maximize the sedative
effect.
Music selected was played in a tempo of 60 to 80 beats per minute in all studies
except Cutshall and colleagues’ (2011). Music was played with a controlled, soft
rhythm could be comfortably heard by the subjects. Though Cutshall and colleagues
19
(2011) did not mention music with high tempo and strong rhythm was played, only one
type of music, a combination of music and sound in nature, with four sub-categories
were available for selection, namely Summer, Autumn, Bird and Night Song. It would
not be a comfortable music experience if subject show no interest in such combination
of music and sound in nature.
Voss and colleagues (2004) emphasized a wide variety of music in likes of harp,
piano, slow jazz, orchestra, synthesizer and flute were provided with terms “new age”,
“classical”, “slow modern”, “popular in the United States from 1940s to 1980s” and
highlighted a culturally acceptable selection of American Indian flute music was
offered, catering the American Indian population. Meanwhile, Jafari and colleagues
(2012) highlighted cultural conditions of their Iranian society was put into
consideration of music choice. Type of music sensitive to cultural condition of the
subjects is suggested to be selected by patients as emotional response varies from
culture to culture (Jensen & Yang, 2007). Therefore if music pieces were more
culturally acceptable or attractive to subjects, according to the gate control theory of
pain proposed by Melzack and Wall (1965), a more significant stimulation by non-
noxious input is able to suppress pain and hence prevents pain sensation from travelling
to the central nervous system. The linkage between subjects and music and the
resonance created would achieve a better sedative and soothing effect in postoperative
20
stage.
2.3.2.3 Duration of Music Therapy
Three studies adopted a thirty-minute music intervention (Voss et al., 2004,
Nilsson, 2009 & Jafari et al., 2012). The remaining two delivered a twenty-minute
music therapy (Sendelbach et al., 2006 & Cutshall et al., 2011). Meanwhile, a minimum
duration of thirty minutes was recommended to serve as an effective clinical practice
in a systematic review (Nilsson, 2008). Therefore, a longer session suggested a more
significant outcome in early postoperative pain control.
2.3.2.4 Dose and Date of Music Therapy
Voss (2004) and Nilsson (2008) and their colleagues delivered music
intervention once on POD one while Jafari and colleagues (2012) offered once on POD
zero after surgery.
It suggested that earlier music intervention would achieve a more significant pain
relief. Music could be used as a prompt intervention which brings along satisfactory
pain control. In addtition, in the study of Jafari and colleagues, data was collected
immediately, thirty minutes and one hour after intervention. The reduction in pain score
was 2.7, 3.3 and 3.4 respectively which showed that pain control can sustain for an hour.
Repeated measures by ANOVA also suggested a significant of pain in their study
(p=0.0001).
21
The remaining two studies provided music intervention twice a day through three
consecutive days after surgery, i.e. through POD one to three in the morning and
evening (Sendelbach et al., 2006) and through POD two to four in the morning and
afternoon (Cutshall et al., 2011). These two studies did not conclude with a significant
pain control which can sustain for a longer period. In Sendelbach and colleagues’ study,
missing values were prevalent in POD two and three due to patients’ refusal of music
intervention and repeated data collection. Meanwhile, in Cutshall and colleagues’ study
(2011), missing value was scarce and a positive result was manifested through POD
four. However, it was reported that subjects including controls have been exposed to
the music intervention outside study session as researchers did not restrict subjects from
using their own music. Frequency, duration and time of self-initiated music session in
either group were not provided in this study. It was documented that some subjects
listened to music in intraoperative stage. Participants may listen to music right before
study session which may significantly amplify the effect of intervention itself.
2.3.2.5 Comparisons
Voss and colleagues (2004) adopted a three-group design, namely thirty-minute
music intervention during chair rest, thirty-minute chair rest with eyes closed and usual
care during chair rest as control. It was the only study used chair rest as control which
is a common routine early mobilization and also adopted in my setting in POD one.
22
Meanwhile, usual care with chair rest was the control and this reflected a real clinical
situation. The outcome extracted in Voss and colleagues’ study (2004) could be referred
as a genuine condition in my clinical setting. Moreover, this was the only study
mentioned usual care as control while other studies adopted bed rest (Cutshall et al.,
2011, Sendelbach et al., 2006 & Nilsson, 2009) with a sign indicating intervention in
progress was posted on the door of a private room to minimize interruption. It was
hardly possible and practical in my setting as private room was scarce and was only
used for isolation purpose.
Control in Jafari and colleagues’ study (2012) was placed in bed rest with
headphone put on but no music was played in a private room. Music was the only
dependent variable and the presence of headphone would block surrounding sound
which was another measures to minimize interruption. The pain intensity reported by
the control showed no change immediately after intervention and an increase of 0.1 and
0.2 thirty-minutes and one hour after intervention. It might suggest that subjects focus
more on their pain and suffering with the elimination of surrounding sounds and being
separated in a private room.
In Nilsson’s study (2009), a thirty-minute bed rest was arranged to both
intervention and control group before intervention. In other words, intervention group
received a thirty-minute bed rest and thirty-minute music while control group received
23
a total of sixty minutes bed rest. His study concluded with a significant pain reduction
in music group. However, the bed rest session before music intervention would provide
a relaxation effect to subjects before study and amplify the actual effect of music
intervention itself.
2.3.2.6 Outcome Measurement
Two pain measuring instruments were used in the reviewed articles. Three
studies adopted zero-to-ten point Numeric Rating Scale (NRS) (Sendelbach et al., 2006,
Nilsson, 2009 & Jafari et al., 2012). The remaining two adopted Visual Analog Scale
(VAS). A hundred-millimeter horizontal VAS was used (Voss et al., 2004) while a
zero-to-ten point VAS was adopted (Cutshall et al., 2011). Three studies have done a
validity and reliability test with their measuring tools except the remaining two
(Cutshall et al., 2011 & Jafari et al., 2012).
2.3.2.7 Preparation before Intervention
Three studies mentioned assisting patients to a comfortable or relaxing position
on bed by nurses (Sendelbach et al., 2006, Nilsson, 2009 & Cutshall et al., 2011). In
the study of Voss and colleagues (2004), a pivot transfer to chair was assisted by nurses
while patients’ personal needs were met before intervention. Chest physiotherapy on
chair rest was performed to participants before intervention (Nilsson, 2009). Ankle
exercises were offered to all participants for 1 to 2 minutes before intervention was
24
given during chair rest, and were followed by a pivot transfer to a chair (Voss et al.,
2004). Chest physiotherapy and limb mobilization provided by physiotherapists are
common routine in my setting in POD one. The approach in Nilsson’s (2009) and Voss
and colleagues’ studies was similar with my clinical setting and should be regarded as
a reference.
2.3.2.8 Effect Size
There was no odds ratio, relative risk orβ-coefficient calculated in all 5 studies.
Therefore, the effect size of respective studies was provided in terms of the mean
difference before and after intervention compared with control group.
Four studies showed a significant decrease in patients’ postoperative pain after
music intervention was given after cardiac surgery except Nilsson’s study (2009) which
reported no such difference.
Nilsson’s study (2009) was the only article reported no significant difference
between intervention and control group. Stress marker (serum cortisol) was the primary
outcome while subjective pain was the secondary outcome of the study. By using an
NRS for pain level measurement, a 1.4-point decrease was noted before and
immediately after intervention while a 1.3-point decrease was noted in control group.
A 1.7-point decrease was calculated before and 30 minutes after intervention while a 1
point decrease was noted in control group.
25
In Cutshall and colleagues’ study (2011), there were totally 6 sets of data
collected as the music intervention was delivered twice daily through POD 2 to 4. A
1.4-point decrease using VAS was noted before and after second session of music
intervention on POD 2 while a 0.4-point decrease was noted in control group (p = 0.001).
It was the only significant result among 6 sets of data.
Sendelbach and colleagues (2006) studied postoperative pain and anxiety score
as major outcome, offered music intervention twice daily through POD one to three,
hence, there should be originally six sets of data similar to Cutshall and colleagues’
study. However, as missing data was substantial due to refused intervention and data
collection, only three sets of data collected: morning and afternoon session of POD one
and morning session of POD two. There were zero change in mean pain score (NRS)
in pretest and posttest value for all 3 sessions respectively in control group. Meanwhile,
a 0.9-point decrease in both morning and afternoon session of POD 1 in intervention
group was detected. A 1.1-point decrease was noted in morning session of POD 2 (p =
0.009).
In Jafari and colleagues’ study, pain intensity (NRS) was the only measured
outcome measured. There was a 0.2-point increase when subjects in control group was
assessed in pretest until one hour after without listening any music. In contrast, for
intervention group, a 2.7-point decrease was noted before and immediately after
26
intervention. A further 0.6-point decrease in the next thirty minutes. An hour after
music intervention, a 3.4-point decrease was noted when compared with pretest value.
No significant difference in baseline pain intensity between two groups (p = 0.08).
Variance analysis by repeated measures showed significant reduction of pain intensity
(p < 0.0001).
In Voss and colleagues’ study (2004), anxiety score, pain sensation and pain
distress were primary outcomes. Comparison between intervention group and control
group was made before and after intervention on POD one. The mean difference of
pretest and posttest was calculated. Twenty-six-point decrease was noted in pain
sensation (p = 0.001) and thirty-four-point decrease was noted in pain distress (p <
0.001). Bonferroni’s adjustment for multiple comparisons was used (P < 0.017).
27
CHAPTER 3
TRANSLATION AND APPLICATION
In Chapter 2, 5 selected articles have been reviewed, showing evidence that
music intervention is effective to reduce postoperative pain for patients undergone
cardiac surgery. Before translating such pain management strategy into clinical practice,
a thorough assessment concerning the implementation potential of music therapy in
patients after cardiac surgery is suggested to be done. Therefore, in Chapter 3,
transferability, feasibility and cost-benefit ratio are discussed prior to an evidence-
based practice guideline of music intervention to reduce postoperative pain for patients
undergone cardiac surgery is developed.
3.1 Transferability
3.1.1 Target Audience
The target audience are the adult patients in early postoperative stage of elective
open heart surgeries mainly CABG and valve surgery. Urgent and emergency
procedures are not included. Patients who undergone cardiothoracic or thoracic surgery
are excluded from our study. They are excluded if they have hearing or cognitive
impairment. Patients who are diagnosed with mental illness such as depression,
Alzheimer’s disease or dementia should not be included. Patients included should be
extubated and free from sedation who are able to talk and complete a pain assessment
28
by the Visual Analog Scale (VAS). Patients with unstable postoperative physiological
parameters namely arrhythmias, tachypnea, desaturation or chief complain of angina or
chest pain would not be included.
Our practice setting performs cardiac surgery majorly to male patients, around
70 % and patients’ age ranges from 50 to 80 years old. Demographic characteristics of
the target audience is generally comparable to those of the selected studies in the
systematic review, showing male patients are major target, around 70-76% and mean
age range from 57 to 66 years old.
All five selected studies provided music intervention to targets undergone
elective and non-emergency open heart operation, mostly referring to CABG or valve
repair surgery, which is identical to our settings.
Three out of five studies carried out music intervention in the setting of
cardiovascular surgical intensive care unit and the remaining underwent intervention in
cardiovascular intermediary units. In our settings, we recruit targets both in ICU and
general ward.
Three out of five studies provided patients with intervention in postoperative day
one once as they focused on pain control in early postoperative stage which is similar
to our setting.
Two out of five studies used VAS as pain level measurement method. The
29
remaining three adopted NRS. We used VAS in our setting which has been proved to
have a high correlation with NRS. Moreover, it will increase workload of frontline
colleagues if we change our pain score measuring tools (VAS) that we used it routinely
to assess patients’ pain intensity. Targets in two selected studies had a pretest pain score
3 (NRS) and have shown a decrease by 1 point. The majority of targets in other two
studies had a pretest pain score above 4 (VAS) and also have shown a decrease by 1
point. This is similar to our setting as our patients’ chief complaint is poor pain control
after surgery according to general observation.
Targets in three of the selected studies were allowed to choose their music for
intervention. Among these three studies, targets in two of them were allowed to listen
to part of the music pieces before intervention. This is similar to our setting.
3.1.2 Target Setting
Our proposed setting is a cardiothoracic surgical unit (CTSU) of the surgical
department of an acute regional hospital under the management of the Hospital
Authority (HA) in Hong Kong. Annually, our unit provides the largest number of open
heart surgeries in Hong Kong. There are 2 scheduled elective open heart operations per
day during weekdays. Therefore, by summation, there would be around 40 patients per
month and hence 480 patients per year who could benefit from our innovated
intervention which is a significant number of clients to be cared for better postoperative
30
pain control.
Once the operations completed, patients would be transferred to a designated
intensive care unit (ICU) under the management of CTSU and then back to general
CTSU ward as condition stabilized. Endotracheal tube extubation and weaning off
sedation would be done before transferring patients back to general ward.
In the selected studies, intubated patients were excluded from the studies. Only
one studies mentioned to exclude patients administered narcotics 4 hours before
intervention. Targets in another studies would be administered with regular opioids such
as fentanyl and oxycodone. None of the studies mentioned targets were sedation-free
but provided that targets were alert to report their pain level and able to communicate.
Patients in the selected studies were allocated in private rooms and received
intervention which is different from our setting. Private room is scarce in our setting
and only be occupied by patients who are under airborne precaution.
3.1.3 Philosophy of Care
Our hospital is dedicated to provide patient-centered high quality service to the
community by concerted effort of multidiscipline teams in order to enhance clients’
satisfaction and facilitate staffs’ motivation. There are 3 slogans reflecting our missions
as a healthcare provider, “To care with empathy”, “To serve with expertise” and “To
serve with excellence”. Regarding the room of improvement concerning a better early
31
postoperative pain control and patients’ subjective complaints addressed in our clinical
setting, nurses are going to initiate an evidence-based guideline by making use of music
intervention to relieve patients’ postoperative pain after open heart surgery. This
proposed intervention is expected to synchronize with the missions of our hospital.
3.2 Feasibility
3.2.1 Freedom of Use
Music intervention has been proven as a safe non-pharmacological pain
management with little or even no risk of adverse effect. It does not require doctor’s
prescription before use and hence nurses have authority to provide innovated
intervention for pain relief or to terminate if patients’ condition is considered to be
unstable and undesirable according to nurses’ professionalism.
3.2.2 Adjustment on Routine for Intervention
The innovated intervention lasts for thirty minutes and is set to carry out after
bed bath at 9 a.m. while medical round usually takes place at 10 a.m. Our target audient
is prioritized as the first patient to have bed bath so they are comfortably positioned and
ready for music intervention at around 9:15 a.m. with the most relaxed state. It is
expected not to crash with the medical round surgeons’ assessment at 10. If case
surgeons attend during intervention, they will be reminded patient is undergoing music
intervention and advised to attend other patient first. They will be informed once
32
intervention ended.
A nurse in morning shift performs bed bath for 3 patients in average. Case nurse
of target audient will continue such routine only within the cubicle of the target. Patient
who starts music intervention will be given a call bell in advance his or her
physiological parameters continue to be monitored such as bedside electrocardiogram,
arterial and non-invasive blood pressure, heart rate, respiratory rate and oxygen
saturation. Shift in charge, who does not take part in bed bath, will also be informed
that target is receiving music intervention. If patient deteriorates during intervention,
intervention will be abandoned and case surgeon will be informed.
3.2.3 Administrative Support
The annual plan of the Hospital Authority in 2013-2014 targeted to provide a
higher quality of patient care by enhancing the acute pain services for post-operative
patients. Evidence-based practice is the emphasis of my workplace to ensure health care
quality and integrity which is parallel to patients’ expectation. Such supportive and
positive climate builds confidence for health care professionals to utilize their research
on innovated intervention.
Approval of our innovation from administration support would be critical for
funding and implementation of our intervention. We would seek for professional advice
and guidance from colleagues with experience of evidence-based practice. Regular
33
report will be submitted to managerial personnel and our experience of implementing
the innovation is hoped to be promoted and shared with other departments.
3.2.4 Consensus
Music intervention is new to all frontline nursing staff, surgeons and
administrators in my setting. Uncertainties and queries over the effectiveness of pain
relief by this innovation are expected and project runner will follow by email. Potential
benefits should be tested in each season in terms of patients’ feedback and cost-benefit
ratio. Seasonal report of the innovation will be presented to administrators and frontline
staff to demonstrate the advantages versus disadvantages of music therapy via email
and ward meeting. For example, patients’ satisfaction on music therapy and reduced
usage of analgesics and improved pain score during in early postoperative stage and
upon discharge will be shown transparently in the report.
3.2.5 Availability of Staff and Resources
The utilization project requires frontline nurses help operate the music playing
device, ipod. Patient’s postoperative pain intensity is assessed by VAS which is already
used in my setting. A refresh session of ten minutes would be held for frontline nurses
to reinforce standard use of VAS and ipod in case they have any queries or never used
ipod before.
Two weeks before cardiac surgery, patients are routinely scheduled for a pre-
34
operative assessment screening in which surgeon and anesthetist will be consulted
respectively in a day ward. After registration, a day ward nurse is responsible to
describe the intervention and obtain patient’s written consent for participation when
they are waiting for consultation. Patients will listen to selected music pieces in various
styles as recommended in reviewed studies via ipod with headphone and report their
favorite music piece to day ward nurse before they receive the admission appointment
for operation and leave. The next chapter will explain the solution for day ward nurse
in case patient fails to pick their music piece within the given list.
Patient will admit CTSU one day before surgery. A routine pre-visit session will
be provided by ICU nurse to orientate patients with ICU setting. In this session, nurse
will confirm patients with their choice of music and clarify patients’ concern over music
intervention if any.
For the equipment required, 3 ipod players with headphones are needed to ensure
choice of music is non-lyrical and in a soothing tempo with given beats while cultural
context is considered. 3 eye shields and disposable ear probes for headphones are also
needed. Timers are available in current setting. Alarm function in ipod will not be used
to minimize interruption. No special disinfectant is needed as healthcare assistants will
routinely disinfect used devices in ward according to disinfection protocol implemented
by infection control team.
35
3.2.6 Evaluation Tools
Aitken (1969) developed a pain measuring tool, VAS, which was a linear scale
indicating that a zero refers to no pain while a ten refers extreme pain. A Chinese
version of VAS is available in my setting. The VAS has been adopted as a standard and
universal pain score measurement in my hospital since 2005.
3.3 Cost-benefit Ratio
Balancing the costs and benefits of innovation is essential to sustain the success
of the innovation in long run.
3.3.1 Potential Risks
Music intervention is considered as a safe and simple non-pharmacological pain
control strategy as suggested in the reviewed studies. No injury or other adverse effect
were reported during implementation in the studies. In case of patients developing
arrhythmias or chest pain or other discomfort, they have the freedom to stop and report
to case nurse. Case nurse keeps monitor patients during intervention by physiological
monitor and will seek medical consultation if unstable condition encountered.
There is an extra workload exerted on day ward and ICU nurses. This may lower
morale of frontline colleagues, worsen staff turnover rate and absenteeism. Feedback
and evaluation are always welcome and suggestions or complaints made by staff will
be reviewed and followed by the communication team. Certificate will be awarded as
36
acknowledgement of participation and patients’ appreciation will be delivered in details
via email.
3.3.2 Potential Benefits
Patients’ poor controlled postoperative pain mentioned in the previous chapter is
expected to improve by music intervention in early postoperative stage. Adequate
postoperative pain management results in a better deep breathing and coughing effort
and more effective mobilization which lower the incidence of postoperative
complications such as pneumonia and deep vein thrombosis (DVT) (Yorke, 2004).
Better mobilization will improve and reinforce patients’ satisfaction and wellness over
surgery so that they are able to participate in expected activities like deep breathing and
coughing exercise and sit out (Milgrom, 2004).
In my current setting, there are two pharmacological pain management for
patients after they are extubated and free from sedation. They will be prescribed with
patient-control anesthesia (PCA) with morphine or regular oral analgesics, Panadol 500
milligram and tramadol 50 milligram every six hour. PCA morphine is a systemic
medication that may cause respiratory depression and excessive sedation while a PCA
device is bulky and hamper patient’s mobilization. Meanwhile, dizziness is a common
complaint made by patients in my setting after taking oral tramadol. Risk of fall is
therefore increased which makes patients more vulnerable to injury. Hence, our
37
innovation is a safe alternative for pain relief so that patients can achieve a similar or
better pain control by using less analgesics and weaning off PCA morphine as early as
possible.
Music intervention is easy to implement and its outcome is also easy to measure.
Pain evaluation (VAS) by patients will be done after intervention and upon discharge.
A positive outcome on postoperative pain control and patients’ admiration will improve
staff morale and job satisfaction. The success of music intervention will boost nurses’
confidence and efficacy on pain management which directly enhance patients’ outcome.
3.3.3 Costs
The followings are the financial costs of the innovation. A 16-Gigabit (GB) Ipod
touch with headphone and two-year warranty coverage costs Hong Kong Dollars (HKD)
1,816. Therefore, it is HKD 5,448 for 3 devices. A single music piece acquired from
ITunes Store costs HKD 8 and each album costs HKD 80 in average. The downloaded
music can be shared within the three devices under one account. For every music styles
recommended in reviewed studies, twenty albums will be purchased. Hence, it is HKD
1,600 in total. The project runner is a registered nurse, who is responsible to prepare
and hold meetings and presentations to medical staff, frontline nurses and
administrators, and deliver multiple ten-minute refresh sessions. These will take a total
of fifteen hours and cost HKD 3,750 as the medium of hourly salary of a registered
38
nurse is HKD 250. Frontline nurses will spend twenty minutes for music intervention
and evaluation. There will be 480 cardiac surgeries per year. Hence, HKD 40,000 will
be spent for music intervention by nurses. Therefore, the total cost is HKD 71,364 in
the first year.
Further details concerning costs of set-up, training and attendance and
maintenance will be illustrated in Appendix 1.
3.4 Evidence-based Practice Guideline
The evidence-based practice guideline for music intervention to reduce
postoperative pain in patients undergone cardiac surgery is presented in Appendix 2.
These recommendations are then graded from A to D according to Grades of
Recommendations (Scottish Intercollegiate Guidelines Network, 2014) in Appendix 3,
which indicates the strength of each recommendations.
39
CHAPTER 4
IMPLEMENTATION PLAN
4.1 Communication Plan
4.1.1 Stakeholders
A planned and scheduled communication strategies with stakeholders of our
proposed intervention will proceed before implementing the innovation. Managerial
personnel such as Chief of Service (COS) of cardiothoracic unit (CTU), General
Manager of Nursing (GMN), Department Operating Manager (DOM) of CTU. They
are responsible of making administrative decisions and approving the implementation
of the proposed intervention. Ward manager (WM), nursing officers (NO) and advanced
practicing nurses (APN) are ward-based colleagues who facilitate and supervise the
intervention as a role of shift in charge. Cardiothoracic surgeons will be acknowledged
that patient is undergoing music intervention with a signage is hoisted in bedside. They
will be introduced with the guideline and rationale of the intervention before
implementation. Registered nurses (RN) from ICU, general ward and day ward are
frontline clinical professionals who are intervention providers and also behave as case
nurse of targets. Healthcare assistants (HCA) are supporting colleagues who will be
notified not to interrupt the intervention by doing their daily routine such as equipment
and environment disinfection. Patients, recipient of the intervention, are also
40
stakeholders who are vital to the intervention by their support, consent and evaluation.
4.1.2 Communication Strategy
A communication plan between intervention proposer and stakeholders is
scheduled and estimated to last for eleven weeks, which is demonstrated in Appendix
1. The aim of communication plan is to facilitate the introduction of the intervention,
to promote discussion on improving patient outcomes and effectiveness of innovation,
to provide platform for raising questions and clarifying concerns or doubts. With the
support and thorough understanding from frontline staff to administrative personnel,
our proposed intervention is bound to succeed.
The communication plan starts with a questionnaire (Appendix 2) for frontline
nurses, mainly RNs and APNs, which looks into staff’s perspective on their
management of patients’ postoperative pain such as confidence, willingness to tackle
and satisfaction. Such investigation period will last for a week. Then, a fifteen-minute
presentation will be conducted in ward meeting which is held monthly. It includes a
ten-minute powerpoint slideshow and a five-minute question and answer session. The
powerpoint will illustrate the rationale of a new practice, the need for changes, and
conclude with an evidence-based practice guideline of proposed intervention suggested
in selected studies, cost and benefit analysis and clinical outcome. They need to sign
after attended the presentation. Presentation period will take place from week two to
41
four so as to cater for all RNs and APNs who did not attend ward meeting or took a
two-week annual leave.
4.1.2.1 Forming a Communication Team
During presentation period, intervention proposer will recruit a communication
team (CT) composed of three RNs who will not be included in rotation program in the
following year, and one APN from fifty staff. They are recruited at the end of the
presentation which is voluntary. Once they are recruited, they will be introduced with
the details of protocol, the schedule and role of CT. Team members will be rewarded
with a certificate recognizing their role of evidence-based protocol practitioner and
appraised in their annual staff development report after a year of practice. Duty of team
members will last for a year and they will be rotated to other bundles such as fall
prevention and pressure sore surveillance team. In other words, team members will be
different every year under the guidance of intervention proposer in order to maximize
staff’s opportunity to explore evidence-based practice in clinical setting. All members
are voluntary.
4.1.2.2 High-rank Nursing Support
Data from the questionnaire for frontline staff concerning their points of view to
provide a new non-pharmacological approach for postoperative pain control will be
analyzed and demonstrated in the meetings between CT and WM and DOM. They are
42
welcome to raise concerns over intervention and suggest areas for improvement and
extra information to be included in the proposal. Meetings will be conducted in week
five to seven.
Once the proposal of the evidence-based practice guideline of intervention is
approved by DOM, it indicates all levels of nursing staff in the CTU has reached
consensus and support for the innovation. An official proposal including budget details,
timeline of pilot study plan and evaluation plan will be submitted to DOM by week
nine who will hold meetings with COS and GMN concerning the proposed intervention.
Once it is approved by COS and GMN, funding will be allocated according to the
budget plan. Approval of proposed intervention will be announced by WM in daily
handover section and a poster will be placed in nurse station in week eleven. Meanwhile,
all medical and nursing staff by GMN and COS will be informed by email.
4.1.2.3 Introducing a Change
Twenty-minute workshops organized by CT will be conducted for all frontline
nurses from week twelve to fifteen. Timeline for patients scheduled for a cardiac
surgery from attending a Pre-Admission Screening and choosing music pieces in day
ward, to taking part in a thirty-minute music intervention in early postoperative stage
will be illustrated during workshops. Participants will pair up and familiarize
themselves with the new practice by playing a role of a nurse or patient who delivers
43
and receives music intervention respectively. They are required to complete a
questionnaire (Appendix 3) to evaluate the workshop.
4.1.2.4 Sustaining a change
All stakeholder can reflect their views in the evaluation of the pilot study. Once
the intervention is implemented, they are welcome to write comments on a designated
boards located in nurse station or send email to CT members. A seasonal report
concerning outcomes of patients, healthcare providers and system will be released in
ward meetings and via email.
4.2 Pilot Study Plan
4.2.1 Pilot Test Procedure
Funding approved will be consumed for the purchase of all required equipment
related to the innovation before pilot study begins. CT members are responsible for the
storage and maintenance of equipment.
Day ward nurses will screen for suitable targets according to the inclusion and
exclusion criteria mentioned in Chapter 3 and ask for consent of patient’s participation
in the pilot test. They will explain the entire intervention to targets and facilitate them
to pick their interested music piece in the PAS section one week before operation.
Patient undergone cardiac surgery will be transferred to general ward or ICU for
postoperative care under cardiothoracic unit with fifty frontline nurses in total.
44
Meanwhile, there are two patients in average clinically admitted for cardiac surgery
such as CABG and valve operation per week. Two nurses will pair up and conduct the
intervention to a patient in pilot test. It is ensured that all frontline nurses will be
involved in the test and able to implement the intervention once at least. Therefore,
fourteen weeks will be used for target recruitment and implementing intervention.
4.2.2 Pilot Test Evaluation
Nurses who have conducted the intervention will immediately complete a
questionnaire (Appendix 4) concerning their views and satisfaction over the flow of
intervention. They are welcome to provide suggestions on what extra support is needed
or what items need to be erased to smoothen the procedure and raise out difficulties or
hindrance of maximizing the effect of intervention during pilot test. Nurses are
encouraged to comment about the intervention on a designated board in nurse station
or via email through intranet to the communication team members.
Patients who have undergone the intervention will be immediately interviewed
by case nurse. Completing a questionnaire concerning their experience and satisfaction
of music intervention (Appendix 5) is most preferred but it depends on patient’s
postoperative physical condition. Patient’s postoperative pain after intervention will be
measured by a ten-point Visual Analog Scale (VAS). Patients will be interviewed again
by CT members upon discharge to evaluate their pain intensity and experience of pain
45
management by music intervention.
Data collected from frontline nurses and patients will be analyzed and
summarized. Their views and comments will be highlighted in powerpoint which will
be presented in ward meeting and sent to the whole department two weeks after pilot
test. Following meetings with COS, GMN, DOM, WM and CT will be held to discuss
about opinions from nurses and patients and seek for response and suggestion from
high-level nursing personnel. A finalized and official report after refining the clinical
guideline based on pilot results will be submitted to COS, DOM and WM two weeks
later.
The pilot test will last for eighteen weeks. During the period, the feasibility of
intervention will be explored. Meanwhile, potential problems and difficulties will be
identified before implementation of protocol. These are decisive elements to facilitate
a success of the innovation which enhances patient postoperative outcomes.
4.3 Evaluation Plan
Objectives of a structured evaluation plan for the innovation are as follows, to
evaluate the effectiveness of intervention in reducing patient’s postoperative pain and
patient’s satisfaction of intervention as a non-pharmacological pain management; to
evaluate frontline nurses’ compliance over a new clinical guideline, to review nurses’
efficacy on tackling patient’s complaint of postoperative pain; to evaluate costs and
46
benefits derived from the new protocol.
4.3.1 Patient Outcomes
Patient’s early postoperative pain intensity is the primary outcome of the
proposed intervention. Throughout the innovation, patient’s pain score will be assessed
with VAS which has been adopted as a routine observation in my workplace. The
highest the pain score, the most pain patients suffered. Patient’s pain score will be
assessed before and after the intervention.
Case nurse will deliver patients a questionnaire concerning patient’s experience
and satisfaction over the details of intervention (Appendix 5) after attended their pain
score. For example, setting, timing and duration of the intervention, choice of music
and any disturbance encountered are included. If patients are not physically comfortable
of filling in questionnaire by themselves, nurse will read out the questions and record
patients’ answers. Those questions are mainly five-point Likert Scale in which a one
refers to a total disagreement and a five means a strong agreement.
Patients will be attended by the communication team upon discharge. They will
be asked for their pain score, frequency of using music intervention during
hospitalization and their comments over the intervention as an effective pain relief
method.
4.3.2 Healthcare Providers’ Outcome
47
Frontline nurses are required to complete a self-report questionnaire mainly a
five-point Likert Scale (Appendix 4) concerning their perception of the intervention. A
one and a five means totally disagree and strongly agree respectively. Questions
towards their workload and satisfaction of the innovation, efficacy on pain management,
and possibility of further use of music intervention will be asked. If the music
intervention is suspended before a thirtieth-minute mark, nurses are required to provide
reasons.
To evaluate long-term nurses’ compliance of intervention, a pre-printed nursing
prescription and nursing care plan form will be prepared by CT members for patients
admitted for cardiac surgery. Case nurse will be notified to sign once they have
conducted music intervention to patients.
4.3.3 System Outcome
The effectiveness of the intervention towards health care system will be assessed
in terms of cost and benefit ratio. The decreased expenditure on analgesics administered
and medication due to adverse effect of analgesics will be measured. Length of
hospitalization of patients clinically admitted for cardiac surgery will be compared
annually. With the set-up, manpower and maintenance cost provided, a financial report
will be delivered to managerial personnel as a reference on system outcome.
Data collected will be analyzed every season and results will be presented in ward
48
meetings. An annual report summarizing the outcomes of new clinical guideline will
be delivered via email to the entire department.
4.3.4 Sample Size Calculation
The primary outcome of the intervention is the pain score (VAS). Data will be
collected pre and post intervention. According to the reviewed studies, the most
conservative mean of difference of pain score (VAS) 1.4 from Cutshall et al. (2011) and
standard deviation 2.1 from Jafari et al. (2012) are chosen. By using Faul’s (2009)
sample size calculator, a sample size for a one-tailed t test is 16 to ensure a power of
ninety percent and a significance level of 0.05. A higher power would reinforce nurses
to work on the innovation which promote patient outcomes significantly. Considering
the small attrition rates among five selected studies in early postoperative stage, while
the ease of conducting proposed intervention is emphasized, we assumed a thirty
percent drop-out rate considering nurse-initiated guideline is rarely adopted in my
setting and an example showing a poor compliance of another nurse-initiated guideline
a year ago. Therefore, 30 patients will be recruited. Regarding there are two patients
per week admitted for cardiac surgery in average, 15 weeks will be needed
approximately.
4.3.5 Data Analysis
All data collected from patients and frontline staff will be analyzed by a
49
statistically analysis tool, namely Statistic Product and Service Solution (SPSS)
Statistics 23. To evaluate patient’s outcome, the mean reduction of pain score before
and after intervention will be computed and a one-tailed t-test will be conducted with a
0.05 significance level. Their satisfaction and experience over the intervention will be
reflected in the five-point Likert Scale in the questionnaire. A one-tailed z-test will be
performed. The analytical results will be released and presented in ward meetings every
three months.
Meanwhile, the healthcare providers’ outcome such as the perception of the
intervention measured by another five-point Likert Scale will be computed and a two-
tailed z-test will be conducted in data analysis plan. Nurses’ compliance of the new
clinical guideline will be audited every six months and statistical chart will be provided
in annual report. In certain circumstances such as poor compliance, a refresh session
and meetings for feedback and discussion will be held.
For the system outcome, the expenditure and benefits derived from the
innovation will be evaluated and compared season by season. Similarly, a financial
report of the innovation will be presented in ward meetings every three months.
4.4 Basis for Implementation
The proposed intervention will be considered effective if the defined outcomes
listed below are fulfilled.
50
Immediate pain relief after music intervention with a mean reduction of pain
score by one point at least is regarded as effective since acute postoperative pain is the
chief complaint from the patients according to my general observation in my settings
which is a similar outcome in reviewed studies. The overall patient’s satisfaction of the
innovation would be considered as an acceptable pain control alternative if the score
reaches three out of five in their self-report questionnaire which indicates intervention
bring positive outcome in early postoperative stage. It is a success if patient’s pain score
upon discharge is equal to or less than four as patients report a poor pain control upon
discharge in my current setting. Based on previous experience of poor nurses’
satisfaction (less than three) on other evidence-based protocols, if nurses’ average
satisfaction score is three out of five, our proposed intervention is acceptable for nurses
which also indicates nurses’ efficacy of patient’s pain control is increased. Meanwhile,
their compliance of intervention should be over seventy percent. For system outcome,
if the benefit of the innovation is capable of covering the cost, this intervention is
worthy of implementing in long-term practice.
51
CHAPTER 5
CONCLUSION
Postoperative pain is the major suffering of patients in which room of improvement is
always identified. Despite the routine use of analgesics after surgery in most of the
settings, unrelieved postoperative pain is always the chief complaint which hinders
patients’ recovery and brings along with increased risk of postoperative complications.
Systematic review and critical appraisal over related studies were completed and there
is evidence showing that music therapy is a safe, easy and effective non-
pharmacological approach to reduce postoperative pain for patients who undergone
cardiac surgery. An evidence-based practice guideline was developed by translational
nursing research. It is to propose a sustainable and standardized change in my current
clinical setting. Cost and benefit ratio of the innovation has been addressed. Feasibility
of music intervention has been assessed with an implementation and evaluation plan.
With the use of this guideline to tackle postoperative pain after cardiac surgery, it is
hoped that patients, healthcare professionals and health system would be benefited.
52
Appendix 1: Table showing keys to evidence statements and grades of
recommendations by SIGN
Level of Evidence Description
1++ High quality meta-analyses, systematic reviews of RCTs, or
RCTs with a very low risk of bias.
1+ Well-conducted meta-analyses, systematic reviews, or
RCTs with a low risk of bias.
1- Meta-analyses, systematic reviews, or RCTs with a high
risk of bias.
2++ High quality systematic reviews of case control or cohort or
studies High quality case control or cohort studies with a
very low risk of confounding or bias and a high probability
that the relationship is causal.
2+ Well-conducted case control or cohort studies with a low
risk of confounding or bias and a moderate probability that
the relationship is causal.
2- Case control or cohort studies with a high risk of
confounding or bias and a significant risk that the
relationship is not causal.
3 Non-analytic studies, e.g. case reports, case series.
4 Expert opinion.
53
Appendix 2: Excluded Studies
1. Ӧzer, N., Karamen Ӧzlü, Z., Arslan, S. & Günes, N. (2013). Effect of music on
postoperative pain and physiological parameters of patients after open heart
surgery. Pain Management of Nursing, 14(1), 20-28.
2. Mirbagher Ajorpaz, N., Mohammadi, A., Najaran, H. & Khazaei, S. (2014). Effect
of music on postoperative pain in patients under open heart surgery. Nursing
and Midwifery Studies, 3(3), e20213.
54
55
Appendix 3: Tables of Evidence
Citation / Design /
Study Quality
Sample
Characteristics
Intervention
(A)
Comparison
(B) & (C)
Length of follow
up
Outcomes
(100-mm
horizontal VAS)
Effect Size
(Pretest means minus Posttest
means)
Voss et al. (2004) /
Pretest, repeated
posttest three-
group design,
single-blinded RCT
/ High Quality
(1++)
1. Adult
postoperative
open-heart
surgery patients
(CABG = 80%)
(valve repair =
14%)
2. ICU patients
3. Mean age = 63
years (SD = 13)
4. Male = 64%
5. Chest tube
removed prior
to study = 72%
A 30-minute patient-
selected sedative music
tape from one of six
types of music,
including synthesizer,
harp, piano, orchestra,
slow jazz and flute, was
played with a rate of
60-80 beats per minute,
using soft open-air
headphone and a tape
player during patients’
chair rest.
(n=20)
B. 30-minute
scheduled
chair rest
with eyes
closed
(n=21)
C. Treatment as
usual during
chair rest
(Control
group)
(n = 21)
Before and after
intervention on
postoperative
day 1
1. Anxiety Score
2. Pain Sensation
3. Pain Distress
(*Difference of
Pretest-posttest
means)
1. A VS B: 20[6.1] (p=0.003)
A VS C: 35[7.4] (p<0.001)
B VS C: 15[9.1] (p=0.121)
2. A VS B: 21[6.8] (p=0.006)
A VS C: 26[6.6] (p=0.001)
B VS C: 5[8.4] (p=0.527)
3. A VS B: 23[7.5] (p=0.005)
A VS C: 34[6.9] (p<0.001)
B VS C 11[9.2] (p=0.248)
(*[ ] = Standard Error)
(**Bonferroni’s adjustment for
multiple comparisons was
used, P<0.017)
RCT = Randomized Controlled Trial; CABG = Coronary Artery Bypass Grafting; ICU = Intensive Care Unit; SD = Standard Deviation; VAS =
Visual Analog Scale
56
Citation / Design /
Study Quality
Sample Characteristics Intervention (I)
Control (C)
Length of
follow up
Outcomes
Effect Size
Intervention (I) VS
Control (C)
Sendelbach et al.
(2006) / Pretest,
repeated posttest,
single-blinded RCT
/ Low Quality (1-)
1. Patient undergone
elective open-heart
surgery: CAB
(69.8%) or valve
replacement (19.8%)
or CAB with valve
replacement (10.5%).
(p = 0.051)
2. Non-intubated patient
in cardiovascular
units in 3 hospitals
3. Mean age = 63.3 (SD
= 13.5), (p = 0.43)
4. Male = 69.8%
(p = 0.065)
5. First use of music or
relaxation = 81.2%
(p = 0.14)
A 20-minute patient-
selected music was
delivered on tape by
headphone twice daily
on POD 1 to 3 with
following criteria:
1. No dramatic
changes
2. Consonance
3. Instrumental
music
4. 60-70 beats per
minute
(n=50)
Remarks:
A brief session of
relaxation was given
before intervention.
A 20-minute
resting period
in bed with a
comfortable
position
(n=36)
Remarks:
No relaxation
suggestion
were given
for the
controls
Immediately
before and
after each 20-
minute
session on
POD 1 to 3
Remarks:
Due to high
rate of
missing data,
change scores
were only
calculated for
first 3 time
points.
A. Change in mean pain
score after
1. AM session of POD 1
2. PM session of POD 1
3. AM session of POD 2
(0-10 point NRS)
B. Change in anxiety
score after
1. AM session of POD 1
2. PM session of POD 1
3. AM session of POD 2
(10-item State Anxiety
Inventory with response
anchors of 1 = not at all to 4
= very much)
A1. I: -0.9 VS C: 0
A2. I: -0.9 VS C: 0
A3. I: -1.1 VS C: 0
(p = 0.009)
B1. I: -5.34 VS C: -0.88
B2. I: -3.50 VS C: -0.53
B3. I: -4.17 VS C:+0.08
(p = 0.0004)
RCT = Randomized Controlled Trial; CAB = Coronary Artery Bypass; ICU = Intensive Care Unit; POD = Postoperative Day; NRS = Numeric Rating Scale
57
Citation / Design /
Study Quality
Sample
Characteristics
Intervention (I)
Control (C)
Length of
follow up
(*On POD 1)
Outcomes
Effect Size
Mean (SD)
Nilsson, U.
(2009) / Pretest,
repeated posttest,
RCT / Acceptable
(1+)
1. Patient undergone
elective open-heart
surgery: CABG
or aortic valve
replacement
2. Swedish patients
3. Cardiothoracic
Intermediary Unit
A 30-minute bed rest
with only one type
of soft and relaxing
music distributed
through music
pillow connected to
an MP3 player, with
a rate of 60-80 beats
per minute and a
volume of 50-60 dB
(n=28)
30-minute bed
rest without
music
(n=30)
A. Before
intervention
B. Immediately
after
intervention
C. 30-minute
after
intervention
Primary Outcome
Stress Marker: Serum
Cortisol Level (mmol/L)
1. Before intervention
2. Immediately after
intervention
3. 30-minute after
intervention
Secondary Outcome
Subjective Pain
(0-10 Numeric Rating
Scale)
1. Before intervention
2. Immediately after
intervention
3. 30-minute after
intervention
Primary Outcome
1. I: 630.7 (259.4)
C: 766.3 (270.7)
2. I: 484.4 (209.4)
C: 618.8 (218.9)
(p < 0.02)
3. I: 426.6 (167.8)
C: 496.9 (184.5)
Secondary Outcome
1. I: 3.3 (0-8)
C: 2.7 (0-10)
2. I: 1.9 (0-7)
C: 1.4 (0-10)
3. I: 1.6 (0-6)
C: 1.7 (0-10)
No significant difference
between groups
RCT = Randomized Controlled Trial; CABG = Coronary Artery Bypass Grafting; ICU = Intensive Care Unit; dB = Decibel; POD =
Postoperative Day; SD = Standard Deviation
58
Citation / Design /
Study Quality
Sample Characteristics Intervention (I)
Control (C)
Length of
follow up
Outcomes
(0-10 point VAS)
Effect Size
Intervention (I) VS
Control (C)
Cutshall et al.
(2011) / A repeated
Pretest-posttest,
single-blinded
stratified RCT /
Low Quality (1-)
1. Patient undergone
first-time elective
CABG or cardiac
valve surgery or both
2. Cardiovascular ICU
adult patients without
intubation on POD 2
and hearing disorder.
3. 76% male
(Intervention group)
78% male
(Control group)
4. Majority of patients
with a baseline pain
score of 4 or less
A 20-minute
patient-selected
ambient music
from 4 compact
discs (CDs) of
Summer Song,
Autumn Song, Bird
Song or Night
Song. Music was
played through CD
player on the
nightstand next to
bed in patient’s
room
(n=49)
A 20-minute of
resting period on
bed twice daily
on POD 2 to 4
(n=51)
Remarks:
Participants
were allowed to
listen own music
outside study
session and in
operation room.
Before and
after each 20-
minute
session on
POD 2 to 4
A. Change in mean pain
score after second session
of POD 2
B. Change in mean
relaxation score after
first session of POD 2
C. Change in mean anxiety
score after second session
of POD 3
D. Change in mean
diastolic blood pressure
(mmHg) after second
session of POD 4
Remarks:
These 4 sets of data were the
most significant outcome in
the study.
A. I: -1.4 (SD = 1.4)
C: -0.4 (SD =1.4)
(p = 0.001)
B. I: 1.9 (SD = 2.7)
C: 0.3 (SD = 2.9)
(p = 0.03)
C. I: -0.3 (SD = 1.4)
C: -0.6 (SD = 1.4)
(p = 0.09)
D. I: -3.5 (SD = 9.0)
C: -0.6 (SD = 6.4)
(p = 0.047)
CABG = Coronary Artery Bypass Graft; ICU = Intensive Care Unit; VAS = Visual Analog Scales; SD = Standard Deviation; POD =
Postoperative Day
59
Citation / Design /
Study Quality
Sample
Characteristics
Intervention (I)
Control (C)
Length of follow
up
Outcomes
Effect Size
Intervention (I) VS Control (C)
Jafari et al. (2012) /
Pretest, repeated
posttest, single-
blinded RCT / High
Quality (1++)
1. Patient undergone
elective open-heart
surgery: CABG
(91.7%) & cardiac
valve surgery
2. ICU non-intubated
patient
3. Mean age = 57.83
(SD = 10.62)
4. Iranian patients
A 30-minute patient-
selected relaxation music
piece, which was
suggested by literature
and was selected by
music expert with a
tempo 60-80 beats per
minute, was played by a
MP3 player with a
headphone between 3pm
and 6pm of the day after
surgery when patients’
routine care was
completed.
(n=30)
Headphones
were used
without playing
any music
(n=30)
A. Before
intervention
B. Immediately
after
intervention
C. 30-minute after
intervention
D. 1-hour after
intervention
Remarks:
Intervention was
given on
postoperative day 1
Pain
Intensity
(0-10 point
Numeric
Rating
Scale)
1. I: Mean = 5.8 (SD = 1.7)
C: Mean = 4.7 (SD = 2.8)
2. I: Mean = 3.1 (SD = 2.1)
C: Mean = 4.7 (SD = 2.8)
3. I: Mean = 2.5 (SD = 2.1)
C: Mean = 4.8 (SD = 2.8)
4. I: Mean = 2.4 (SD = 2.2)
C: Mean = 4.9 (SD = 2.9)
Remarks:
1. No significant difference
regarding baseline pain
intensity among the two
groups (p = 0.08)
2. Repeated measures analysis
of variance (ANOVA)
indicated music to
significantly reduce pain
intensity
(p < 0.0001)
RCT = Randomized Controlled Trial; CABG = Coronary Artery Bypass Graft; ICU = Intensive Care Unit; SD = Standard Deviation
60
Appendix 4: Appraisal Checklists (SIGN, 2014)
S I G N
Methodology Checklist 2: Controlled Trials
Study identification:
Voss, J. A., Good, M., Yates, B., Baun, M. M., Thompson, A. & Hertzog, M. (2004). Sedative music reduces anxiety and pain
during chair rest after open-heart surgery. Pain, 112, 197-203.
Section 1: Internal validity
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and
clearly focused question.
Yes.
1.2 The assignment of subjects to treatment groups is randomized.
Yes.
1.3 An adequate concealment method is used.
Yes.
Note: Various block size in sealed envelopes
masked the administrators who enrolled patients.
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
No.
Note: Nurses, as an outcome investigator, were
blinded.
1.5 The treatment and control groups are similar
at the start of the trial.
Yes.
1.6 The only difference between groups is the
treatment under investigation.
Yes.
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes.
Notes: 100-mm Visual Analog Scale for outcome
measurement of anxiety, pain sensation and pain
distress
1.8 What percentage of the individuals or
clusters recruited into each treatment arm of
the study dropped out before the study was
completed?
5% (Sedative music group)
0% (Scheduled rest group & Control group)
61
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Yes.
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
No.
Note: Single-centered study at an surgical intensive
unit at a rural hospital of Midwestern USA
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimize
bias? High Quality (++)
2.2 Taking into account clinical considerations,
your evaluation of the methodology used,
and the statistical power of the study, are
you certain that the overall effect is due to
the study intervention?
Yes.
Note: Preliminary analyses after 62 patients were
enrolled and significant group differences and large
effect size for anxiety, pain sensation and pain distress
were revealed.
2.3 Are the results of this study directly
applicable to the patient group targeted by
this guideline?
Yes.
2.4 This study showed sedative music therapy with patients’ preference produced a significant reduction
on postoperative pain sensation, pain distress and anxiety in early postoperative stage of open-heart
surgery during chair rest in postoperative day 1. This study was a three group pretest-posttest design
which showed comparable outcomes between sedative music and scheduled chair as interventions and
also respective comparison with control group.
62
S I G N
Methodology Checklist 2: Controlled Trials
Study identification:
Sendelbach, S. E., Halm, M. A., Doran, K. A., Miller, E. H. & Gaillard, P. (2006). Effect of Music Therapy on Physiological
and Psychological Outcomes for Patients Undergoing Cardiac Surgery. Journal of Cardiovascular Nursing, 21(3), 194-
200.
Section 1: Internal validity
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and
clearly focused question.
Yes.
1.2 The assignment of subjects to treatment
groups is randomized. Yes.
Note: Assign participants into intervention or
control group by the flip of coin.
1.3 An adequate concealment method is used.
Yes.
Note: Mixed blocks and using cards in sealed
envelopes masked the administrators who enrolled
patients.
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
No.
Note: Intervention providers were the same persons
collecting physiological data
1.5 The treatment and control groups are similar
at the start of the trial.
Yes.
1.6 The only difference between groups is the
treatment under investigation.
Yes.
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes.
Notes: 0-10 point Numeric Rating Scale for pain
score and 10-item State Anxiety Inventory with
response anchor of 1 to 4 for anxiety scoring
1.8 What percentage of the individuals or
clusters recruited into each treatment arm of
the study dropped out before the study was
completed?
0%
63
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Can’t say.
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
Yes.
Note: Data were collected in cardiovascular units in
3 hospitals.
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimize
bias? Low Quality (-)
2.2 Taking into account clinical considerations,
your evaluation of the methodology used,
and the statistical power of the study, are
you certain that the overall effect is due to
the study intervention?
Yes.
Note: Sample size was calculated for the repeated-
measures procedures ranged between 27 and 38 of a
potential 86. Meanwhile (n = 36 for control group; n =
50 for intervention group)
2.3 Are the results of this study directly
applicable to the patient group targeted by
this guideline?
Yes.
2.4 This study showed relaxation music therapy produced a significant reduction on postoperative pain and
anxiety in early postoperative stage (Day 1 and 2). Missing values in later study stage (Postoperative
Day 3) were prevalent due to refused intervention and data collection and hence repeated-measure
analysis for later postoperative stage was impossible. This study provided a brief session of relaxation
with preprinted script before intervention while there was no relaxation suggestions given to control
group. In other words, the intervention group consisted of a 20-minute music session and a brief
relaxation session while controls received a 20-minute bed rest.
64
S I G N
Methodology Checklist 2: Controlled Trials
Study identification:
Nilsson, U. (2009). The effect of music intervention in stress response to cardiac surgery in a randomized clinical trial. Heart
& Lung, 38(3), 201-207.
Section 1: Internal validity
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and
clearly focused question.
Yes.
1.2 The assignment of subjects to treatment
groups is randomized. Yes.
1.3 An adequate concealment method is used.
Yes.
Note: Code of group allocation was revealed to
researcher once data collection and laboratory
analyses were complete.
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
No.
Note: Research nurses and participants were aware
of the interventions
1.5 The treatment and control groups are similar
at the start of the trial.
Yes.
1.6 The only difference between groups is the
treatment under investigation.
Yes.
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes.
Notes: Serum cortisol level & 0-10 point Numeric
Rating Scale for subjective pain sensation
1.8 What percentage of the individuals or
clusters recruited into each treatment arm of
the study dropped out before the study was
completed?
3.33%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Can’t say.
1.10 Where the study is carried out at more than No.
65
one site, results are comparable for all sites. Note: Single-centered study
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimize
bias? Acceptable (+)
2.2 Taking into account clinical considerations,
your evaluation of the methodology used,
and the statistical power of the study, are
you certain that the overall effect is due to
the study intervention?
Yes.
Note: A sample size of 42 patients was suggested to
provide a power of 80%. 30 patients in each group was
hence reached to cover attrition.
2.3 Are the results of this study directly
applicable to the patient group targeted by
this guideline?
Yes.
2.4 This study showed music therapy with patients’ preference produced a significant reduction on
postoperative stress but no significance difference in pain reduction. This study showed no blinding
method which may affect the result. Intervention group received a 30-minute bed rest with music and
followed by another 30-minute of bed rest without music, while the controls received a total of 60
minutes of bed rest. The latter half of bed rest without music in intervention group could be considered
as another intervention (relaxation).
66
S I G N
Methodology Checklist 2: Controlled Trials
Study identification:
Cutshall, S. M., Anderson, P. G., Prinsen, S. K., Wentworth, L. J., Olney, T. L., Messner, P. K. et al. (2011). Effect of the
Combination of Music and Nature Sounds on Pain and Anxiety in Cardiac Surgical Patients: A Randomized Study.
Alternative Therapies, 17(4), 16-23.
Section 1: Internal validity
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and
clearly focused question.
Yes.
1.2 The assignment of subjects to treatment groups is randomized.
Yes.
Note: Stratification of randomization was based on
pain level of 4 or less or greater than 4.
1.3 An adequate concealment method is used.
Yes.
Note: Mixed blocks and using cards in sealed
envelopes masked the study coordinator who
enrolled patients.
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
No.
Note: Nurses, as an outcome investigator, were
blinded.
1.5 The treatment and control groups are similar
at the start of the trial.
Yes.
1.6 The only difference between groups is the
treatment under investigation.
No.
Note: Some participant listened to their own music
outside of study sessions for both intervention and
control group.
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes.
Notes: 0-10 point Numeric Rating Scale
1.8 What percentage of the individuals or
clusters recruited into each treatment arm of
the study dropped out before the study was
completed?
41.3% (Control group)
43.0% (Intervention group)
67
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Can’t say.
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
No.
Note: Single-centered study
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimize
bias? Low Quality (-)
2.2 Taking into account clinical considerations,
your evaluation of the methodology used,
and the statistical power of the study, are
you certain that the overall effect is due to
the study intervention?
Yes.
Note: An effect size of 0.60 at 80% power for a 2-
tailed Wilcoxon rank sum test with an α level of 0.05.
2.3 Are the results of this study directly
applicable to the patient group targeted by
this guideline?
Yes.
2.4 This study showed combination of music and nature sounds produced a significant reduction on
postoperative pain and improvement on postoperative relaxation in early postoperative stage (Day 2).
However, a high drop-out rate would weaken the effect of the intervention. Besides, participants in
control and intervention group were able to listen to their music out of study period and in the operation
room, which might produce a high risk of interference over the study outcome.
68
S I G N
Methodology Checklist 2: Controlled Trials
Study identification:
Jafari, H., Zeydi, A. E., Khani, S., Esmaelli, R. & Soleimani, A. (2012). The effects of listening to preferred music on pain
intensity after open heart surgery. Iranian Journal of Nursing and Midwifery Research, 17(1), 1-6.
Section 1: Internal validity
In a well conducted RCT study… Does this study do it?
1.1 The study addresses an appropriate and
clearly focused question.
Yes.
1.2 The assignment of subjects to treatment
groups is randomized. Yes.
1.3 An adequate concealment method is used.
Can’t say.
Note: Author did not mention any concealment
method used.
1.4 Subjects and investigators are kept ‘blind’
about treatment allocation.
No.
Note: Nurses, as an evaluator on patients’ pain
intensity, were blinded.
1.5 The treatment and control groups are similar
at the start of the trial.
Yes.
1.6 The only difference between groups is the
treatment under investigation.
Yes.
1.7 All relevant outcomes are measured in a
standard, valid and reliable way.
Yes.
Notes: 0-10 point Numeric Rating Scale
1.8 What percentage of the individuals or
clusters recruited into each treatment arm of
the study dropped out before the study was
completed?
0%
1.9 All the subjects are analysed in the groups to
which they were randomly allocated (often
referred to as intention to treat analysis).
Can’t say.
1.10 Where the study is carried out at more than
one site, results are comparable for all sites.
No.
Note: Single-centered study
69
SECTION 2: OVERALL ASSESSMENT OF THE STUDY
2.1 How well was the study done to minimize
bias? High Quality (++)
2.2 Taking into account clinical considerations,
your evaluation of the methodology used,
and the statistical power of the study, are
you certain that the overall effect is due to
the study intervention?
Yes.
Note: Sample size was calculated. An 80% power and
95% level of confidence were achieved.
2.3 Are the results of this study directly
applicable to the patient group targeted by
this guideline?
Yes.
2.4 This study showed music therapy with patients’ preference produced a significant reduction on
postoperative pain in intensive care unit setting. Intervention in this study was closely related to local
social culture. Type of music and duration of intervention were suggested by literature. This study
suggested a high feasibility in real ICU setting, requiring only an MP3 player and headphone. Repeated
posttest in a short period of time, i.e. immediately, 30 minutes and 1 hour after intervention might
induce a Hawthorne effect on study outcome would be enlarged.
70
Appendix 5: Estimated Cost for Music Intervention
Hardware Cost (HKD)
Item Unit cost Quantity Total Cost
16 GB Ipod touch with
headphones plus two-year
warranty coverage
HKD 1,816 3 HKD 5,448
Music album HKD 80 20 HKD 1,600
Single music piece
(backup)
HKD 8 10 HKD 80
Disposable ear probe (30
pairs a pack)
HKD 50 20 HKD 1,000
Eye shield HKD 12 3 HKD 36
Total Equipment Cost: HKD 8,164
Software Cost (HKD)
Rank Hourly salary Unit of
Nurse
Number
of hours
Total cost
Preparation RN HKD 250 1 5 HKD 1,250
Presentation RN HKD 250 1 5 HKD 1,250
Delivery of
training and
refresh session
RN HKD 250 1 10 HKD 2,500
Attendance of
training,
presentation,
feedback and
ward meeting
RN HKD 250 50 1 HKD
12,500
APN/NO HKD 400 6 1 HKD 2,400
WM/DOM HKD 550 3 2 HKD 3,300
1Total Training & Attendance Cost: HKD 23,200
Total Set-up Cost: HKD 31,364
Remarks: Mean of hourly salary of a registered nurse (RN) is HKD 250
Mean of hourly salary of an advanced practice nurse (APN) and nursing
officer (NO) is HKD 400
Mean of hourly salary of a ward manager (WM) and Department of Manager
(DOM) is HKD 550
71
Appendix 5: Estimated Cost for Music Intervention (Con’d)
Maintenance Cost (HKD)
Expense Quantity Total Cost
Manpower
- Time spent by RN in day
ward for orientation and
consent: 10 minutes
- Time spent by RN in
ICU/general ward for
confirmation,
implementation and
evaluation for music
intervention: 10 minutes
Salary of RNs for music
intervention on 1 patient:
HKD 250 x 20/60 = HKD
83.3
HKD 40,000
(For 480 cardiac
surgeries per year)
72
Appendix 6: Grade of Recommendations (SIGN, 2014)
A - At least one meta-analysis, systematic review, or RCT rated as 1++,
and directly applicable to the target population; or
- A body of evidence consisting principally of studies rated as 1+,
directly applicable to the target population, and demonstrating overall
consistency of results
B - A body of evidence including studies rated as 2++, directly applicable
to the target population, and demonstrating overall consistency of
results; or
- Extrapolated evidence from studies rated as 1++ or 1+
C - A body of evidence including studies rated as 2+, directly applicable
to the target population and demonstrating overall consistency of
results; or
- Extrapolated evidence from studies rated as 2++
D - Evidence level 3 or 4; or
- Extrapolated evidence from studies rated as 2+
73
Appendix 7: Evidence-based Practice Guideline
Evidence-based Guideline of Music Intervention for Adult Patients Undergone
Cardiac Surgery in the Cardiothoracic Surgical Unit
Minimizing postoperative pain is the goal of this evidence-based guideline of the music
intervention. The recommendations used in this guideline are graded according to SIGN
(2014). There are 4 grades, “A”, “B”, “C” and “D” representing the grade of
recommendation. By alphabetic order, grade “A” indicates the evidence is the most
credible while grade “D” means the evidence should be the least credible. Meanwhile,
there are eight levels of evidence for the reviewed studies in the previous chapter.
Aim
To match the core values of the hospital in providing patient-centered high quality
healthcare service by minimizing postoperative pain for adult patients undergone
cardiac surgery by use of music in early postoperative stage.
Objective
- To improve patient’s satisfaction after cardiac surgery with the best available
evidence
- To facilitate nurses to implement music intervention after cardiac surgery in
evidence-based approach
- To increase nurses’ initiative to improve patient’s pain sensation by music
74
intervention, a non-pharmacological alternative of pain control
Target Users
The evidence-based guideline is used by nurses working in the ICU or general ward
under the CTSU.
Target group
The inclusion criteria include:
1. Aged 18 or above
2. Elective operation
3. Without hearing problems
4. Conscious and oriented, without mental illness
5. Literate, without cognition and perception problems
6. Extubated patient
7. Sedation-free
Recommendations
1. Adult patients without hearing and mental illness will be given music
intervention. (Grade A)
Adult patients with hearing (Jafari et al., 2012 (1++); Voss et al., 2004 (1++); Nilsson,
2009 (1+); Cutshall et al., 2011 (1-)) or mental (Jafari et al., 2012 (1++); Cutshall et al.,
2011 (1-); Voss et al., 2004 (1++)) disorders are excluded from the innovation in the
75
reviewed studies.
2. Patients undergone elective cardiac surgery are target for music intervention.
(Grade A)
Patients with an emergent procedure will be excluded from the music intervention in
the reviewed studies (Nilsson, 2009 (1+); Jafari et al., 2012 (1++).
3. Extubated and sedation-free patients are eligible for music intervention.
(Grade A)
Patients who were still intubated (Jafari et al., 2012 (1++); Cutshall et al., 2011 (1-))
and using sedation (Jafari et al., 2012 (1++)) are excluded from the innovation
4. Patients can choose their music pieces for music intervention. (Grade A)
Patient’s preference of music is respected. They can pick their favorite music within a
music list with various types (Voss et al., 2004 (1++); Jafari et al., 2012 (1++); Cutshall
et al., 2011 (1-); Sendelbach et al., 2006 (1-) which reduce pain sensation with their
desired music.
5. The type of music should be given in a tempo of sixty to eighty beats per minute.
(Grade A)
Relaxing and sedative music pieces are offered for music intervention with a tempo of
sixty to eight beats per minute (Jafari et al., 2012 (1++); Sendelbach et al., 2006 (1-);
Voss et al., 2004 (1++); Nilsson, 2009 (1+)).
76
6. Patient can listen to the music pieces before making their choice for music
intervention. (Grade A)
Patients are given time to listen to one minute (Jafari et al., 2012 (1++)) or thirty
seconds (Voss et al., 2004 (1++)) of each music pieces before choosing their interested
music for intervention. Therefore, patient can make the best decision for music
intervention by familiarizing themselves with each music pieces.
7. Music is played via headphone. (Grade A)
The reviewed study delivered music intervention via headphone (Voss et al., 2004 (1++);
Jafari et al., 2012 (1++); Sendelbach et al., 2006 (1-)). A CD player with speaker was
used (Cutshall et al., 2009) but this would cause distraction and disturbance against
nurses and surgeons in ward setting.
8. Patients receiving music intervention should be arranged in a private room.
(Grade B)
Music intervention is given in private room (Voss et al., 2004 (1++); Sendelbach et al.,
2006 (1-); Cutshall et al., 2011 (1-); Nilsson, 2009 (1+) with a signage posted on the
door indicating “Do not disturb”. However, private room is rare in my setting and only
designated for patients under single-room isolation indicated by infection control team.
Even only private room is vacant, patients undergone cardiac surgery in early
postoperative stage will not be arranged in it as the private room is located in the corner
77
of general ward. They will be placed in central cubicle for better monitoring. Closure
of curtain will keep patients away from nurses’ monitoring. To minimize interruption
with respect to the feasibility of current setting, use of eye shield and posting a signage
on the wall would be the best available option.
9. Dose of music intervention should last at least thirty minutes. (Grade A)
Two reviewed studies (Cutshall et al., 2011; Sendelbach et al., 2006) with 1- level of
evidence provided a twenty-minute music intervention. Meanwhile, studies of (Nilsson,
2009 (1+)) and (Voss et al., 2004 (1++); Jafari et al., 2012 (1++)) offered a thirty-minute
music intervention.
10. Music intervention should be given once at postoperative day (POD) one.
(Grade A)
A higher dose of music intervention, i.e. twice a day for three consecutive days, POD
two to four (Cutshall et al., 2011 (1-)) and POD one to three (Sendelbach et al., 2006
(1-)) does not achieve a better pain control but also produce high rate of missing values.
Heavy workload on frontline nurses for pain evaluation would lower the feasibility of
the innovation. Meanwhile, starting music intervention at POD one once only (Nilsson,
2009 (1+); Voss et al., 2004 (1++); Jafari et al., 2012 (1++)) produce satisfactory pain
control for patient
11. Cultural context of patients should be considered for the choice of music to be
78
administered. (Grade A)
Cultural conditions of the society and targets’ cultural background are taken into
account for selecting music pieces (Jafari et al., 2012 (1++); Voss et al., 2004 (1++)).
In my setting, For example, Chinese and Hong Kong style of music released in 1950s
to 1970s will be in favor of our targets with the mean age of their sixties.
12. The type of music intervention to be given should include new age, classical,
jazz and instrumental music. (Grade A)
Suggestion of music type from the reviewed studies are as follows. Instrumental,
classical and jazz (Sendelbach et al., 2006 (1-)). Soft with volume of fifty to sixty
decibel and relaxing new age music (Nilsson, 2009 (1+)). Synthesizer, harp, piano,
orchestra, slow jazz, flute and new age music (Voss et al., 2004 (1++)).
79
Appendix 8: Gantt Chart for Music Intervention Implementation in a 50-week Period
Weeks
Communication Plan 1 2-4 5-7 8-9 10-11 12-15 16-30 31-32 33-34 35-50 50
Investigating frontline
perspective
Powerpoint presentation
Communication team
recruitment
Meetings with WM &
DOM for approval
Draw up official
proposal
Seek approval from COS
& GMN
Announcement of
approval & funding
allocated
Workshops
Pilot test
Pilot test evaluation
Report on refined
guideline
Implementation
Evaluation & Report
80
Appendix 9: Questionnaire for Frontline Nurses on Their Perspectives on
Postoperative Pain Control
Please put a tick in one of the O for each question.
1. Do patients complain of acute postoperative pain in early postoperative stage?
O Always O Usually O Often O Sometimes O Never
2. Do you feel confident of managing patient’s postoperative pain during work?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
3. Are you willing to deal with patient’s postoperative pain?
O Yes O No
4. Are you satisfied with your effort on tackling patient’s postoperative pain?
O Always O Usually O Often O Sometimes O Never
5. Do you think nurses are capable of providing pain management strategies?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
6. Do you think you are competent to provide pain management strategies?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
7. Do you want to step up more on tacking patient’s postoperative pain?
O Yes O No
8. Are you willing to learn more pain management strategies on top of current practice?
O Yes O No
-Thank you very much-
81
Appendix 10: Questionnaires for Nurses after Workshop
Please put a tick in one of the O for Question 1-6.
1. Do you think the length of the workshop is appropriate?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
2. Do you think the format (role-play) of the workshop is appropriate?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
3. Do you think the information of the music delivery (ipod player usage) was
adequate?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
4. Are you confident of using the intervention in clinical setting after attended the
workshop?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
5. Do you think the workshop is useful?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
6. Do you think the workshop is helpful for you to familiarize with the intervention?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
7. Is there any part need to be deleted or added in the workshop?
8. Is there any comment for the workshop?
-Thank you very much-
82
Appendix 11: Questionnaire for Nurses Concerning Their Views of Innovation
Please circle one of options in Question 1-15
1. Do you think the duration of music intervention is appropriate?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
2. Do you think the music delivery (ipod & headphone) is appropriate?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
3. Do you think the settings (hoisting signage “music intervention in progress” &
providing eye shield) is appropriate?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
4. Do you think the time of intervention is appropriate?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
5. Do you think the intervention is easy to use?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
6. Do you think the intervention interrupts your daily routine?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
7. Do you think the intervention interrupts surgeon’s consultation?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
8. Are you confident of using the intervention as pain management strategy?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
9. Are you fearful of using the intervention as pain management strategy?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
10. Do you think the intervention brings benefits to you and nursing colleagues?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
11. Do you think the intervention is effective of tacking patient’s postoperative pain?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
12. Do you think patient is satisfied with the intervention?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
13. Will you continue to adopt the innovation as your nursing intervention as a pain
relief method?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
14. Will you recommend this intervention to others as postoperative pain management?
5 Strongly agree 4 Agree 3 Neutral 2 Disagree 1 Totally disagree
15. How do you rate the intervention? (5 mark is full mark, 1 mark is the lowest mark)
5 4 3 2 1
16. What extra support do you want to improve the guideline?
17. Was the music intervention suspended or interrupted before the 30th-minute mark?
If any, why?
18. Any other comments about the intervention?
-Thank you very much-
83
Appendix 12: Questionnaire for Patients after Music Intervention
Please put a tick in one of the O for each question.
1. Is the choice of music adequate?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
2. Is the choice of music wide enough?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
3. Is the mode of music delivery appropriate?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
4. Is the timing for music intervention appropriate?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
5. Is the setting appropriate for music intervention?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
6. Is the eye shield useful to minimize environmental disturbance on you?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
7. Is the music intervention conducted smoothly?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
8. Is the music intervention useful to decrease your postoperative pain intensity?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
9. Will you continue to adopt music intervention as one of your pain relief method?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
10. Will you recommend this intervention to others as postoperative pain management?
O Strongly agree O Agree O Neutral O Disagree O Totally disagree
11. How do you rate the intervention? (5 mark is full mark, 1 mark is the lowest mark)
5 4 3 2 1
-Thank you very much-
84
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