Running head: INTEGRATIVE LITERATURE REVIEW

Integrative Literature Review

Courtney Browning

Bon Secours Memorial College of Nursing

Christine Turner, PhD

NUR 4122: Nursing Research

April 15, 2018

“I pledge…”
Running head: INTEGRATIVE LITERATURE REVIEW
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Abstract

Purpose: The purpose of this integrative literature review is to identify whether music is

beneficial as a nonpharmacological therapy in reducing pain for hospitalized patients.

Background: Patients in the hospital setting typically experience pain to some degree.

Unrelieved pain despite the use of analgesics is frequently reported, so alternative and

complementary therapies are worth exploring.

Method: Articles for this integrative review were collected from nursing databases. The articles

included in this review are both quantitative and qualitative, picked based on specific criteria.

The information gathered helped to determine the efficacy of music therapy on pain and anxiety

levels in hospitalized patients.

Limitations: The most significant limitation is the lack of experience of the author conducting

this review of literature. Other limitations include the lack of published literature on this topic

and the criteria used to choose the five articles used in this review.

Results and Findings: The summation of the research collected for this integrative review

supports music therapy as being beneficial for reducing pain in hospitalized patients in

conjunction with pharmacological or standard treatment.

Implications and Recommendations: The use of music therapy with standard treatments can be

implemented easily, economically, and with minimal risk for harm to the patient. However, it is

recommended that more research be done in varying settings with larger sample sizes in order to

confirm the results found in the articles discussed in this review.

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Integrative Literature Review

The purpose of this integrative literature review is to identify the efficacy of music as an

adjunct therapy to help control pain of hospitalized patients. According to the American

Academy of Pain Medicine unrelieved pain can result in longer hospital stays, more frequent

rehospitalizations, increased outpatient visits, and ultimately a decreased ability to function once

pain starts to become chronic (“Facts and figures on pain”, n.d.). Pain is a health problem that

costs society approximately $600 billion annually (“Facts and figures on pain”, n.d.). Standard

therapies for pain management in hospitals are mostly comprised of pharmacological methods,

which do not always fully relieve pain. Patients respond differently to pain medications and there

are many different types of pain and causative factors, making it worthwhile to consider other

pain relief techniques.

Clinical practice guidelines have made a recommendation for nonpharmacological

therapies, such as the use of music for managing pain in hospitalized patients (Ames et al.,

2017). Music therapy is a low-cost, non-invasive intervention that can be easily incorporated by

nurses (Yaghoubinia et al., 2016). The positive effects of music therapy on the wellness of

patients’ health were first highlighted by Florence Nightingale in the early 1800s (Çiftçi et al.,

2015). It was then that music therapy was recognized as a nursing intervention to reduce pain,

with the aim to increase a patient’s comfort (Çiftçi et al., 2015). The aim of this review is to

investigate and analyze data related to the author’s PICOT question: Do patients who utilize

music as a nonpharmacological therapy versus standard pharmacological treatments alone

experience lower pain intensity or better pain management during hospitalization?

Design and Methods

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This integrative literature review focuses on five research articles. The method by which

articles were found began with a search on EBSCO’s Discovery Service database. To find

articles related to the author’s PICOT question, the following search words were used: music

therapy, music listening, music, intensive care, critical care, pain, and anxiety. The results

yielded approximately 500,000 articles on the database. To narrow the field of results the author

filtered the findings by year and peer-review status. Many articles were eliminated after filtering

the results, leaving about 70,000 to then filter by PICOT question relevance.

The five articles included in this review were as closely related to the PICOT question as

possible, but with limited research having been done on this topic it was more difficult to find

articles exclusively focused on postoperative patients in the ICU. For this reason articles on

postoperative patients on medical surgical units, postoperative patients in the ICU, and patients

in the ICU with loss of consciousness or a cerebral vascular accident (CVA) are included in this

review. Qualifications of researchers were also made a priority, preferring those with credentials

including Doctor of Philosophy (PhD), Advanced Registered Nurse Practitioner (ARNP), Master

of Science in Nursing (MSN), and Registered Nurse (RN). The author chose four quantitative

studies (Comeaux & Steele-Moses, 2013; Yaghoubinia et al., 2016; Çiftçi & Öztunç, 2015), one

qualitative study (Bhana & Botha, 2014), and one mixed methods study for this review (Ames et

al., 2017).

Findings

The results of the articles all conclude that there is a positive correlation between the use

of music therapy a decrease in pain intensity or better pain management in hospitalized patients

(Ames et al., 2017; Bhana & Botha, 2014; Çiftçi & Öztunç, 2015; Comeaux & Steele-Moses,

2013; Yaghoubinia et al., 2016). Despite the correlations noted in each article, the studies all
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measured variables that differed slightly and on differing populations due to the lack of

published research available. Following the conclusion of this integrative review are summary

tables that correspond with all five articles. A brief overview of the findings of each article will

be provided here.

Comeaux & Steele-Moses (2013) conducted a study to determine if music therapy was

effective in decreasing state anxiety; how someone feels at a specific time, under specific

conditions (Çiftçi et al., 2015), increasing pain management, and satisfaction with environmental

noise levels for patients in the postoperative stage. This pilot study was quasi-experimental with

a non-equivalent control group design. The pilot study was done with forty-one postoperative

patients, with hematology-oncology diagnoses, in order to determine the feasibility of the study’s

methods. A larger study was still ongoing on a medical surgical unit at a medical center in

Louisiana at the time the article was published. The researchers collected their data by using an

initial survey and two follow-up surveys. The State-Trait Anxiety Inventory (STAI) and the

Press Ganey survey were used to assess state trait anxiety; how someone generally feels,

regardless of the condition they are in (Çiftçi et al., 2015), pain, and environmental noise

satisfaction. A four-point Likert scale was used to determine the level of satisfaction or

dissatisfaction. Data was analyzed with the use of descriptive statistics to summarize the

samples’ demographic characteristics. A paired t-test allowed for comparison of the mean

differences within each group. An independent t-test was completed to analyze the difference

between the groups.

Comeaux & Steele-Moses (2013) determined that the intervention group saw an

improvement in pain management and their satisfaction with environmental noise, but state

anxiety levels did not change. The control group saw no difference in state anxiety, pain
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management, or environmental noise satisfaction. The results of the study partially support music

therapy being an effective non-pharmacological alternative, or addition to analgesia, for

improving pain management and environmental noise satisfaction, because no change was noted

in state anxiety.

Ames et al. (2017) conducted a study to determine the effectiveness of listening to music

as a way to reduce pain, anxiety, distress, and the use of opioids for patients that are in critical

care postoperatively. This study, a randomized control trial, utilized mixed-methods analysis.

Forty-one patients were randomized into control or intervention groups. Patients were all

postoperative and staying in the intensive care unit, no specific diagnosis or surgery had to be

performed to qualify. The data was collected by the use of the General Anxiety Disorder

questionnaire (GAD-7), State-Trait Anxiety Inventory (STAI) questionnaire, Emotional

Thermometers (ETs) helped to measure anxiety and distress, and the Visual Analog Scale (VAS)

or Numerical Rating Scale (NRS) were used to measure pain. The data was analyzed using

descriptive statistics, and bivariate relationships were examined using the Spearman correlation

coefficient. All data analyses were completed by the use of IBM SPSS statistics and SAS. NVivo

was used to determine theme patterns and in order to understand the prevalence of each theme.

The Fisher exact test, t-test, ANOVA, and the Mann-Whitney U test were used to examine

differences in demographics, clinical variables, and the main outcomes for each group. Linear

mixed models were utilized to determine whether there was a change in pain, anxiety, or distress

between the two groups after the first four time points of the study. Akaike Information Criterion

(AIC) and Bayesian Information Criterion (BIC) were used to compare the models. The pain

levels were significantly decreased in the intervention group, but remained stable in the control
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group. It was determined that music was an appropriate intervention to improve patients’

experiences in the postoperative phase, according to patients’ self-reporting.

Yaghoubinia et al. (2016) conducted a study to determine what effect music had on the

intensity of pain in patients admitted to the ICU with loss of consciousness (LOC). The study

was an experimental, randomized clinical trial, with sixty patients participating. Pain scores were

collected using the Behavioral Pain Scale (BPS) and a demographic form was collected that

included information regarding patient’s gender, age, marital status, and underlying disease. The

data was analyzed using SPSS. Specifically, the independent t-test, Chi-square, and analysis of

covariance (ANCOVA) were completed. The results showed that music could reduce pain

intensity among patients that experience LOC in the ICU. Upon evaluation of the mean pain

scores from the three days of intervention, a major decline was noted in pain scores of the

intervention group. No significant difference was seen in pain scores of the control group.

Bhana & Botha (2014) conducted a study to expose cardiac surgery patients in the ICU to

music therapy as a part of their routine care in their first three days postoperatively, and to then

describe the effect that the therapy had on their experience. Qualitative data was utilized in this

study, with an explorative, descriptive, and contextual research design. The sample size was

small, with only nine patients being included. The researchers chose a non-random sampling

method. The patients chose their music type and volume, with noise-blocking headphones.

Interviews were conducted with each participant, and the following question was asked: “How

did you experience the music that was played to you after the operation?” (Bhana & Botha, 2014,

p. 4). Interviews were recorded and transcribed word for word. Content analysis was completed

to analyze the data. The researchers found that, based on the interviews, therapeutic use of music
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is reportedly beneficial to cardiac surgery patients, and should be paired with routine

postoperative care.

Çiftçi & Öztunç (2015) conducted an experimental, quantitative study to determine the

effects of music on pain, anxiety, and general comfort levels of patients in the ICU with a CVA.

A goal of the study was to enhance the use of nonpharmacological interventions, to be used

alongside pharmacological methods for pain relief. The researchers utilized an experimental

study design that was conducted as a self-controlled clinical study. Seventy-two patients

volunteered to participate in the study. Six different methods were used to gather data, including

– patient identification form, a vital signs form (measuring blood pressure, heart rate, breathing

rate, and pulse oximetry), visual analogue scale, faces anxiety scale, STAI, and general comfort

questionnaire. The data was then analyzed using SPSS software and evaluated using paired

samples t-test. The results of the study showed that positive effects were seen on systolic blood

pressure and pulse oximetry. However, changes in the diastolic blood pressure, heart rate, and

respiratory rates were not statistically significant. Decreases in VAS pain scores in patients

listening to music suggests a positive correlation between listening to music and a decrease of

pain. The use of music did decrease face anxiety and state anxiety levels as well. General

comfort levels were also increased.

Discussion/Implications

The articles used in this review all show a positive correlation between the use of music

therapy on decreased pain levels or better pain management. Despite the differences in the

studies, the results all point to music therapy being efficacious to patients during hospitalization.

The author of this review will show the relation of these articles’ findings to the PICOT question,
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discuss the implications for nursing practice, and make recommendations for future practice

based on findings of this review.

Patient Outcomes

Articles used in this review included research on patients postoperatively in the ICU

(Ames et al., 2017) (Bhana & Botha, 2014), postoperatively on a medical surgical unit (Comeaux

& Steele-Moses, 2013), and in the ICU with either loss of consciousness (Yaghoubinia et al.,

2016) or recovering from a CVA (Çiftçi & Öztunç, 2015). The findings of these studies, albeit

on differing types of patient diagnoses in different units of the hospital, suggest that music

therapy is either effective in bettering pain management or decreasing pain intensity in

hospitalized patients. Common tools used to report pain levels among the studies were the NRS

and VAS. Pain management and decreased pain intensity are crucial components postoperatively

and during hospitalization in general. In the healthcare field there is a general consensus that pain

is easy to treat, but many times other factors play into pain, leaving it only partially treated by

standard treatments alone. For this reason anxiety levels were also measured in four of the

studies, including (Ames et al., 2017; Bhana & Botha, 2014; Çiftçi & Öztunç, 2015; Comeaux &

Steele-Moses, 2013), because it is thought to play a role in the occurrence and intensity of pain.

However, it is not relevant to the author’s PICOT question.

Music as an Intervention

As previously mentioned, music therapy can be easily utilized in hospitalized patients as

a simple, cost effective, and low-risk intervention in addition to standard treatments in attempt to

control pain for patients. The use of music therapy has not been widely utilized, as it is a

complementary therapy that is not included in standard care plans for patients’ recovery. Music

is a highly subjective experience, but based on the findings of the research in this review, nurses
Running head: INTEGRATIVE LITERATURE REVIEW
10

may wish to offer music therapy to patients during their hospitalization. If a few music players

were available on each unit, with a selection of non-lyrical Compact Discs (CDs), it would be a

very cost effective method with the potential to lower the need for pain medications throughout

the patient’s stay. All of the reviewed studies suggested implementing music as an intervention

for hospitalized patients (Ames et al., 2017; Bhana & Botha, 2014; Çiftçi & Öztunç, 2015;

Comeaux & Steele-Moses, 2013; Yaghousbinia et al., 2016). (Bhana & Botha, 2014) suggested

the use of music in addition to creating a calming environment, by dimming the lights, and

decreasing environmental noise. (Bhana & Botha, 2014) and (Comeaux & Steele-Moses, 2013)

both report that music therapy may help to create a distraction from the noise of the machines

and other environmental noise while in the ICU, therefore decreasing anxiety and pain levels.

Recommendations for Further Research

The researchers, except (Bhana & Botha, 2014) due to the nature of the study, had

different approaches to deliver music therapy to their intervention groups in conjugation with

standard treatments. All of the researchers utilized non-lyrical music with the use of headphones

for their intervention groups (Ames et al., 2017; Bhana & Botha, 2014; Çiftçi & Öztunç, 2015;

Comeaux & Steele-Moses, 2013; Yaghoubinia et al., 2016). (Ames et al., 2017) found in their

research that patients complained of the inability to hear ambient noise, which increased anxiety.

Therefore, more studies using non-lyrical music, delivered in a different manner, such as through

a music player in the room would be helpful as all music was delivered in the same format.

All researchers suggest further research be done in order to fully understand the

relationship between the use of music on pain levels in hospitalized patients. All studies, other

than (Ames et al., 2017) who conducted fifty-minute sessions, conducted their music therapy for

twenty or thirty minute intervals, future researchers should consider implementing longer periods
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11

of time for the intervention or shorter time periods with greater frequency. Most of the studies

were also done on a smaller scale, so it would be important for larger samples to be utilized in

future research. Lastly, conducting more research on patients with the same underlying

conditions or pathologies may be useful in determining whether the music therapy is beneficial

or not.

Limitations

Limitations of this integrative review on the author’s behalf include a lack of experience,

lack of in-depth education on the process of writing a review, and having a limited understanding

of the statistical methods used to analyze data in studies. Limitations unrelated to the author of

this review includes being limited to reviewing five articles, the availability of articles relating

specifically to the author’s topic within the 5 year guideline, peer-reviewed, and published. The

aforementioned details lend to the inability to generalize the findings of this review. The articles

found were on varying demographics, in different units of the hospital, on different presenting

causes, and with different problem statements or aims of the specific study. The lack of

consistency in the articles made it difficult for the author to create a concise integrative review of

the literature.

(Ames et al., 2017) noted that limitations in their study included a decreased sample size,

the lack of patient’s ability to choose the type of music, and the lack of an objective measure for

pain. (Ames et al., 2017) also mentioned that their control group also received a “rest period”

without music, which is not typically part of standard care, which may have affected the

findings. (Bhana & Botha, 2014) conducted a qualitative study, but suggested that a quantitative

study be done with a larger population, as well as in additional settings to help increase

awareness and interest in music therapy. (Çiftçi & Öztunç, 2015) report limitations including a
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12

small sample size, being limited to a short-term study, and restricting music to what was chosen

by the researchers, rather than being patient driven. (Comeaux & Steele-Moses, 2013) identified

limitations including patients being assigned in a non-predictive manner rather than being

random, and unexpected cross-over of the groups as some in the control group reported listening

to music as well. (Comeaux & Steele-Moses, 2013) also reported a small sample size in the pilot

study as a limitation, and data collection being limited on the last collection round due to a

participant’s failure to complete the form the day of discharge, or the patient not making it to the

third day of the study. (Yaghoubinia et al., 2016) indicates limitations of the study as the

following: being limited to a teaching hospital, having a small sample size, and the unknown

effect that underlying disease may play on pain levels. The greatest limitation for each study was

the small sample size.

Conclusion

The studies compiled for this integrative review support the belief that the use of music

can decrease pain levels and increase pain management in hospitalized patients (Ames et al.,

2017; Bhana & Botha, 2014; Çiftçi & Öztunç, 2015; Comeaux & Steele-Moses, 2013;

Yaghousbinia et al., 2016). This conclusion relates directly to the themes of patient outcomes

and nursing interventions. The use of music therapy in addition to standard treatment or

analgesics alone in hospitalized patients will help to decrease pain levels and/or allow for better

pain management. Having a handle on pain management may allow for a shorter hospital stay,

less rehospitalizations and fewer complications down the road, as well as increased comfort

levels in hospitalized patients. In relation to future research regarding music therapy and pain

levels for patients in the hospital, larger sample sizes should be utilized, differing lengths of time

should be considered for the interventions, and different populations should be studied. In
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relation to the PICOT question being addressed in this review, whether pain levels in

hospitalized patients can be decreased by the use of music therapy in addition to standard

therapy, the literature reflects a positive correlation and suggests implementation of music

therapy into practice.

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References

AAPM facts and figures on pain. (n.d.). Retrieved from

http://www.painmed.org/patientcenter/facts_on_pain.aspx

Ames, N., Shuford, R., Li, Y., Moriyama, B., Frey, M., Wilson, F., & ... Wallen, G. R. (2017).

Music listening among postoperative patients in the intensive care unit: a randomized

controlled trial with mixed-methods analysis. Integrative Medicine Insights, 22, 1-13.

doi:10.1177/1178633717716455

Bhana, V.M. & Botha, A.D.H. (2014). The therapeutic use of music as experienced by cardiac

surgery patients of an intensive care unit. Health SA Gesondheid, 19, (1), 1-9. doi.

org/10.4102/hsag.v19i1.684

Çiftçi, H., & Öztunç, G. (2015). The effect of music on comfort, anxiety and pain in the intensive

care unit: A case in turkey. International Journal of Caring Sciences, 8(3), 594-602.

Comeaux, T., & Steele-Moses, S. (2013). The effect of complementary music therapy on the

patient's postoperative state anxiety, pain control, and environmental noise

satisfaction. MEDSURG Nursing, 22(5), 313-318.

Yaghoubinia F., Navidian, A., Tabatabaei, S.M., & Sheikh, S. (2016). Effect of music on pain

intensity among patients with loss of consciousness in an intensive care unit. Medical-

Surgical Nursing Journal, 4 (4), 35-40.

 Running head: INTEGRATIVE LITERATURE REVIEW
First Author (Year)/Qualifications
Background/Problem Statement
Conceptual/theoretical Framework
15
First Author (Year):
 Comeaux (2013)
Citation:
 Comeaux, T., & Steele-Moses, S. (2013). The effect of complementary music
therapy on the patient's postoperative state anxiety, pain control, and
environmental noise satisfaction. MEDSURG Nursing, 22(5), 313-318.
Qualifications:
Comeaux
 APRN, FNP-C, CEN… is CICU staff nurse in Baton Rouge @ hospital where
study took place
Steele-Moses
 DNS, APRN-CNS, AOCN…is research director @ hospital where study took
place
Search words → Postoperative pain control + music therapy
QUANTITATIVE STUDY!!!!
Unrelieved post-op pain is a common issue despite advances in pain management
(pharmacologically). Lack of sleep is common in the hospital due to environmental
noise- which can cause irritability, anxiety, and increased pain levels. Analgesia is
commonly used, but pain can frequently remain unrelieved.
Complementary music therapy can help to create a distraction from
pain/anxiety/worry/sadness and increase patient satisfaction postoperatively.
 “Principles inherent to Relationship-Based Care (RBC) delivery model
supported the study”
 “Three crucial relationships in RBC include care of self, care of colleagues,
and care of patients and families” … “Nurses convey caring and compassion
through touch, kindness, clinical interventions, active listening, and
understanding of the patient’s experience”
 Running head: INTEGRATIVE LITERATURE REVIEW
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical Considerations
Major Variables Studied (and their
definition), if appropriate
16
 A quasi-experimental non-equivalent control group design
 This is a pilot study (first 41 data sets collected to test the efficacy and
feasibility of the study methods) & larger study is still ongoing (w/ three
groups: control/music therapy/white noise therapy)
 Patients were assigned based on room number, not randomly
 Control group = participants on hallway A (standard care)
 Intervention group = participants on hallway B (complementary music therapy
+ standard care)
 “Non-equivalent control design… neither analgesia type or route was
controlled”
 Each participant was enrolled for a total of 3 days or until discharge, whichever
came first & outcome measures were collected upon enrollment (time one) and
for the next 2 consecutive days (time 2 and time 3)
 Intervention group was encouraged to listen to non-lyrical music and low
decibel for 30 mins after analgesia administered.
 Sample size = 41 patients
 Setting = Surgical unit at Our Lady of the Lake Regional Medical Center
(OLOLRMC)
 Med-sug unit (SURG) has 27 beds and 2 wings (Hall A has 11 beds, Hall B
has 16 beds)
 Implied consent process used – verbal consent (bc written consent ties the
participant to the study, precluding exempt criteria definition)
 Patients were protected by not having a name linked – surveys were coded
based on hallway assignments, participant number, and the day it was
completed
 The pilot & larger study were granted exempt status
 Inclusion criteria: 3-day hospital length of stay, A&O, 18yr+, hematology-
oncology diagnosis
 Upon enrollment (time one): state anxiety, trait anxiety, and pain management
and environmental noise satisfaction over the previous 24 hour period were
measured
 Time Two and Three measured state anxiety, patient’s pain score, and noise
satisfaction
 Running head: INTEGRATIVE LITERATURE REVIEW 17

Measurement Tool/Data Collection  Surveys used to collect data (initial survey, then two follow-up)
Method  State trait anxiety & pain & environmental noise satisfaction assessed using
State-Trait Anxiety Inventory (STAI) and two standardized questions from the
Press Ganey survey (2 questions = “during previous 24 hours, I am satisfied
with my pain control” and “during the previous 24 hours I am satisfied with the
noise level in and around my room”
 STAI was broken into two subscales → STAI Form Y1 and STAI Form Y2
 STAI Form Y1 = 20 items, used to measure state anxiety
 STAI Form Y2 = measures current emotion (calm or nervous)
 4-Point Likert scale used to measure feelings on a scale
Data Analysis  Descriptive statistics → for summarizing the sample demographic
characteristics
 Comparative analysis → of the mean differences within the groups was done
w/ a paired t test
 Analysis between groups → difference between groups done w/ an
independent t test

Findings/Discussion  The intervention group experienced an improvement in pain management and

satisfaction with environmental noise, but no change was found in state anxiety
… no difference existed in state anxiety, pain management or environmental
noise satisfaction for the control group
 No significant change in state anxiety was found, suggesting that music
therapy did not decrease situational anxiety as previously thought
 Results of this study partially supported the thought that music therapy is
effective as a non-pharmacological adjunct to analgesia in increasing pain
management and environmental noise satisfaction

Appraisal/Worth to practice  The use of music therapy in combination with analgesia can improve pain
management and environmental noise satisfaction (distraction from negative
experiences by using music can increase satisfaction in the post-op period)
 Inexpensive & easy to implement
 Running head: INTEGRATIVE LITERATURE REVIEW
First Author (Year)/Qualifications
Background/Problem Statement
Conceptual/theoretical Framework
18
First Author (Year):
 Ames (2017)
Citation:
 Ames, N., Shuford, R., Li, Y., Moriyama, B., Frey, M., Wilson, F., & ...
Wallen, G. R. (2017). Music listening among postoperative patients in the
intensive care unit: a randomized controlled trial with mixed-methods
analysis. Integrative Medicine Insights, (12), 1-13.
doi:10.1177/1178633717716455
Qualifications:
 Nursing department, clinical center @ National institutes of Health in Bethesda
MD
 Pharmacy Department @ National Institute of Health
 Department of Perioperative Medicine @ NIH
 Biostatistics and Clinical Epidemiology Service @ NIH
Search words → Music listening + postoperative + intensive care
QUANTITATIVE STUDY!!!
 Music listening may reduce the physiological, emotional, and mental effects of
distress and anxiety. It’s unclear whether music listening may reduce the amount of
opioids used for pain management in critical care, postoperative patients or whether
music may improve patient experience in the intensive care unit (ICU)
 Purpose → to determine efficacy of music listening as a means of reducing pain,
anxiety, distress, and opioid use in patients admitted to a critical care unit following
surgery
 No specific framework noted
 Running head: INTEGRATIVE LITERATURE REVIEW 19

Design/  Control group = received standard postop care w/ 50 minute period of rest to
Method/Philosophical match the 50 minute music period of the experimental group
Underpinnings  Randomization was done by using opaque sealed envelopes with group
designations that were previously prepared by a statician using a computer
generated, permuted block randomization schema
 Music listening group was exposed to MusiCure Dreams album for 50 minutes
with noise-canceling headphones
 Control group had 50 minutes resting period at the same time
 Max of 3 sessions each day at 8 hour intervals
 Before and after each resting period or music intervention, anxiety and distress
were measured using ETs and postop pain was determined using NRs and VAS
 Opioid intake was measured by PCA device
Sample/ Setting/Ethical Considerations  41 surgical patients were randomized to music listening or control groups upon
ICU admission
 Consented before surgery, were randomized postsugery
 Approval obtained by the National Cancer Institute’s intramural Institutional
Review Board
 Inclusion criteria: adults 18+, surgical patients at the NIH CC who understood
and spoke English or Spanish, w/ anticipated ICU stay of 24-48 hrs and
anticipated use of PCA
Major Variables Studied (and their  Anxiety
definition), if appropriate  Pain
 Distress
 (All in patient’s postoperatively in the ICU)
Measurement Tool/Data Collection  GAD-7 (General Anxiety Disorder questionnaire) was used to determine
Method anxiety levels prior to surgery (patients with 15-21 were excluded)
 State-Trait Anxiety Inventory (STAI)…a 2 part, 40 question survey for state &
trait anxiety.
 Emotional Thermometers (ETs) were also used (for anxiety and distress)
 Pain was measured by the visual analog scale (VAS) and numerical rating scale
(NRS) … VAS → scale from 0 to 10, NRS 0-10
Data Analysis  Randomized, controlled trial with 2 groups
 Descriptive statistics were performed on all study variables at each time point
 Running head: INTEGRATIVE LITERATURE REVIEW
Findings/Discussion
20
 Bivariate relationships of the main outcomes (pain, anxiety, distress) were
examined by correlations (Spearman correlation coefficient)
 Fisher exact test, t test, 1-way analysis of variance, & the Mann-Whitney U test
were used to examine the differences in demographic, clinical variables, and
main outcomes between groups
 Unless otherwise noted, data are presented as mean values and their standard
deviations
 Linear mixed models were used to examine whether there was a change in pain,
anxiety, or distress b/w groups during the first 4 interventions
 Difference scores were calculated by subtracting pre-intervention from post
 Separate set of mixed models examined whether a statistical difference existed
b/w the 2 groups
 Akaike information criterion (AIC) and Bayesian information criterion (BIC)
were used to compare models. In linear mixed models, the response depends on
both population-level parameters (fixed effects) and subject-specific random
effects.
 ALL data analyses were done using IBM SPSS statistics version 21 and SAS
version 9.3
 P value of .05 or less was considered statistically significant
 Qualitative analysis was performed from the transcribed interviews of the
music group
 NVivo was used to better visualize theme patterns and understand the
prevalence of each theme
 No significant difference in pain, opioid intake, distress, or anxiety scores b/w
control and music listening groups during first 4 time points of study. Mixed
modeling analysis examining the pre- and post-intervention scores at the first
time point revealed significant interaction in the numeric rating scale for pain
b//w the music and control groups. NRS decreased in the music group but
remained the same in the control group.
 Despite limited sample size, the study identified music as an appropriate
intervention to improve patient’s post-intervention experience, according to pt’s
self-report.
 Running head: INTEGRATIVE LITERATURE REVIEW 21

 More studies need to be done to examine qualitative patient perspectives

Appraisal/Worth to practice  Music could be a safe, simple complementary therapy

 Music listening is a subjective experience
 A non-medical approach to symptom management could be used in the ICU

First Author (Year)/Qualifications First Author (Year)

 Yaghoubinia (2016)

Citation:
 Yaghoubinia F., Navidian, A., Tabatabaei, S.M., & Sheikh, S. (2016). Effect
of music on pain intensity among patients with loss of consciousness in an
intensive care unit. Medical-Surgical Nursing Journal, 4 (4), 35-40.

Qualifications:
 First 3 = Assistant professors @ Zahedan University of Medical Sciences &
4th= an MSc student of critical care nursing

Search words → Pain + music + intensive care unit

QUANTITATIVE STUDY!!!

Background/Problem Statement  Patients with LOC experience pain as a result of invasive procedures,
mechanical ventilation, and the physical setting of the ICU. Current study
was conducted to determine the effect of music on pain intensity among ICU-
admitted patients with LOC.
Conceptual/theoretical Framework  Randomized clinical trial, experimental (no framework noted – do not need
to include this in paper)
Design/  RCT performed on non-trauma patients w/ LOC under mechanical
Method/Philosophical ventilation
Underpinnings  Sample size was randomized (using permuted-block randomization)
 Study comprised of two groups (music group, control group)
 Running head: INTEGRATIVE LITERATURE REVIEW
Sample/ Setting/Ethical Considerations
Major Variables Studied (and their
definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author (Year)/Qualifications
22
 Intervention group exposed to music for 30 min over 3 consecutive days
 Pain scores documented for unconscious patients, using BPS at 5 mins before
intervention and 5 mins after
 Control group received routine care
 60 patients
 Data was obtained after getting permission from university ethics committee
and hospital authorities
 Consent forms were obtained after explaining study objectives and
intervention process to families of eligible patients
 Pain intensity of patients w/ LOC in ICU
 BPS (behavioral pain scale)
 Demographic form (personal info: pt’s age, gender, marital status, and
underlying disease)
 Statistical analysis → independent t-test, Chi-square, and analysis of
covariance (ANCOVA) were performed, using SPSS version 15
 Major decline was found over 3 days in the intervention group
 According to the results, music can reduce pain intensity among pt w/ LOC
 Can be used as simple, effective, and inexpensive method for pain relief
First Author (Year):
 Bhana (2014)
Citation:
 Bhana, V.M. & Botha, A.D.H. (2014). The therapeutic use
of music as
experienced by cardiac surgery patients of an intensive care unit. Health SA
Gesondheid 19(1). doi. org/10.4102/hsag.v19i1.684
 Running head: INTEGRATIVE LITERATURE REVIEW
Background/Problem Statement
Conceptual/theoretical Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical Considerations
Major Variables Studied (and their
definition), if appropriate
Measurement Tool/Data Collection
Method
23
Qualifications:
 Department of Nursing Science @ University of Pretoria in South Africa
 Department of Health Studies @ University of South Africa
Search words → Music + surgery + intensive care unit
QUALITATIVE STUDY!!!!!
 Critical care can cause stress and anxiety
 Anxiety must be avoided in cardiac surgery patients to avoid post-op
complications
 Aim of the study → describe cardiac surgery patients’ experiences of music as
a therapeutic intervention in the ICU of a public hospital
 Qualitative research w/ an explorative, descriptive, contextual research design
 A qualitative research methodology, using a contextual, explorative and
descriptive research design was used
 Sample = 9 … b/w ages of 30 – 70
 Population = cardiac surgery pt admitted to the ICU of a public hospital
 Non-random sampling method, purposive sampling
 Informed consent obtained
Cardiac pt
Music therapy
Pain
 Patients were given a CD with 4 types of music pre-operatively, they’d choose
which they liked the best and what they would want to listen to after their
surgery.
 Participants listened for 20 minutes at a time during ICU stay
 After a pt was discharged from ICU, an unstructured interview was conducted
by researchers during the recovery period… open-questions were asked
 Running head: INTEGRATIVE LITERATURE REVIEW
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author (Year)/Qualifications
24
 An unstructured interview was conducted w/ each participant and content
analysis and coding procedures were used to analyze the data
 Four main themes were identified in the results → practical/operational
aspects of the music sessions, participants’ experiences, discomfort due to
therapeutic apparatus & the ICU environment, and the role of music and
recommendations for music therapy as an intervention
 Interviews were recorded and transcribed verbatim
 Content analysis and coding procedures were used to analyze
 Aspects – such as type of music, time music is played, how frequently its
played, and duration of sessions (as well as therapeutic environment) are
important aspects to consider when planning to do this intervention
 Based on interviews it was determined that therapeutic use of music is
beneficial to pt who have had cardiac surgery & with routine post-op care it
can promote hoslitic patient care
 Nurses can make a favorable and more therapeutic environment by dimming
lights, decreasing noise levels, coordination b/w routine nursing care and
music session
 Provide a low stimuli environment
 Music sessions should be implemented during the day when nurse is available
to conduct & when visitors aren’t there
 Patients reported that it helped to distract from pain
First Author (Year):
 Ciftci (2015)
Citation:
 Çiftçi, H., & Öztunç, G. (2015). The effect of music on comfort, anxiety and
pain in the intensive care unit: A case in turkey. International Journal of
Caring Sciences, 8(3), 594-602.
 Running head: INTEGRATIVE LITERATURE REVIEW 25

Qualifications:
 RN @ Adana State Hospital in Adana, Turkey
 PhD, professor @ University Health College of Adana Nursing Department in
Turkey

Search words → Music + Pain + Intensive Care Unit

QUANTITATIVE STUDY!!!!
Background/Problem Statement  Increased anxiety levels in ICU – this study is to assess the effect of music on
pain, anxiety, and general comfort levels of ICU patients to enhance the use of
nonpharmacological methods such as music together w/ pharmacological
methods, and to be a model for future studies in the field

Conceptual/theoretical Framework  None specified

Design/  Experimental study conducted as a self-controlled clinical study

Method/Philosophical
Underpinnings

Sample/ Setting/Ethical Considerations  72 patients

Major Variables Studied (and their
definition), if appropriate
 18 yrs +
 Volunteer to participate
 Permissions were obtained from ethical committee of the hospital where the
study was conducted
 Patients and patients relatives signed the informed consent
 Verbal consent obtained before each interview
 Anxiety, pain, and comfort in patients w/ CVA in the ICU of a state hospital

Measurement Tool/Data Collection  6 different methods →

Method  Patient identification form
 Vital signs form
 Visual analogue scale (rate pain 1-10)
 Running head: INTEGRATIVE LITERATURE REVIEW 26

 Faces anxiety scale

 STAI-1 and STAI-2 (20 questions – rated on 4 point likert scale) … State =
anxiety at specific moment and under specific conditions, Trait = how
individuals feel in general
 General Comfort Questionnaire (4 point likert questionnaire…
Data Analysis  Statistical analysis was performed with SPSS (statistical package for social
sciences) and evaluated using descriptive statistics (like the t-test for
dependent and independent samples)

Findings/Discussion  Positive effects were noted on systolic tension arterial and pulse oximeter
mean scores
 No statistically significant difference was found in terms of the diastolic
tension arterial, heart rate, and breath rate mean scores
 Significant decrease in VAS pain scores of the patients after listening to music
… indicates positive effect of music on reducing pain
 Music seems to decrease face anxiety and state anxiety levels (increase
relaxation by decreasing anxiety)
 General comfort levels increased after listening to music

Appraisal/Worth to practice  More research is needed on effects of music