Background
The article describes ‘pain’ as a key source of patient stress in critical care. It further indicates that up to 70% of ICU patients report experiencing pain during routine nursing care, including during wound dressing. Additionally, it is noted that severe pain affects the emotional and physical wellbeing of the patients, which reduces their treatment outcomes. In this view, interventions that promote pain relief, including non-pharmacological ones, need to be explored.
Also, a clear definition and the types of non-pharmacological interventions (NPIs) nurses use in palliative care are given. It also describes the interventions found in literature, namely, “cognitive-behavioral, emotional support, physical, help with ADLs, and comfortable environment” (Gelinas et al., 2013, p. 308). Citing past studies, the article claims that evidence for the efficacy of breathing exercises and body massages in palliative care is lacking. Music therapy, which is among the earliest forms of non-pharmacological interventions, has analgesic effects. The authors cite recent findings that indicate that a 45 min music intervention reduces pain significantly in post-operative patients. In contrast, the researchers establish that deep breathing techniques have no impact on pain scores. On the other hand, the evidence cited shows that ice therapy, compared to a placebo, causes a significant decrease in pain among ICU patients. The researchers conclude that some non-pharmacological interventions could be used as adjuncts to analgesics in palliative care.
The research design used in the study is the qualitative descriptive method. Semi-structured focus groups are used to explore the views of the nurses and patients on NPIs. The researchers use a convenience sampling strategy to recruit 38 participants comprising of 6 patients and 32 nurses. Data collection involved eight focus group interviews, each lasting for 45 min, with the investigators acting as facilitators. The researchers provided the participants with a discussion guide and a list of NPIs prior to the interviews.
Data analysis involved a qualitative approach. This entailed a transcription of the audiotapes obtained from the focus groups. The key phrases or words identified from the audiotapes were organized into categories of NPIs. The researchers examined the recurrence of the NPIs discussed in the focus groups. Three central categories were identified, namely, useful (cognitive-behavioral therapy), relevant (massage), and feasible (emotional support) NPIs in the ICU context (Gelinas et al., 2013).
The researchers conclude that four NPIs, namely, body massage, music, CBT, and family support are “useful, relevant, and feasible” for palliative care (Gelinas et al., 2013, p. 315).
Assessment of Evidence
The researchers used qualitative focus groups to obtain data from the participants. They were involved in data transcription and analysis to identify related conceptual meanings. The concepts from the eight focus groups examined reflect the participants’ experiences with NPIs in critical care. The four most relevant and useful categories of NPIs are drawn from the views and perspectives of the 38 participants. For this reason, the researchers are right to conclude that body massage, music, CBT, and family support are useful in critical care. They do not generalize the study’s results to a large population due to the small sample size.
Ethical Issues
One ethical issue evident in the research is protecting the subjects from harm. The study involved six former ICU patients. Thus, the study had the potential of exposing them to emotional stress associated with their experiences in palliative care. To overcome this ethical challenge, the researchers sought informed consent from adult patients. Furthermore, they provided a discussion guide to the focus group participants. This ensured that the participants understood the objectives and expected outcomes of the research. The researchers also grappled with the issue of participant anonymity and confidentiality of responses. They used codes/identifiers when quoting the participants’ verbatim statements in the article.
Type of Research
The type of research used in the article is the qualitative descriptive study. This approach entails the recording and analysis of qualitative data with an aim of understanding people’s experiences or behaviors. The intention is not to generalize the findings to other populations. The researchers sought the views of critical care nurses and patients on the most effective NPIs for pain relief. Focus group interviews were conducted to obtain qualitative data. The study is descriptive because it does not involve the manipulation of any variables.
Other Types of Research
The study sought the views of the participants through focus group interviews. An experimental design would not have been appropriate for exploring the participants’ views, as it would require the manipulation of certain study variables. Thus, a qualitative approach was appropriate for uncovering the perspectives of ICU patients and nurses on the effectiveness of NPIs. However, it would have been more appropriate to use a quantitative approach to determine the effect of each NPI on pain intensity reduction.
Problem
Pain is a serious problem in the intensive care unit. Intense pain or painful procedures can affect treatment outcomes and patient satisfaction. Therefore, pain management is essential in critical care. NPIs provide cheap and safe interventions for pain management, especially in post-operative care. Chan (2007) established that music therapy lasting 0.75hrs had a significant decline in pain intensity during a c-clamp procedure. This shows that music has analgesic effects during painful procedures. Studies have also shown that deep breathing is analgesic during chest intubation. Friesner et al. (2006) found that patients exposed to breathing exercises as an adjunct to painkillers experienced less pain than those receiving analgesics alone.
Evidence shows that patients may benefit from NPIs during painful procedures, such as chest intubation or extubation. In one study, Demir and Khorshid (2010) found that ice therapy provides relief from pain in patients following an extubation procedure. In this study, a “20-min application of cold packs” and an analgesic after extubation had significantly higher analgesic effects than a placebo (a standard pharmacological treatment) (Demir & Khorshid, 2010, p. 189). This shows that NPIs, as adjuncts to standard care, can help relieve pain in post-surgery patients. However, the effectiveness of other NPIs in pain management is not clear. Nurses and patients report that “music therapy, family support, and massages” are the most effective NPIs in pain management (Gelinas et al., 2013). The evidence shows that NPIs in conjunction with analgesic treatments can be useful in managing pain in intensive care units.
Annotated Bibliography
Gelinas, C., Arbour, D., Michaud, C., Robar, L., & Cote, J. (2013). Patients and ICU Nurses’ Perspectives of Non-pharmacological Interventions for Pain Management. Nursing in Critical Care, 18(6), 307-318.
The article reports a qualitative descriptive study examining the views of patients and critical care nurses on effective NPI interventions. The analysis of the qualitative data generated from focused group interviews involving 38 participants uncovered four themes (useful NPI categories), namely, CBT, music therapy, family support, and body massage (Gelinas et al., 2013). The authors conclude that the four NPIs can be used as adjuncts to analgesic drugs in pain management. However, more evidence is needed to corroborate the use of NPIs as complete analgesics.
Chan, M. (2007). Effects of Music on Patients Undergoing a C-clamp Procedure After Percutaneous Coronary Interventions: a Randomized Controlled Trial. Heart & Lung, 36, 431–439.
The study involves a randomized controlled trial assessing the impact of music therapy on the patients’ physiological well-being. Its 66 subjects were drawn from Hong Kong patients receiving a “C-clamp procedure after percutaneous coronary intervention” (Chan, 2007, p. 435). The experimental group received a 45-min music therapy session while the control received a 45-min rest after PCI. The results showed a statistically significant decline in respiratory rate, heart rate, and pain intensity in the treatment group compared to the control. Thus, music is an effective therapy for pain management during a C-clamp procedure for PCI patients.
Cooke, M., Chaboyer, W., Schluter, P., Foster, M., Harris, D., & Teakle, R. (2010). The Effect of Music on Discomfort Experienced by Intensive Care Unit Patients During Turning: a Randomized Crossover Study. International Journal of Nursing Practice, 16, 125–131.
The article examines the discomfort and pain that patients feel when being turned. It uses a single-blind randomized design to evaluate the impact of music therapy on pain/discomfort perceptions of 17 patients during turning (Cooke et al., 2010). The researchers measured the discomfort experienced by the subjects before and after being turned. They found that music therapy has no significant effect on the level of discomfort experienced during turning. Thus, exposure to music does not lower the level of anxiety or pain felt during turning.
Demir, Y., & Khorshid, L. (2010). The Effect of Cold Application in Combination with Standard Analgesic Administration on Pain and Anxiety during Chest Tube Removal: a Single-blinded, Randomized, Double-controlled Study. Pain Management Nursing, 11(3), 186–196.
This randomized, single-blinded study investigated the analgesic effects of ice therapy during extubation in cardiac surgery patients (Demir & Khorshid, 2010). It involved a convenience sample of 90 ICU patients under intubation. Icy and warm packs were administered near the intubations of the experimental and control groups, respectively, following a paracetamol IV. Data collection involved questionnaires. The results showed that the experimental group reported less intense pain compared to the control group. The cold application also reduced the frequency with which the patients requested analgesics.
Friesner, S., Miles, D., & Moddeman, G. (2006). Comparison of Two Pain-Management Strategies during Chest Tube Removal: Relaxation Exercise with Opioids and Opioids Alone. Heart & Lung, 35(4), 269–276.
The aim of this study was to evaluate the effect of the deep breathing technique as a complementary intervention to opioids in pain management during extubation. The study used a quasi-experimental design and a study sample of 40 heart surgery patients. The treatment group was exposed to deep breathing techniques and received opioids applied intravenously while the control received an opioid IV only. Pain scores were found to be significantly lower in the experimental group than in the control group. Thus, deep breathing techniques can complement opioid analgesics in pain management.
Lindberg, J., & Engstrom, A. (2011). Critical Care Nurses Experiences: a Good Relationship with the Patient is a Prerequisite for Successful Pain Relief Management. Pain Management Nursing, 12(3), 163–172.
This study explores the experiences of ICU nurses regarding pain management when providing critical care. Qualitative interviews involved six participants who were nurses at a Swedish hospital ICU. A content analysis of the qualitative data revealed that analgesic administration is the first-choice intervention in pain relief. Furthermore, pain assessment and management is essential in improving the outcomes of patients under post-operative care (Lindberg & Engstrom, 2011). The study concludes that nursing knowledge on NPIs might be useful in post-operative care.
Iblher, P., Mahler, H., Heinze, H., Huppe, M., Klotz, K., & Eichler, W. (2011). Does Music Harm Patients after Cardiac Surgery? A Randomized, Controlled Study. Applied Cardiopulmonary Pathophysiology, 15(1), 14–23.
The article describes a randomized controlled study involving 126 cardiac surgery patients. The aim was to investigate the effect of music therapy administered soon after heart surgery. The intervention groups received variable music interventions while the control received none. A self-evaluation questionnaire was used to measure patient satisfaction and pain score. Iblher et al. (2011) found a significant exacerbation of in peri-operative “pain, nausea, and thirst” in the intervention groups (p. 18). This shows that music therapy increases peri-operative pain and discomfort in patients.
Nilsson, U. (2009). The Effect of Music Intervention in Stress Response to Cardiac Surgery in a Randomized Clinical Trial. Hurt & Lung, 38(3), 201-207.
The objective of this randomized clinical trial was to determine the impact of music therapy on postoperative stress levels. It involved 58 heart surgery patients in a Swedish hospital. The author measured stress levels in subjects exposed to 30-min bed rest and music based on the “level of serum cortisol, heart rate, and respiratory rate” (Nilsson, 2009, p. 204). The study found that the intervention group had significantly lower cortisol levels than the control group, an indication that music therapy and rest can reduce stress and discomfort in heart surgery patients.
Bauer, B., Cutshall, S., Anderson, P., Prinsen, S., Wentworth, L., Onley, T.,…Sundt, T. (2011). Effect of the Combination of Music and Nature Sounds on Pain and Anxiety in Cardiac Surgical Patients: a Randomized Study. Alternative Therapy Health Medicine, 17(4), 16-23.
Bauer et al. (2011) investigated the role of music in pain relief in a randomized study conducted in a cardiovascular surgical unit. The study involved hundred surgery patients randomized into a treatment group (music and standard care) and a placebo group (standard palliative care only). Analog scales were used to assess the pain and anxiety scores of the subjects. The results indicated that pain scores, anxiety, and relaxation improved in the intervention group compared to the control group, providing evidence for the use of music therapy in pain management.
Sandelbach, S., Halm, M., Doran, K., Miller, E., & Gaillard, P. (2006). Effects of Music Therapy on Physiological and Psychological Outcomes for Patients Undergoing Cardiac Surgery. Journal of Cardiovascular Nursing, 21(3), 194-200.
This experimental study compares the impacts of music intervention versus serene relaxation on pain and anxiety of post-surgery patients (Sandelbach et al., 2006). It used a sample of 86 subjects randomized into experimental and control groups. The control group received a 20-min music therapy while the control group relaxed for 20 min following heart surgery. The results showed a significant decline in pain and anxiety in the experimental group compared to the control group. Thus, music therapy may beneficial to post-heart surgery patients.
Efficacy
The 10 articles provide different levels of evidence. Seven of the articles involve randomized controlled trials (RCTs) and thus, give strong evidence (level II) for the use of NPIs in pain management in critical care units. One study used a quasi-experimental design (level III evidence) while the remaining two used a qualitative descriptive approach (level VI evidence). All the RTCs reviewed, except one, provide strong evidence for the use of NPIs, as adjuncts, in palliative care. Furthermore, the evidence from the quasi-experimental and descriptive studies also supports the use of NPIs to manage pain. Thus, the evidence is adequate to recommend a practice change in palliative care.
Identification of Researcher Tools
The types of tools used depend on the nature of the data being collected. Bauer et al. (2011) and Friesner, Miles, and Moddeman (2006) used visual analog scales to measure anxiety and pain intensity in the subjects while Sandelbach et al. (2006), Demir and Khorshid (2010), and Iblher et al. (2011) used patient satisfaction questionnaires. Other tools used included serum cortisol test (Nilsson, 2009), audio tapes (Gelinas et al., 2013 and Lindberg & Engstrom, 2011), Likert-type and face anxiety scales (Cooke et al., 2010), and a universal pain score (Chan, 2007).
Chosen Tools
The researchers chose different tools to measure pain, anxiety, and discomfort in the subjects. The tools used were more diverse in RTCs than in qualitative studies. They included analog scales, patient satisfaction questionnaires, anxiety scales, and universal pain scores. In contrast, qualitative studies only used audiotapes to collect data.
Effect on Results
The writer believes that the researchers’ tools had no significant effect on the quality of the results. They chose validated tools, including visual analog and anxiety scales, to measure variables such as pain and anxiety. Additionally, some studies used more than one tool to enhance data validity. The analysis of the data collected followed standard guidelines. In this regard, the type of tool chosen in each study had no effect on the results.
Evidence Summary
The primary objective of the review was to find evidence for the use of NPIs in pain management. Using the level of evidence as a criterion, the RCTs reviewed found music therapy sessions lasting for 20 min could relieve pain and anxiety in post-heart surgery patients (Sandelbach et al., 2006). Relaxing music and cold application also decrease anxiety/pain (Bauer et al., 2011; Demir & Khorshid, 2010) and stress (Nilsson, 2009) in post-surgery patients.
Using the nursing procedure as a criterion, research evidence shows that deep breathing techniques, when used as adjuncts to the analgesic (opioid) treatments, can relieve the pain felt during the extubation and C-clamp procedures (Friesner, Miles, & Moddeman, 2006; Chan, 2007). However, music therapy has been found to exacerbate pain and stress during turning and peri-operative care (Cooke et al., 2010; Iblher et al., 2011). Research evidence also shows that nurses and patients value the use of NPIs in pain management (Lindberg & Engstrom, 2011; Gelinas et al., 2013).
Recommendation
Research evidence shows that NPIs, such as music therapy, may have analgesic effects, particularly on post-surgery patients. However, only a few NPIs are safe and less costly interventions for acute pain relief. It is recommended that ICU nurses should use music therapy as adjuncts to analgesic treatments in pain management. Evidence shows that a short session of music therapy is effective in pain relief for post-heart surgery patients (Sandelbach et al., 2006). It is an effective intervention during nursing procedures such as extubation and C-clamp application (Chan, 2007). However, music interventions may not be effective during the turning of critically ill patients or during perioperative care.
It is evident that the evidence is not enough to support the use of NPIs as complete analgesics. Thus, they can only be used to complement standard analgesic care in pain relief. Nurses can also use music therapy as an intervention to relieve stress, anxiety, and discomfort when providing standard nursing care.
Theoretical Models
A nursing theory combines interrelated concepts about a particular process or procedure. It provides a framework for predicting and understanding research variables. Theoretical models are developed through an inductive process involving an examination or observation of natural phenomena or processes. Thus, they provide a theoretical rationale for hypothesis testing, choice of the research design, interpretations of the research results, and generalization of study findings to other populations.
Theoretical models guide the entire research process. They are substantiated by past studies or practice observations. Theories provide researchers with conceptual models for data analysis and proposal development. Nursing research generates evidence that has practice implications. Such evidence helps improve patient safety, satisfaction, and health outcomes. Theoretical models provide investigators with a framework for determining the relationships between variables and making meaning of the research findings.
References
Bauer, B., Cutshall, S., Anderson, P., Prinsen, S., Wentworth, L., Onley, T.,…Sundt, T. (2011). Effect of the Combination of Music and Nature Sounds on Pain and Anxiety in Cardiac Surgical Patients: a Randomized Study. Alternative Therapy Health Medicine, 17(4), 16-23.
Chan, M. (2007). Effects of Music on Patients Undergoing a C-clamp Procedure After Percutaneous Coronary Interventions: a Randomized Controlled Trial. Heart & Lung, 36, 431–439.
Cooke, M., Chaboyer, W., Schluter, P., Foster, M., Harris, D., & Teakle, R. (2010). The Effect of Music on Discomfort Experienced by Intensive Care Unit Patients during Turning: a Randomized Crossover Study. International Journal of Nursing Practice, 16, 125–131.
Demir, Y., & Khorshid, L. (2010). The Effect of Cold Application in Combination with Standard Analgesic Administration on Pain and Anxiety during Chest Tube Removal: a Single-blinded, Randomized, Double-controlled Study. Pain Management Nursing, 11(3), 186–196
Friesner, S., Miles, D., & Moddeman, G. (2006). Comparison of Two Pain-Management Strategies during Chest Tube Removal: Relaxation Exercise with Opioids and Opioids Alone. Heart & Lung, 35(4), 269–276.
Gelinas, C., Arbour, D., Michaud, C., Robar, L., & Cote, J. (2013). Patients and ICU Nurses’ Perspectives of Non-pharmacological Interventions for Pain Management. Nursing in Critical Care, 18(6), 307-318.
Iblher, P., Mahler, H., Heinze, H., Huppe, M., Klotz, K., & Eichler, W. (2011). Does Music Harm Patients After Cardiac Surgery? A Randomized, Controlled Study. Applied Cardiopulmonary Pathophysiology, 15(1), 14–23.
Lindberg, J., & Engstrom, A. (2011). Critical Care Nurses Experiences: a Good Relationship with the Patient is a Prerequisite for Successful Pain Relief Management. Pain Management Nursing, 12(3), 163–172.
Nilsson, U. (2009). The Effect of Music Intervention in Stress Response to Cardiac Surgery in a Randomized Clinical Trial. Hurt & Lung, 38(3), 201-207.
Sandelbach, S., Halm, M., Doran, K., Miller, E., & Gaillard, P. (2006). Effects of Music Therapy on Physiological and Psychological Outcomes for Patients Undergoing Cardiac Surgery. Journal of Cardiovascular Nursing, 21(3), 194-200.