NUR 315 Module 3 EBP Paper 2: Quantitative Critical Appraisal Example

Nineteen and a Half Points Calmer: Appraising a Three-Arm Trial of Patient-Directed Music for Ventilated Adults

Student Name

Edson College of Nursing and Health Innovation, Arizona State University

NUR 315: Nursing Research and Application to Practice

Instructor Name

Month Day, Year

Nineteen and a Half Points Calmer: Appraising a Three-Arm Trial of Patient-Directed Music for Ventilated Adults

Introduction

My PICO(T) question asks whether patient-directed music, compared with usual care, reduces anxiety and sedative exposure for adults on mechanical ventilation. The quantitative article I selected is a randomized clinical trial by Chlan et al. (2013). This paper appraises the study's purpose, design, sample, intervention, measures, results and limitations, and then judges how well it answers my question.

Purpose and Design

The study tested whether patient-directed music reduced anxiety and sedative exposure compared with noise-canceling headphones and usual care. It was a randomized clinical trial with three groups, the design best suited to cause and effect, since chance assignment spreads patient differences evenly across the arms, including differences no one thought to measure (Chlan et al., 2013). Including a headphones group was a careful choice: it tells apart what music adds from what quiet alone achieves.

Sample and Setting

Its 373 patients came from 12 ICUs in five hospitals in the Minneapolis-St. Paul area between 2006 and 2011. Participants were receiving mechanical ventilation for respiratory failure, had a mean age of 59 and were fairly ill, with a mean APACHE III score of 63. The sample was 86% white. Multiple ICUs strengthen the study, but the mostly white, single-region sample limits how confidently the results apply to the more diverse patients in Phoenix ICUs.

Intervention

In the music group, a music therapist helped each patient choose preferred music, which was loaded onto a player with headphones. Patients started and stopped the music themselves whenever they wished. Patient direction is a strength because it reflects real choice, but it also meant that use varied widely: the mean was about 80 minutes a day, while the median was only 12 minutes. Some patients used music a great deal and others very little.

Measures

Anxiety was measured daily with a 100-millimeter visual analog scale, on which patients mark their anxiety along a line. This tool is simple enough for patients who cannot speak, which suits ventilated adults. Sedative exposure was measured in two ways, intensity and frequency of sedative doses, using data from the medical record, which avoids relying on patient recall.

Results

Using a statistical approach that follows each patient over time, the researchers found that at any time point, anxiety in the music group ran 19.5 points below usual care on the 100-point scale than patients in usual care, with a 95% confidence interval from 6.8 to 32.2 points lower and a p value of .003 (Chlan et al., 2013). By the fifth study day, anxiety in the music group had fallen by 36.5%. Music also significantly reduced both measures of sedative exposure over time.

What does this mean at the bedside? A 19.5-point drop on a 100-point line is roughly a fifth of the scale, a difference a nurse and a patient would likely notice. Zero sits outside the confidence interval, which is why the finding counts as statistically significant, but its width tells me the true effect could be as small as about 7 points or as large as about 32. Statistical significance shows the effect is unlikely to be chance; clinical significance asks whether it matters to patients, and here the size of the effect and the reduction in sedation both suggest it does.

Limitations and Risk of Bias

Patients and nurses could not be blinded, since everyone could see the headphones, which may have influenced anxiety ratings. The visual analog scale depends on patients being alert enough to use it, so the sickest or most sedated patients may be underrepresented. Wide variation in music use makes it hard to say how much music is needed. The trial took place more than a decade ago, before current guidelines that emphasize lighter sedation, so usual care may now differ.

Agreement With Other Evidence

The results are consistent with a Cochrane review of 14 trials, which reported that listening to music cut anxiety substantially in ventilated patients and noted that one large trial, this one, reported reduced sedative intake (Bradt & Dileo, 2014). Current sedation guidelines encourage nonpharmacologic strategies that help keep sedation light (Devlin et al., 2018), which music could support.

Conclusion

The trial is well designed and directly answers my PICO(T) question. Its results show a meaningful reduction in anxiety and sedative exposure with patient-directed music. Limits in blinding, sample diversity and dose leave some uncertainty, but because music is low cost and low risk, the evidence supports offering it to ventilated adults who can choose, alongside careful assessment.

References

Bradt, J., & Dileo, C. (2014). Music interventions for mechanically ventilated patients. Cochrane Database of Systematic Reviews, (12), Article CD006902. https://doi.org/10.1002/14651858.CD006902.pub3

Chlan, L. L., Weinert, C. R., Heiderscheit, A., Tracy, M. F., Skaar, D. J., Guttormson, J. L., & Savik, K. (2013). Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: A randomized clinical trial. JAMA, 309(22), 2335-2344. https://doi.org/10.1001/jama.2013.5670

Devlin, J. W., Skrobik, Y., Gélinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., ... Alhazzani, W. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine, 46(9), e825-e873. https://doi.org/10.1097/CCM.0000000000003299