Essay Evidence Based Practice and Applied Nursing Research

Evidence Based Practice and Applied Nursing Research: Task 1

Running head:  An Evidentiary Analysis of Sleep Disturbance.

An Evidentiary Analysis of Sleep Disturbance.

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EBT1 Task 1

Western Governors University

A1. Article

Su, C.P., Lai, H.L., Chang, E.T., Yiin, L.M., Perng, S.J., & Chen, P.W. (2013). A randomized   controlled trial of the effects of listening to non-commercial music on quality of nocturnal sleep and relaxation indices in patients in medical intensive care unit. Journal of Advanced Nursing, 69(6), 1377-1389. doi: 10.1111/j.1365-2648.2012.06130.x

A2. Graphic Summary

Article Su, C.P., Lai, H.L., Chang, E.T., Yiin, L., M., Perng, S., J., & Chen, P.W. (2013). A             randomized controlled trial of the effects of listening to non-commercial music on                   quality of nocturnal sleep and relaxation indices in patients in medical intensive care               unit. Journal of Advanced Nursing, 69(6), 1377-1389.   doi: 10.1111/j.1365-                2648.2012.06130.x
Introduction	The researchers presented a clear and unambiguous purpose statement which was to examine the effects of non-commercial music on quality of sleep and relaxation indices, including heart rate, mean arterial pressure, and respiratory rate in patients in intensive care units. The article began with a straightforward abstract that was organized into the following headings: aim, background, design, methods, findings, conclusions and keywords. The abstract was followed by a logical and illuminating discussion of the phenomena of sleep disturbance, common treatment for sleep disturbance, pharmacology treatment and related adverse reactions, and also provided a rationale for the research study. The researchers briefly discussed the emergence of holistic nursing theory and provided a synopsis of the mind body connection. Inclusive in the discussion was an acknowledgement of the limited mind-body research studies specifically related to music therapy as an intervention to improve sleep.   Towards the end of the introduction section, the researchers further clarified their reasoning for this study, stating that music as a method to improve sleep lacks conclusive evidence as a complementary intervention in which this study attempts to remedy by using an objective tool, the polysomnography (PSG).
Literature Review	The literature review which is presented after the introduction and before the methods section consists of 20 peer-reviewed journal articles

	and is divided into two sections with the following headings: A theoretical base and music and sleep. The theoretical base section provides a logical overview of the psychophysiological theory which describes the biological mechanisms for music’s therapeutic effect. Evidence in this section spans from 1998 to 2012. The music and sleep section includes historical evidence from 1968 and recent primary research from 2003 to 2011. In addition, factors involved in patients sleep disturbances on the ICU unit and sleep patterns of ICU patients in the context of stages of sleep are discussed. The literature review provides a comprehensive basis for the study by the presentation of relevant evidence.   It also includes the hypothesis and rationale for the study.
Methodology	The methods section of the article clearly delineates this quantitative experimental, randomized controlled trial study and research methods utilized. The participants were randomly assigned to a control or experimental group with the experimental group receiving therapeutic music intervention, which included 45 minutes of soothing noncommercial music at nocturnal sleep time. Tools utilized for outcome measure were the Verran and Synder-Halpern Sleep Scale (VSH) and a portable wireless polysomnography.
Data Analysis	The data was collected from 28 patients on a medical ICU unit in Taipei, Taiwan. The results were analyzed using PASW for Windows.   The researchers who conducted the statistical analysis were not aware of the patient’s group assignment to avoid bias and decrease error. The researchers presented their data analysis in a simple and easy to follow manner. Statistical t-test and x2 tests were used to determine any significant difference in the group characteristics and pre-experimental baseline measures.   The findings indicated that no statistical difference was observed. In terms of sleep outcomes, general estimating group differences statistics were employed which revealed a statistical improvement in self-reported sleep quality, measured by VSH sleep scale (p=.012), and in stage N2 (p=.014) and stage N3 (p=.008) as measured by the polysomnography.
Conclusion	The researcher’s conclusions included limitations of the study and the application to nursing practice. The researchers provided a straightforward and uncomplicated discussion of the findings.   The researchers concluded based on statistically significant results that listening to sedating music can evoke a considerable autonomic nervous system response and reported that patients in medical ICU benefit from
	improved quality of sleep if nurses offer a short period of time for listening to music at nocturnal sleep.

A3. Analysis of Five Areas

Through a detailed analysis of the components of this research study and the evidence presented, the determination is that the researchers’ conclusions are merited in their interpretation of the results. According to Polit and Beck (2010), “To determine the credibility of a research study, a careful analysis of the study’s methodological and conceptual limitations and strengths is required” (p. 443). Through a comprehensive review of previous literature, the researchers were able to develop a study that was well grounded in relevant evidence. The researchers demonstrated the need for this study and reported the purpose was “to build on established knowledge and increase the empirical evidence available for music therapy as an appropriate non-pharmacological sleep intervention” (Su et al., 2013). Furthermore the choice of the study was appropriate to the stated purpose, increasing the reliability and credibility of the researchers’ results and conclusions. The research design facilitated the minimization of error by utilizing control and experimental groups and randomized group assignments. In addition, statistical researchers and data collectors were blind to participants’ status in terms of control or experimental group assignment. The researchers also sought to minimize error through their statistical handling of data, by utilizing t and x² statistics to determine if any significant difference was of characteristics and baseline measures was present. The results demonstrated the lack of statistical difference and further increased the reliability of the studies results. Finally, the researchers identification of weaknesses and limitations of the study provide a starting point for future research in this area. The results showed statistical significant improvement in self-reported sleep and stage N2 and N3 after music intervention which combined with the credibility of the research design, provided a solid foundation for their conclusion that music therapy at nocturnal hours improves the quality of sleep in ICU patients.

A4. Ethical Issues

According to Polit and Beck (2010), “Ethical concerns are especially prominent in nursing research because the line of demarcation between what constitutes the expected practice of nursing and the collection of research data cam sometimes get blurred” (p. 118). In an attempt to ensure that ethical violations did not occur in this study, the researchers ensured compliance with ethical standards. The researchers complied with the ethical norms by utilizing methods that avoid error such as blinding the researchers performing statistics and designing a randomized control trial. In addition, the study protocol was approved by the hospital institutional review board and the researchers ensured that patients’ rights were protected by obtaining informed consent. Finally the authors state no conflict of interest in performing this study and report the study was funded by a grant from the Buddhist Tza Chi General Hospital.

A5. Type of Research

According to Burns and Grove (2005), “Quantitative research is defined as a formal, objective, systematic process in which numerical data are used to obtain information” (p.23). The researchers designed an objective and systematic study in which results were analyzed using statistical methods. In addition to being a quantitative study, the research was experimental in nature, in that the researchers “actively introduced an intervention or treatment” (Polit & Beck, 2010 p. 70). The researchers randomly assigned the 28 participants to either a control or experimental group, which is the definition of a randomized control trial, which according to Polit and Beck (2010), “is a full experimental test of an intervention, involving random assignment to treatment groups” (p. 566). In summary, this study was a quantitative, experimental, randomized control trial. It consisted of 28 patients who were on a medical ICU. The patients were randomly assigned into a control or experimental group, which received a soothing music intervention at nocturnal sleep time.

A5 a. Appropriateness of Other Research Types

In considering the appropriateness of other research study designs, for the aim of this study to determine if music therapy at nocturnal hours is an effective treatment for sleep disturbances on the medical ICU, the experimental design is the most empirically based design. In considering a descriptive design type, according to Polit and Beck, (2010) the main objective is to accurately portray the characteristics of a phenomenon.   A descriptive design is appropriate to describe the sleep disturbances that naturally occur on the medical ICU. Descriptive studies have been previously conducted identifying the problem of sleep disturbance on medical ICU units. The researchers purpose was to evaluate music therapy as an effective treatment for sleep disturbance, thus the descriptive design is inappropriate to measure the effectiveness of music therapy. A correlation study would also be inappropriate for this study because there is a manipulation of the independent variable, which is not part of a correlation study. According to Polit and Beck (2011), “Correlational research explores the interrelationships among variables without researcher intervention” (p.551). Finally, a quasi-experimental would have consisted of a similar design but the results would have been less credible due to the lack of randomness in the assignments of groups (experimental, control) and potential for error.

B1. Problem

Sleep disturbances whether in the hospital setting or in an individual’s home environment, can have severe consequences of people’s health and wellbeing, such as risk of myocardial infarction, diabetes, fatal accidents at work and hormonal imbalance (Akerstedt & Nilsson, 2003).   Lai and Good (2006), reports that sleep disorders can result in tiredness, fatigue, depression, greater anxiety, irritability, pain sensitivity, muscle tremors, immunosuppression and lack of daytime alertness. According to Morin et al. (2006), “The presence of insomnia in the general population is estimated to be 29.9%”.   The prevalence of insomnia in the population results in direct medical cost of approximately 13.9 billion annually in the United States (Martin, Aikens, & Chervin, 2004). The most common treatment for sleep disturbances is pharmacotherapy. According to DeMartinis, Kamath and Winokur (2009), “Pharmacology management can be contraindicated due to unwanted drug effects, tolerance, dependence, altered sleep stages and rebound insomnia. Chang, Lai, Chen, Hsieh and Lee (2012), report “insomnia has become a critical issue that evidence-based nursing must address”. This paper seeks to address sleep disturbance.

B2. Matrix

Author(s)	Source	Date (year)	Research Type	Population/ sample size	Outcome measures	Pertinent data from results	Suggested Conclusions	Comments
Lai, H.,& Good, H.	Journal of Advance Nursing, CINAHL	2006	Quantitative, experimental	60 community based participants ages 60-83, Taiwan	Quality of sleep	35% sleep improvement (TX group) 0% improvement (control)	Easy and quick to learn intervention that nurses can use to improve sleep, findings provide evidence for music therapy as treatment for sleep disturbance.	3 week duration, home based, sleep improvement with music listening @HS, seniors -PSQI -RCT

Harmat, L., Takács, J., & Bódizs, R.	Journal of Advanced Nursing, CINAHL	2008	Quantitative, experimental	94 students, ages 19-28 at Semmelweis Budapest, Hungary	Sleep quality, depressive symptoms	Music statistically improved sleep, not in control or audiobook group	Relaxing classical music at bedtime improves sleep.  Nurse can use TX.	Easy to implement nursing intervention,  Statistically effective High quality study -PSQI/RCT
Hernandez- Ruiz, E.	Journal of Music Therapy, MEDLINE	2005	Quantitative, quasiexperimental	28 women in domestic violence shelters in Kansas.	Sleep patterns and quality, anxiety, and fatigue levels.	PSQI increase in experimental group. Statistically significant	Music therapy  used with victims of domestic to promote sleep	Domestic violence, mothers, resource to improves sleep and quality of life -PSQI
Deshmukh, A.D., Sarvaiya, A. A.,Seethalaks hmi, R., & Nayak, A.S.	Nordic Journal of Music Therapy, CINAHL	2009	Quantitative, experimental	50 individuals diagnosed with depression in Mumbai, India.	Sleep quality changes, depression symptoms	Improvemen t in sleep in music group Equivalent to medication group	Music therapy effective in vulnerable population to avoid s/e of benzodiazepine s  or other hypnotic meds	Low cost, no s/e TX for sleep problems. -PSQI -RCT
De Niet, G., Tiemens, B., & Hutschemaek ers, G.	British Journal of Nursing, CINAHL	2010	Quantitative, quasiexperimental	72 psychiatric inpatients, Netherlands	Sleep improvement	MAR (music assisted relaxation) statistically significant improvement in sleep quality	Mental health nurses can improve sleep quality of inpatient psych with MAR	-ctrl, SC group and music group, -RCSQ
Chang, E.T., Lai, H.L., Chen, P.W., Hsieh, Y.M., & Lee, L.H.	International Journal of Nursing Studies, MEDLINE	2012	Quantitative, experimental	50 community dwelling participants with insomnia, study conducted at sleep lab in Taiwan.	Sleep quality (objective and subjective)	Statistically improvement in sleep improvement	Soothing music improves sleep	-RCT -PSQI –PSG -sleep lab x nights
Bloch, B., Reshef, A., Vadas, L., Haliba, Y., Ziv, N., Kremer, I., & Haimov, I.	Journal of Music Therapy, MEDLINE	2010	Quantitative, quasiexperimental	24  clinically stable psychiatric outpatients with dx of schizophrenia, Israel	Sleep quality (obj and sub), anxiety, and depression symptoms, positive and negative emotions.	Statistical improvement in sleep latency and efficiency after music intervention	Music relaxation as treatment for insomnia in people living with schizophrenia dx	Objective ACTIGRAPHY (wrist worn) -Technion and MSQ
Ryu, M.J., Park, J.S., & Park, H	Journal of Clinical Nursing, CINAHL	2011	Quantitative, experimental	58 patients in cardiac care unit, DongSan Hospital in Daegu, South Korea.	Quality of sleep.	Sleep statistically improved with music intervention	Easy nursing intervention to increase sleep for ICU patients	Used earplugs in both group with and without music, ICU -VSH
Chan, M.F.	Journal of Clinical Nursing, MEDLINE	2011	Quantitative, experimental	42 community based adults, ages 60 and older, Hong Kong	Sleep quality, blood pressure and heart rate	Statistical sleep improvement at 4th week.	Recommends nurses use music as part of holistic care.	Limited study, results collected weekly and no daily logs kept RCT, PSQI
Su et al	Journal of Advanced Nursing, MEDLINE	2013	Quantitative, experimental	28 patients on medical ICU unit in Taipei, Taiwan	Sleep quality	Statistical sleep quality, N2 and N3 improvement	Nurses can offer music at hours of sleep to improve sleep quality	Objective-PSG and VSH RCT

B3 a. Annotated Bibliography

Bloch, B., Reshef, A., Vadas, L., Haliba, Y., Ziv, N., Kremer, I., & Haimov, I. (2010). The effects of music relaxation on sleep quality and emotional measures in people living with schizophrenia. Journal of Music Therapy, 47(1), 27-52. Retrieved from http://ehis.ebscohost.com/ehost/detail

The purpose of this study was to examine the effects of music relaxation on insomnia and emotional measures in people living with schizophrenia.

Researchers from the psychiatric department in Haemek Medical Center in Afura, Israel conducted this study to determine the effectiveness of music relaxation played at bedtime as a treatment for insomnia. The study consisted of 24 participants who volunteered for the study through the medical center’s outpatient clinics. Inclusionary criteria required that all participants had been taking medication regularly at least for one month and were in stable mental and physical health. The 24 participants received no treatment for 7 days during which time anxiety, negative and positive thinking, depressive symptoms and sleep quality were monitored and recorded. Sleep quality was measured objectively using a continuous wrist worn miniature antigraphy and subjectively using the Technion and Mini-Sleep Questionnaires. The 7 day no treatment trial was immediately followed by a subsequent 7 day treatment trial which consisted of relaxing music listened to at desired bedtime hours without headphones or earplugs. The relaxing music consisted of 52 beats per minute at a moderate volume with no dynamic changes. The results showed an improvement in sleep latency and sleep efficiency after the music was played and a significant correlation between relaxing music and sleep efficacy. The researchers conclude that music has a beneficial effect as a treatment for insomnia in people living with schizophrenia.

Chan, M.F. (2011). A randomized controlled study of the effects of music on sleep quality in       older people. Journal of Clinical Nursing, 20(7-8), 979-987. doi: 10.1111/j.1365-

2702.2010.03368.x

This article discusses a research study that was conducted in Hong Kong with the purpose of determining the effect of music on sleep quality in older people. The participants included 42 adults, 60 years or older, living in the community who reported sleep disturbances. The participants were randomly assigned to a control or experimental group. The experimental group listened to non-lyrical music with approximately 60-80 beats per minute that was 45 minutes in length on a mp3 player. Participants were provided with a mp3 and earplugs and instructions to listen in bed before sleep. The control group received no musical intervention or earplugs. The participants heart rate, blood pressure and sleep quality was assessed and recorded once weekly for four weeks. Sleep quality was measured using the Pittsburgh Sleep Quality Index scale. The results showed only statically significant reduction in sleep scores at week four. The researcher suggests that nurses should use music as part of holistic care for older adults. The study could be improved by having participants keep daily logs and use earplugs in the control group.

Chang, E.T., Lai, H.L., Chen, P.W., Hsieh, Y.M., & Lee, L.H. (2012). The effects of music on The sleep quality of adults with chronic insomnia using evidence from polysomnography and self-reported analysis: a randomized control trial. International Journal of Nursing,

49(8), 921-930. doi:10.1016/j.ijnurstu.2012.02.

The purpose of this study was to evaluate the effect of soothing music on objective and subjective sleep quality in adults with chronic insomnia. The study design consisted of 50 participants who had no history of emotional or substance abuse problems. The participants were randomly assigned into an experimental or control group. The experimental group received soothing music selected by participants for 45 minutes at sleep time. Participants in both groups spent four nights in the hospital sleep lab which was designed to stimulate a home bedroom setting. Sleep quality was measured by PSQI and polysomnophogry. The results showed a significant improvement in reported sleep qualities, rested rating scores, shortened N2 sleep and prolonged REM sleep. In addition, the researchers suggested that soothing music improved subjective sleep quality and limited improvement in objective sleep.

De Niet G., Tiemens B., & Hutschemaekers, G., A. (2010). Can mental healthcare nurses        improve sleep quality for inpatients? British Journal of Nursing, 19 (17), 1100-1105.

This article describes a study that was conducted on three psychiatric units in the Netherlands. The participants, ages 18-60 years old with reported psychiatric mood or anxiety disorders, were assigned to 1 of 3 units upon admission. Each unit received a different treatment: music, stimulus control or no treatment. The music group listened to preselected soothing music on a MP3 player with a built in loud speaker at bedtime. However, beyond soothing, the music qualities were not discussed in this article. The music assisted relaxation intervention showed statistically significant improvement in participants sleep quality. The researchers suggest that mental health nurses can improve the perceived sleep quality of their patients with psychiatric problems by using music assisted relaxation

Deshmukh, A.D., Sarvaiya, A. A., & Nayak, A.S. (2009). Effect of Indian classical music on       quality of sleep in depressed patients: a randomized controlled trial. Nordic Journal of

          Music Therapy, 18(1), 70-78. Retrieved from http://ehis.ebscohost.com

This article describes a research study conducted to investigate the effects of music therapy on the quality of sleep in patients with depression. The study attempted to determine whether listening to Indian classical music at bedtime is an effective non-pharmalogical alternative to sleep problems. The article reported that sleep problems can be an important trigger of relapse for patients with depression. The study was carried out by the psychiatry department on an outpatient basis at BYL Nair Charitable Hospital in Mumbai, India. 50 participants diagnosed with depression that reported current sleep disturbances were randomly assigned into two groups: a music and medication group. The music group received ongoing anti-depressant therapy and music intervention.   The medication group received ongoing anti-depressant therapy in addition to pharmacological treatment for sleep disturbance: diazepam 7mg and clordiazepoxide 10 mg. The study duration was for 45 days with sleep assessment assessed using the Pittsburg Sleep Quality Index and recorded at two follow up visits every two weeks. The difference in PSQI reduction and sleep improvement was significantly more in the music group as compared to the medication group. The researchers recommend based on findings, that music therapy is comparable to hypnotic medication in improving quality of sleep in depressed patients and can assist individuals and health care providers in the management of depression. In addition, researchers suggest that music therapy is a useful low-cost alternative solution that is as effective as benzodiazepines, free of side-effects and easy to administer.

Harmat, L., Takács, J., & Bódizs, R. (2008). Music improves sleep quality in students. Journal              of Advanced Nursing, 62(3), 327-335. doi: 10.1111/j.1365-2648.2008.04602.x.

This article discusses the result of an experimental research study conducted at Semmelweis University in Budapest, Hungry. The purpose of the study was to investigate the effects of music on sleep quality in young participants with reported poor sleep. 94 students, ages 19-28 years old, participated in the three week study. The students were assigned randomly assigned into three groups: a control group which received no treatment, an audiobook group in which students

listened to an audiobook prior to sleep and a music group in which students listened to classical music at bedtime. The results of the study, measured by the Pittsburgh Quality Sleep Index (PSQI), showed statistically significant improved sleep results among the music group and no improvement in both the control and audiobook groups. The researchers concluded that music therapy, that includes listening to relaxing music at bedtime, is an effective treatment for insomnia and indicated nurses can use this easy to learn, easy to implement and inexpensive intervention for patients with difficulty sleeping in their practice.

Hernández-Ruiz E. (2005). Effect of music therapy on the anxiety levels and sleep patterns of   abused women in shelters. Journal of Music Therapy, 42(2), 140-158. Retrieved from               http://ehis.ebscohost.com

The purpose of this article is to explore the effect of music therapy on decreasing anxiety and improving sleep patterns in abused women in shelters. The article describes a study in which, 28 women residing in two domestic violence shelters participated. The participants were assigned to one of two group: an experimental or control group. The control group received no treatment. The experimental group received a twenty minute recording of preselected music with muscle relaxation directions at bedtime. The results indicated a significant effect on sleep quality (measured by PSQI) for the experimental group and no change in the control group. The researchers concluded that music therapy for abused women can be a resource for them and their advocates to improve sleep patterns, anxiety and ultimately their quality of life.

Lai, H., & Good, M. (2006). Music improves sleep in older adults. Journal of Advanced

Nursing, 53(1),134-144. http://dx.doi.org/10.1111/j.1365-2648.2006.03693.x.

This article reports the results of an experimental research study. The purpose of the study was to investigate the effect of music as a non-pharmacological intervention in 60 community based adults, ages 60-83, with reported sleeping difficulties, residing in Taiwan.   The research design included randomized assignment into a control group or treatment group. The participants chose one of six music tapes. The music on the tapes were previously identified as sedative music based on beats per minutes, lack of percussion and non-lyrical.   The participants listened to the music for 45 minutes (length of tape) at bedtime and a log was completed every morning for three weeks. The control group received no music therapy or other treatment.   Pre and post PSQI (Pittsburgh Sleep Quality Index) tools were completed and analyzed for results related to sleep quality. The results of the study indicated a statistically significant improvement in overall quality of sleep in the treatment group with no improvement noted in the control group. Researchers recommend based on findings, the use of music as an effective intervention to improve sleep, indicating that the study provides empirical evidence for music therapy as a treatment for sleep disturbance

Ryu, M.J., Park, J.S., & Park, H. (2011). Effect of sleep-inducing music on sleep in persons with         percutaneous transluminal coronary angiography in the cardiac care unit. Journal of

           Clinical Nursing, 21(5-6), 728-735. doi: 10.1111/j.1365-2702.2011.03876.x

This article discusses a study that was conducted in South Korea with the intention of evaluating the effectiveness of music therapy as an intervention to improve sleep on a cardiac care unit.   The 58 participants, on the cardiac care unit, were randomly assigned to an experimental or control group. The experimental group listed to sleep inducing music through earplugs for 52 minutes beginning at 10 pm.   The earplugs were not removed until 7am the next morning. The control group also had earplugs but without music playing, which again was not removed until 7 am the next morning. In the morning the participants complete the VSH questionnaire daily. The results indicated that participants in the experimental group reported significantly higher sleep quality than the control group. The researchers reported the clinical significance of this study as the acknowledgment for nurses that music is an easy and effective nursing intervention to improve the sleep of intensive care unit patients.

Su, C.P., Lai, H.L., Chang, E.T., Yiin, L.M., Perng, S.J., & Chen, P.W. (2013). A randomized   controlled trial of the effects of listening to non-commercial music on quality of nocturnal sleep and relaxation indices in patients in medical intensive care unit. Journal of Advanced Nursing, 69(6), 1377-1389. doi: 10.1111/j.1365-2648.2012.06130.x

This article describes an experimental, randomized control trial research study conducted on a medical intensive care unit located in Taipei, Taiwan. The study consisted of 28 participants who were randomly assigned into a control or experimental group. The control group received no treatment for sleep disturbance. The experimental group listen to classic music between 60-80 beats with no dramatic changes in volume and rhythm on a CD player. The music was played aloud and automatically shut off after 45 minutes. Sleep was measured objectively with a polysomnography and subjectively with the Verran SnyderHarper Sleep Scale (VSH). The results of the study showed a statistical significant improvement in sleep quality as measured by VSH and in N2 and N3 sleep stages. Based on these results the researchers concluded that patients in medical ICU benefit from improved quality of sleep if nurses offer a short period of time for listening to music at nocturnal sleep.

B3b. Efficacy

The research in this paper outlines the importance of adequate sleep and the consequences of sleep disturbance in regard to health and wellness. The articles identify pharmacology as the standard intervention used in practice today and discuss the problems associated with the intervention. These include significant side effects and cognitive disturbance (Deshmukh et al., 2009), deterioration of emotional and mental condition and tolerance and dependence (Chan, 2012). Through an analysis of the side effects associated with the current treatment for sleep disturbances, it is clear that an alternative and effective intervention which can be easily implemented by nurses is warranted. The research reviewed provides evidence that certain music, classified as sedating or soothing, based on musical qualities, is an effective treatment for sleep disturbance. Lai and Good (2006), Harmat, Takács and Bódizs (2008), Deshmukh et al. (2009), Chang et al. (2012), Su et al. (2013) and Ryu, Park, Park (2011) provided statistically significant evidence that music is an effective therapeutic intervention in improving sleep quality in adults with reported sleep disturbances. While all articles presented in this paper demonstrates the benefit of music therapy as an intervention in reducing sleep disturbances and promoting sleep. The aforementioned research studies provide the most compelling evidence for efficacy of music therapy as an alternative intervention for sleep disturbance because these studies consisted of randomized control trials which according to Polit and Beck (2010), “ provide the highest level of evidence” (p.230). Therefore with the strength of evidence that is presented in this paper it is clear that sleep disturbance and the increase risk of the current treatment practice in patients and individuals is unacceptable with the evidence of an effective, cheaper, non-invasive alternative. Therefore music therapy as described in the evidence, consisting of moderate volume, less than 70 beats per minute, non-lyrical should be implemented as an initial intervention before pharmacological therapy is initiated or in combination with pharmacological therapy to promote pharmacological sleep treatment independence.

B3c. Tools.    

The researchers in the evidence evaluated in this study used similar tools to measure sleep quality and characteristics. All researchers utilized some form of self-reported, quantitative, questionnaire. 6 of the10 studies used the Pittsburgh Sleep Quality Index (PSQI), which is a questionnaire that measures sleep habits. It consists of seven components that assess sleep characteristics. The components are as follows: perceived sleep quality, sleep latency, sleep duration, sleep efficiency, and sleep disturbance, use of sleep medication and daytime dysfunction. 2 of the 10 studies, measured sleep quality with the Verran and Synder-Halpern

Sleep Scale (VSH). One study used another the Richards Campbell Sleep Questionnaire. The

Mini-Sleep Questionnaire, another quantitative questionnaire was used in conjunction with the Technion a qualitative sleep questionnaire. 3 of the 10 studies, also collected objective sleep data, tools employed included a polysomnography in a laboratory setting, wireless polysomnography on medical intensive care unit and a wrist worn actigraphy. All 3 studies combined objective tools with a form of subjective questionnaire.

B3d. Effect on Results

In any research design there is the potential for error. Researchers can minimize that error by carefully choosing and adequate date collection tool and structuring the methods by which data is collected. According to Polit and Black (2010), this means considering who collected the data, how they were trained and whether formal instruments were adequately pretested. In the research evidence reviewed in this paper all studies include a structured questionnaire. 6 of 10 used the pretested and reliable, well-established Pittsburgh Sleep Quality Index. The choice of this data tool provided for reliable results with in the limits of questionnaires. Lai & Good (2006), requested their participants keep daily sleep logs which were weekly used to complete the PSQI, which is a weekly assessment tool). The use of the daily sleep logs in their study was to improve accuracy of recall (Lai & Good, 2006). Whereas in Harmat et al. (2008) study, PSQI was also used and the PSQI collected weekly, but their participants did not keep a daily sleep record. This increases the risk that participants did not accurately complete the PSQI due to poor recall and may have effected their results. Other researchers such as Chang et al. (2012) and Su et al.

(2013), collected objective sleep data using a polysomnography, PSQ. Chang et al. (2012) collected data in a sleep lab. Although the testing rooms in the sleep lab were set up as bedrooms, the artificial environment may have affected the researchers’ results by increasing resistance to sleep. Su utilized a wireless polysomnography on the participants, thereby eliminating any effect of the sleep lab environment. Overall, the tools used in the evidence presented in this paper, may have affected or skewed the researches results, however through quantitative experimental research designs the researchers have attempted to minimize such an effect.

B4. Evidence Summary

It is accepted as general knowledge that a good night sleep is important for optimal functioning and that sleep disturbance disrupts this functioning. This paper presented evidence relating to the sleep disturbance and the effectiveness of music as a non-pharmacological treatment. The key criteria that was used to search and evaluate articles presented in this paper was sleep disturbance, non-pharmacological interventions and quantitative studies.

All of the articles discussed in this paper present evidence and are in agreement that sleep disturbances effects optimum health. While each article discusses specific consequences in different contexts. 3 of the 10 articles (Deshmukh et al., 2009; De Niet, Tiemens &

Hutschemaekars, 2010; and Bloch et al., 2010) discuss sleep disturbance in the context of mental illness or disorder. Deshmukh et al. (2009) presents evidence that sleep disturbance can form a trigger and cause a relapse of depression. De Niet et al. (2010) agrees and indicates that “sleep disturbance is associated with increased risk of recurrence of major depression, bipolar disorder and post traumatic stress disorder” and Bloch et al.(2010) states regarding sleep disorders,

“manifests negative effects on physical and mental health”.

In analyzing the remaining seven studies, five were community based with various populations, such as domestic violence victims living in a community shelter, students, adults and older adults. Lai and Good (2006) and Chan (2011) focused on older adults in the community. They both presented evidence regarding pharmacological methods to improve sleep and adverse reactions, especially in this population, such as “deterioration of emotional and mental condition, impaired psychomotor and cognitive function” (Chan, 2011) and daytime residential effects, tolerance dependence and rebound insomnia (Lai & Good, 2006). Both agree that due to the potential for negative side effects non-pharmacological alternatives for sleep disturbance should be explored.

The remaining two studies, Ryu et al. (2011) and Su et al., (2013) focus on sleep disturbance of patients in an intensive care unit. They agree that a problem of patients in the ICU is sleep disturbance. The researchers concurred that the effects of sleep disturbance can be detrimental, with Su et al.(2013) reporting that “sleep disturbance can impair immune functioning” and Ryu et al. (2011) reporting an increase in mortality.

All articles present in this paper aim to study non-pharmacological methods of improving sleep with a focus on music therapy as an intervention. The articles consisted of experiments with soothing music, as defined by decibels and beats or classic music category, listened to by participants at bedtime in bed with an automatic shut off mechanism.

In terms of research designs, all articles employed quantitative research design. 5 of the 10 studies: Lai and Good (2006), Chan (2011), Ryu et al. (2011), Chang et al. (2012) and Su et al. (2013), designed a randomized control trial which consisted of randomly assigning participants into a non-interventional control and experimental group. The experimental group consisted of relaxing, soothing music intervention. One research study (Hernandez, 2005), which did not randomly assign participants into groups, included an interventional group which used a muscular relaxation script with music therapy. In Bloch et al. (2010), the researchers utilized a within subject design in which all participants received no treatment for seven days followed by a musical treatment at bedtime hours for 7 days.

Harmat et al. (2008) and De Niet et al. (2010), designed a control group with two experimental groups. Harmat et al. (2008) randomly assigned participants into a control group, soothing music group and audio book, in which participants listened to a book on tape in bed at bedtime hours with an automatic shut off. De Niet et al. (2010) study participants were non-randomly assigned to a control or two experimental groups, a music and stimulus control group.   The music experimental group was similar to others presented in this paper and included soothing music at bedtime hours.

Despite the differences in study designs the researchers present evidence that is similar regarding the effect of relaxing music therapy at bedtime as an effective non-pharmacological intervention for sleep disturbance and recommendations for nursing practice. All of the research studies presented results demonstrating some sleep improvement with relaxing and soothing music therapy. Lai and Good (2006), Harmat, et al. (2008), Hernandez (2005), Deshmukh et al. (2009), De Niet et al. (2010), Chang et al. (2012), Bloch et al. (2010), Ryu et al. (2011) and Su et al. (2013), presented statistically significant results for music as non-pharmacological intervention to sleep disturbance.

The presented evidence provides an empirical based rationale for utilizing music in practice as an effective non-pharmacological intervention for patients whether on hospital units, community based as in home care, in psychiatric units, or with significant stressor such as victims of domestic violence to improve their sleep and minimize sleep disturbance without the potential adverse effects of pharmacological interventions.

B5. Recommendation

In analyzing the research evidence presented in this paper, music therapy used at bedtime hours has been demonstrated as an effective non-pharmacological intervention for sleep disturbance. A nursing strategy that I would recommend in practice is the systematic use of music therapy for patients, regardless of setting that are experiencing sleep disturbance. Deshmukh et al. (2009), reports that music therapy is an effective low cost treatment with no side effects.   This intervention would include automatic shut off mp3 with 45 minutes of pre-recording soothing or classical music. According to Harmat et al. (2008), relaxing classical music listened at bedtime improves sleep. The patients may choose which music they would like to listen to from a choice of several preselected options that include music with the following characteristics: non lyrical, less than 70 beats per minute with no dynamic changes. This recommendation is supported by Lai and Good (2006), who reports music therapy used in this manner, “is an easy and quick intervention that nurses can use to promote sleep”.

B6. Theoretical Models

Theory is used in nursing to provide a road map for decisions and interventions in nursing practice and nursing research. In nursing research a researcher makes study designs and choices based on an appropriate theory. According to Nursing Theory (2011), “research without theory results in discreet information or data which does not add to the accumulated knowledge of the discipline.” Nursing is a science, it is evidenced based which means, what we do and how we do it within the discipline in based on research evidence. If the research evidence is not framed within a theoretical context it may fail to provide substantial and relatable evidence, especially research specific to nursing practice. According to Polit and Beck (2011), “Nursing research has been criticized for producing isolated findings that are difficult to integrate because of the absence of a theoretical foundation” (p. 215).   The importance of theory in nursing cannot be underestimated if nursing as a profession is to continue to grow and increase in credibility as a unique science.

References