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A Comparison of the Effects of Jaw Relaxation and Music on Postoperative Pain
OCTOBER 1995, VOL 62, NO 4
nursing actions. The investigator also noted any use of physical restraints. Of the 264 observed nursepatient dyads, 81 were classified as nurse-with-difficult patient, 89 as nurse-with-ideal patient, and 94 as nurse-with-neutral patient. Nearly half the patients were female, and more than half the patients were classified as private paying. The five primary diagnoses in descending frequency for difficult patients were drug or alcohol abuse (16.4%), motor vehicle accidents resulting in altered states of consciousness (12.7%), AIDS or HIV-positive status (1 1.9%), cancer (9.7%), and stroke (9%). The data analysis revealed no significant differences between the difficult, ideal, or neutral patient groups in the number of nursepatient contacts, number of nurseinitiated contacts, or duration of contacts. The number and duration of patient contacts for difficult patients was not lower than for patients classified as ideal or neutral. The number of supportive nursing actions, however, was lower for difficult patients. These patients received the least supportive nursing care, whereas the ideal patients received the most supportive care. The difficult patients also accounted for the highest percentage of physical restraint use.
Perioperative nursing irnpiications. Specific patient characteristics are likely to be associated with the difficult-patient label, which is communicated rapidly among staff members. Perioperative nurses often know about difficult patients before the patients arrive in the OR. In this study, patients perceived as being difficult received less supportive nursing care, although differences in the
number, duration, and identity of the contact initiator were not observed. This suggests that the labeling process relates qualitatively rather than quantitatively to nursing care. This finding is alarming considering the types and number of nursing interventions that hospitalized patients require. The study has a number of methodological limitations. A convenience sample of nurses volunteered to participate. If the investigator had used a random sampling of RNs, the study might have produced different results. The study was conducted in one clinical site, which did not include critical care or ambulatory care units, which limits the generalizability of the findings. The report did not specify the number of data collectors and participant observers. The lack of controls and inter-rater reliability reports on the nurse-patient observations threatens the reliability and validity of the findings. Recognizing these limitations, however, does not reduce the impact of the study results. The difficult patient label can follow the patient from hospital admission to the OR, where it can affect perioperative nurse-patient interaction. Perioperative nurses must be careful not to judge patients negatively, especially patients with stigmatizing illnesses or impaired communication abilities. When nurses avoid and distance themselves from difficult patients, the cycle of avoidance and deviance is perpetuated. This cycle can have deleterious effects on patients’ responses to nursing interventions.
A COMPARISON OF THE EFFECTS OF JAW RELAXATlON AND MUSIC ON POSTOPERATIVE PAIN M Good Nursing Research Vol44 (JanuarylFebruary 1995) 52-57
he unpleasant sensory and affective components of pain can contribute to postoperative patient complications and prolonged hospitalizations and recovery periods after abdominal surgery. Although analgesics may be prescribed to control postoperative pain, their effectiveness sometimes is uncertain and may be augmented through patients’ use of relaxation techniques and soothing music. The purposes of this study were to compare the individual and combined effects of jaw relaxation and music on the sensory and affective components of postoperative patients’ pain after their first postoperative ambulations and to describe self-care use and helpfulness of relaxation techniques and music during the subsequent 48 hours after initial ambulation. The researcher chose a wellknown self-care deficit theory of nursing and the gate-control theory of pain for the conceptual framework of this study. The researcher used an experimental design to investigate differences in sensory and affective pain for three self-care actions (ie, relaxation, music, combined relaxation and music). The researcher defined the sensory component of pain as the unpleasant, physical perception of hurt associated with tissue damage after surgery and used an established pain sensation JANE S. LESKE scale and 24-hour recorded narcotRN, PHD ic use to measure pain sensation. NURSING RESEARCH COMMITTEE The affective component of pain 661 AORN JOURNAL
OCTOBER 1995, VOL 62, NO 4
was defined as general bodily feelings and emotions that occur concurrently with the sensory pain component. The researcher used a pain distress scale and an established anxiety inventory to measure patients’ affective pain. The sample consisted of 84 eligible subjects in four hospitals. They ranged in age from 23 years to 64 years, and they were scheduled for elective, major abdominal surgery. The investigator obtained subjects’ consents and then randomly assigned them to one of four treatment groups: jaw relaxation, music, combined jaw relaxation and music, or control. Jaw relaxation consisted of lowering the jaw, softening the lips, quieting the tongue, and breathing slowly to manage pain through reduced muscle and mental tension. The researcher provided taperecorded instructions on this relaxation technique. Subjects in the music group chose one of five tape-recorded sedative music (ie, no lyrics, controlled volume and tone). Listening to music was designed to reduce pain through distraction or relaxation, Subjects in the combination intervention group used the jaw relaxation technique while listening to the preselected music. Subjects in the three experimental groups retained and used the instructional and/or musical tapes throughout their hospital stays, while subjects in the control group received routine nursing care. Postoperative pain control was provided through PRN intramuscular (IM) or IV analgesia. The subjects were hospitalized for two to three days after their surgical procedures. The average length of time for the abdominal surgical procedures was three and one-half hours. Although 21% of the subjects
spent one to five days in surgical intensive care units, 94% of the subjects ambulated on the first postoperative day. Forty-four percent received IM narcotics, 24% received IV narcotics, and 32% received both IM and IV narcotics PRN for postoperative pain control. The researcher conducted and tape recorded structured interviews with all subjects and administered the anxiety inventory to all subjects preoperatively and postoperatively. The preoperative measurement was designed to assess subjects’ anxiety levels about impending surgery, and the postoperative measurement was conducted after subjects’ first ambulations to measure affective pain. The researcher made the pain measurements after subjects’ first ambulations and recorded subjects’ narcotic intake during the 24 hours after their first ambulations. To determine differences between sensation, distress, anxiety, and postoperative narcotic intake among the four groups of subjects, the researcher used three orthogonal a priori contrast comparisons and used analysis of covariance to assess the significance of these comparisons. Subjects in the relaxation group scored significantly lower on preoperative distress than did subjects in the music group. No significant differences were found among the three treatment groups and control group in sensation, pain, distress, anxiety, or narcotic intake. Although the findings did not support the study’s hypotheses, the subjects reported that the relaxation and music tapes were moderately or very helpful in reducing pain sensation and distress. They stated they would recommend the tapes to other individuals having surgery and 662 AORN JOURNAL
that they would use the tapes if they required future surgical procedures.
Perioperativenursing Implications. The findings of this study were inconclusive, but research reported by other investigators has supported the use of music and relaxation techniques for postoperative stress reduction and pain control. It would appear premature to discount the potential therapeutic value of these interventions for perioperative patient care. Use of appropriate sedative music in ORs, ambulatory surgery waiting areas, and holding units could create therapeutic environments for patients and family members. Perioperative nurses could teach patients to use relaxation techniques and headphone music to block extraneous noise and reduce tension during procedures performed under local or regional anesthesia. Patients who undergo ambulatory surgery procedures and early discharges may benefit from learning and using relaxation techniques. JANICE R. ALLEN RN, MS, CNOR NURSING RESEARCH COMMITTEE
TRANSPLANTATIONNURSING: ACUTE AND LONG-TERM MANAGEMENT By Marie T.Nolan, Sharon M.Augustine 1995,425p p $47.95hardcover
I
rgan transplantation has evolved remarkably during the twentieth centurv. Greater understanding of the immunology of transplantation, organ preservation, and the development and use of increasingly
nursing actions. The investigator also noted any use of physical restraints. Of the 264 observed nursepatient dyads, 81 were classified as nurse-with-difficult patient, 89 as nurse-with-ideal patient, and 94 as nurse-with-neutral patient. Nearly half the patients were female, and more than half the patients were classified as private paying. The five primary diagnoses in descending frequency for difficult patients were drug or alcohol abuse (16.4%), motor vehicle accidents resulting in altered states of consciousness (12.7%), AIDS or HIV-positive status (1 1.9%), cancer (9.7%), and stroke (9%). The data analysis revealed no significant differences between the difficult, ideal, or neutral patient groups in the number of nursepatient contacts, number of nurseinitiated contacts, or duration of contacts. The number and duration of patient contacts for difficult patients was not lower than for patients classified as ideal or neutral. The number of supportive nursing actions, however, was lower for difficult patients. These patients received the least supportive nursing care, whereas the ideal patients received the most supportive care. The difficult patients also accounted for the highest percentage of physical restraint use.
Perioperative nursing irnpiications. Specific patient characteristics are likely to be associated with the difficult-patient label, which is communicated rapidly among staff members. Perioperative nurses often know about difficult patients before the patients arrive in the OR. In this study, patients perceived as being difficult received less supportive nursing care, although differences in the
number, duration, and identity of the contact initiator were not observed. This suggests that the labeling process relates qualitatively rather than quantitatively to nursing care. This finding is alarming considering the types and number of nursing interventions that hospitalized patients require. The study has a number of methodological limitations. A convenience sample of nurses volunteered to participate. If the investigator had used a random sampling of RNs, the study might have produced different results. The study was conducted in one clinical site, which did not include critical care or ambulatory care units, which limits the generalizability of the findings. The report did not specify the number of data collectors and participant observers. The lack of controls and inter-rater reliability reports on the nurse-patient observations threatens the reliability and validity of the findings. Recognizing these limitations, however, does not reduce the impact of the study results. The difficult patient label can follow the patient from hospital admission to the OR, where it can affect perioperative nurse-patient interaction. Perioperative nurses must be careful not to judge patients negatively, especially patients with stigmatizing illnesses or impaired communication abilities. When nurses avoid and distance themselves from difficult patients, the cycle of avoidance and deviance is perpetuated. This cycle can have deleterious effects on patients’ responses to nursing interventions.
A COMPARISON OF THE EFFECTS OF JAW RELAXATlON AND MUSIC ON POSTOPERATIVE PAIN M Good Nursing Research Vol44 (JanuarylFebruary 1995) 52-57
he unpleasant sensory and affective components of pain can contribute to postoperative patient complications and prolonged hospitalizations and recovery periods after abdominal surgery. Although analgesics may be prescribed to control postoperative pain, their effectiveness sometimes is uncertain and may be augmented through patients’ use of relaxation techniques and soothing music. The purposes of this study were to compare the individual and combined effects of jaw relaxation and music on the sensory and affective components of postoperative patients’ pain after their first postoperative ambulations and to describe self-care use and helpfulness of relaxation techniques and music during the subsequent 48 hours after initial ambulation. The researcher chose a wellknown self-care deficit theory of nursing and the gate-control theory of pain for the conceptual framework of this study. The researcher used an experimental design to investigate differences in sensory and affective pain for three self-care actions (ie, relaxation, music, combined relaxation and music). The researcher defined the sensory component of pain as the unpleasant, physical perception of hurt associated with tissue damage after surgery and used an established pain sensation JANE S. LESKE scale and 24-hour recorded narcotRN, PHD ic use to measure pain sensation. NURSING RESEARCH COMMITTEE The affective component of pain 661 AORN JOURNAL
OCTOBER 1995, VOL 62, NO 4
was defined as general bodily feelings and emotions that occur concurrently with the sensory pain component. The researcher used a pain distress scale and an established anxiety inventory to measure patients’ affective pain. The sample consisted of 84 eligible subjects in four hospitals. They ranged in age from 23 years to 64 years, and they were scheduled for elective, major abdominal surgery. The investigator obtained subjects’ consents and then randomly assigned them to one of four treatment groups: jaw relaxation, music, combined jaw relaxation and music, or control. Jaw relaxation consisted of lowering the jaw, softening the lips, quieting the tongue, and breathing slowly to manage pain through reduced muscle and mental tension. The researcher provided taperecorded instructions on this relaxation technique. Subjects in the music group chose one of five tape-recorded sedative music (ie, no lyrics, controlled volume and tone). Listening to music was designed to reduce pain through distraction or relaxation, Subjects in the combination intervention group used the jaw relaxation technique while listening to the preselected music. Subjects in the three experimental groups retained and used the instructional and/or musical tapes throughout their hospital stays, while subjects in the control group received routine nursing care. Postoperative pain control was provided through PRN intramuscular (IM) or IV analgesia. The subjects were hospitalized for two to three days after their surgical procedures. The average length of time for the abdominal surgical procedures was three and one-half hours. Although 21% of the subjects
spent one to five days in surgical intensive care units, 94% of the subjects ambulated on the first postoperative day. Forty-four percent received IM narcotics, 24% received IV narcotics, and 32% received both IM and IV narcotics PRN for postoperative pain control. The researcher conducted and tape recorded structured interviews with all subjects and administered the anxiety inventory to all subjects preoperatively and postoperatively. The preoperative measurement was designed to assess subjects’ anxiety levels about impending surgery, and the postoperative measurement was conducted after subjects’ first ambulations to measure affective pain. The researcher made the pain measurements after subjects’ first ambulations and recorded subjects’ narcotic intake during the 24 hours after their first ambulations. To determine differences between sensation, distress, anxiety, and postoperative narcotic intake among the four groups of subjects, the researcher used three orthogonal a priori contrast comparisons and used analysis of covariance to assess the significance of these comparisons. Subjects in the relaxation group scored significantly lower on preoperative distress than did subjects in the music group. No significant differences were found among the three treatment groups and control group in sensation, pain, distress, anxiety, or narcotic intake. Although the findings did not support the study’s hypotheses, the subjects reported that the relaxation and music tapes were moderately or very helpful in reducing pain sensation and distress. They stated they would recommend the tapes to other individuals having surgery and 662 AORN JOURNAL
that they would use the tapes if they required future surgical procedures.
Perioperativenursing Implications. The findings of this study were inconclusive, but research reported by other investigators has supported the use of music and relaxation techniques for postoperative stress reduction and pain control. It would appear premature to discount the potential therapeutic value of these interventions for perioperative patient care. Use of appropriate sedative music in ORs, ambulatory surgery waiting areas, and holding units could create therapeutic environments for patients and family members. Perioperative nurses could teach patients to use relaxation techniques and headphone music to block extraneous noise and reduce tension during procedures performed under local or regional anesthesia. Patients who undergo ambulatory surgery procedures and early discharges may benefit from learning and using relaxation techniques. JANICE R. ALLEN RN, MS, CNOR NURSING RESEARCH COMMITTEE
TRANSPLANTATIONNURSING: ACUTE AND LONG-TERM MANAGEMENT By Marie T.Nolan, Sharon M.Augustine 1995,425p p $47.95hardcover
I
rgan transplantation has evolved remarkably during the twentieth centurv. Greater understanding of the immunology of transplantation, organ preservation, and the development and use of increasingly