Registed Nurses' Association of Ontario

Implementation of the RNAO’s Assessment and Management of Pain Best Practice Guideline: Non-pharmaceutical Management of Pain in the Post-op Hip and Knee Patient Population

Zixi Huang
Mount Sinai Hospital

The Fellowship: This RNAO ACPF provided a unique opportunity to explore and pilot the introduction and integration of complementary therapy for pain management, specifically music therapy, in a postoperative orthopedic acute care setting. Through this Fellowship, I have benefited tremendously from my mentors who are experts in conducting research and piloting projects, and have outstanding critical thinking and leadership skills.

The overall goal was to explore, introduce and integrate music therapy as an adjunct in postoperative pain management to further enhance patient care quality in an acute care setting. This quality improvement pilot project was based on RNAO BPG recommendation, and the pilot unit was 11 North – an orthopedic postoperative care unit.

The following is a summary for the five objectives that lead the work I completed:

1. Locate best evidence practice in music therapy for postoperative pain management in an acute care setting.

An extensive literature review for studies published in scholarly journals in the past 20 years was conducted. To better capture and present the findings in the literature, I have completed:

• A critical appraisal of available systematic reviews which reviewed studies published from Year 1992 to Year 2010. Based on the quality assessment, three systematic reviews were selected for their high quality and thoroughness, and a summary for the three systematic reviews was conducted and presented to my mentors. The appraisal criteria used were Critical Appraisal Skills Programme (CASP) Systematic Review Checklist 31.05.13.
• A critical appraisal of available guidelines and best practice information sheet published from Year 1992 to Year 2014. The findings were presented to my mentors in written form. The appraisal criteria used were RNAO AGREE II, 2013.
• A literature review of Randomized Controlled Trials published from Year 2011 to Year 2014 was conducted and presented to my mentors. The appraisal criteria used were Critical Appraisal Skills Programme (CASP) Randomized Controlled Trials Checklist 31.05.13.
• A summary of current theories on causal mechanisms in music analgesia effect was conducted and presented to my mentors and unit committees.
• A summary of best practice information sheet was drafted and approved by my mentors, and presented in both written and verbal format to unit committees.

In summary, music therapy utilized as an adjunct in postoperative pain management has been found to be effective due to its remarkable effects of distraction, self-efficacy, and emotional engagement. In addition, it is low cost, easy to use, and free of side effects. The recommendation on music selection is:

• Self -preferred
• Slow and flowing music, approximately 60 to 80 beats per minute
• Non-lyrical
• Maximum volume level at 60 dB
• Each time listening to a minimum 30 minutes with no disturbance
• For hospital stay, use any music players with headphones / earphones

2. Identify/evaluate current music therapy programs and organizations for acute care patients.

Through an extensive environmental scan of Great Toronto Area, the current music therapy programs mainly focus on palliative care, nursing home, rehabilitation, mental disease, and pediatric. No adult acute care setting has adopted music therapy in Toronto hospitals from my environmental scan. Details on the current music therapy programs and organizations have been presented to my mentors and unit committees in both written and verbal forms.

3. Implement music therapy based on the best-evidenced practice.

Patients were recruited in the pre-admission hip/knee surgery preparation class. (Details please see Music Therapy – A complementary pain intervention report).

4. Evaluate outcomes and findings.

The results have shown that the mean score of pain level decreased 15% after music therapy, and the pain management satisfaction score is 100% for the music project group - an increase of 14.6% in comparison with the most recent NRC Picker result of the same unit.
This pilot project has demonstrated a positive result of music therapy in reducing pain for postoperative orthopedic patients on 11 North. Both pain scores and patient satisfaction scores substantially improved. In addition, the methods to carry out the music therapy were best evidence-based and were adapted for the current resources and practices of the unit. The project has received positive feedback and comments from both participants and nurses on the unit.
Music listening is a simple, inexpensive, and side effect free intervention which can be easily provided. The Fellow and her mentors recommend music therapy to be used to enhance postoperative pain management.

5. Create a plan on how to disseminate findings in my unit, hospital pain committee, and other units with interests.

Several action plans are underway: A poster highlighting the project’s process, findings, and recommendations is to be posted in the unit in the week of November 17. A third presentation based on the poster is to give in unit meeting in the same week (Previously, two presentations on the literature best evidence, theory of the causal mechanism of music analgesia effect, and project progress have been presented in unit meeting and unit council meeting respectively). A second presentation will be given in the next meeting of the hospital-wise Pain BPG Committee, currently scheduled in January, 2015. (The first presentation regarding introduction of music therapy in 11 North was conducted in the middle of the project to the Pain BPG Committee in the Mid October). In order to spread the information to patients who are going to have surgery, PTs and OTs who are conducting the pre-admission pre-class will be invited and requested to distribute the best practice information sheet on music listening to the patients pre-admission because they meet patients before their surgeries. The Fellow will continue to encourage patients and family members to bring in music for patients after surgery. The Fellow will encourage colleagues to do so as well to enhance patients’ pain management and quality of care.


Through this fellowship, I have become a resource nurse that can comfortably provide the knowledge and skills that are derived from the best evidence practices in the past 20 years’ literature. I have also acquired valuable experiences from implementing the best practice in a post-operative orthopedic acute care setting. My literature critique skills have largely improved through the use of AGREE II (RNAO) for guidelines and the critical assessment of systematic reviews and RCTs. My leadership skills and project management skills have progressed to a new level and have been tested and practiced throughout the whole project. All the learning has been made possible and highly enjoyable through the profound support and guidance from my mentors.

I have successfully achieved my learning goal – to become a better pain champion and leading resource nurse in music therapy as a complementary intervention for post-operative pain management. I felt tremendous gratitude to the unparalleled opportunity provided by this fellowship because it has given me valuable guidance through the structured application process, precious time to focus on my learning, and exceptional support from my highly skilled and experienced mentors. It has provided a safe, autonomous, and exceptional supportive environment for me to thrive in my learning and its implementation, which in turn will benefit both my future practice and the clinical setting I am working in.

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