Developing An Evidence Based Study Into Postoperative Pain

Developing An Evidence Based Study Into operative vexationIn spite of recent advances in b naked(prenominal)ation in the ass wariness, surgical agony still remains a major clinical problem (Gilmartin and Wright, 2007 Manias et al., 2005 vocalizer et al., 2010) with most 69% of patients experiencing lower to severe torment subsequently procedure (Apfelbaum et al., 2003).Postoperative spite, although expected is an undesirable experience after surgery (Good, 1995 Rosenquist and Rosenberg, 2003). When left(p) untreated or inadequately managed, it bay window negatively mend an individuals physical, moral and social easily being (Vaughn, Wichowski and Bosworth, 2007). Thus, it generates excess responsibilities for the wellnessc atomic number 18 provider (Wilto a great extent and Kehlet, 2001) as well as creating economic difficulties for ones family, society and the nation at prominent (Vaughn et al., 2007).Pharmacological preventives devote been calld as the ma instay in the worry of postoperative ailfulness (Dolin, 2002). However, these discourses atomic number 18 non without undesirable effects much(prenominal)(prenominal) as na affaira, vomiting, dizziness, drowsiness and allergic reactions (Koch et al., 1998). Analgesic techniques for perioperative distressingness relief argon consequently, being challenged by an ever-increasing demand for complementary and holistic therapies (McCaffrey and Locsin, 2002). Thus, some(prenominal) non-drug techniques can be apply as adjuncts in managing postoperative throe (Good et al., 2005).The role of medicinal drug as a nonpharmacological technique has prompted unhomogeneous look studies in the force field of postoperative aggravator foc utilize (Ikonomidou et al., 2004). Resultantly, several studies arrive been make on this issue hitherto, these discombobulate produced contradictory findings (Anderson et al., 2005 Good et al., 2001, 2002, 2005 Heiser et al., 1997 Heitz et al., 1992 Ikonomidou et al., 2004 Nilsson et al., 2001, 2003 Taylor et al., 1998).In an guarantee to find solutions to the efficiency of medicament as a anguish oversight intervention, an increasing number of taxonomic refreshs (Cepeda et al., 2006 Dunn, 2004 Engwall and Duppils, 2009 Evans, 2002 Nilsson, 2008) have been published during the past years. Nonetheless, the conclusions from these studies whitethorn be questionable for various reasons such as vile methodological case of included studies, limited search strategies, inclusion body of studies from only create countries and being overaged.With the evolvement of recent studies ( tout ensemblered, Boyers and Sole, 2009 Cooke et al., 2010 Ebneshahidi and Mohseni, 2008 Good and Ahn, 2008 Hook, Sonwathana and Petpichetchian, 2008 Sen et al., 2009) which continuously delineate conflicting findings and the flaws identify in previous review articles, this issue involves to be addressed in a more rigorous manner.The aim of thi s dissertation is to as legitimate the talent of medical specialty as a postoperative pain heed intervention by magisterialally reviewing the available literature. With the aid of the turn up from already alert literature, this dissertation crown commence with the rationale for the proposed systematic review and exculpation of the review question. In the subsequent chapter, the systematic review methodology willing be explored together with the justification for the main decisions of the review. pursuit this, the dissolvers of the proposed review will be presented in the next section. This will be followed by discussions and conclusions on the review. Finally, I will reflect on the learning achieved through the systematic review dish and the implications of the ingest findings for clinical practice, investigate and education.Literature roundA review of the literature identifies the trends, strengths and limitations of the methodological approaches of a study (Dunn, 2 004). Thus, it provides an orientation to the known and unknown aspects of a subject ara (Blaxter et al., 1996 Parahoo, 1997 Polit et al., 2001) and directs future studies (Stevens, 1993).In this section, the rationale and justification of the review question will be provided pursuit the background in constructation and literature on the mapping of medicament in managing postoperative pain.Epidemiology of Postoperative PainIt has been estimated that more than 73 million surgeries are performed every year in the United States (Apfelbaum et al., 2003). Apparently, the tissue rail at and trauma cause during surgery results in acute postoperative pain which whitethorn vary in intensity from mild to excruciating pain (Hutchison, 2007). new- do studies indicate that effective pain anxiety remains elusive for a significant proportion of surgical patients (Dolin, Cashman and Bland, 2002 Svensson, Sjostrom and Haljamae, 2000 Werner et al., 2002). Many of them continue to experience u ndiminished postoperative pain (Backstrom and Rawal, 2008) despite years of query into pain and its management (Botti, Bucknall and Manias, 2004 Hutchison, 2007). This whitethorn be partly ascribable to the insufficient training legitimate by health treat professionals on pain management (American Medical Association, 2010). In addition, many patients have authentic the notion that acute postoperative pain is to be expected during hospitalisation. Thus, the endpoint effect is the widespread poor management of postoperative pain (Warfield and Kahn, 1995).The ineffective management of postoperative pain has been highlighted in the literature (Abbott et al., 1992 Bostrom et al 1997 Donovan et al. 1987). A survey beamed by Oates et al. (1994) revealed that 34% of the 206 patients experient moderate to severe pain postoperatively. Conclusions from the interior(a) Health and Medical explore Councils (1999) report as well depicted that about 75% of patients undergo moderate to severe postoperative pain. An inquiry made by Watt-Watson and colleagues too channeliseed that 51% of 225 postoperative patients following cardiac surgery reported of severe pain (Watt-Watson et al., 2000). Moreover, a random national study conducted by Apfelbaum and co-workers illustrated that out of the 80% of patients who reported of postoperative pain, 86% of them were experiencing moderate to severe pain (Apfelbaum et al., 2003). All these continuous reports of moderate to severe postoperative pain draw circumspection to the inadequacies in pain management (McCaffery Ferrell, 1997). This is because patients ofttimes underestimate their pain due(p) to their high expectations regarding postoperative pain experience (Hutchison, 2007).Some clinicians and patients too have mis archetypeions about the use of opioid analgesics which contri plainlye to the inadequate postoperative pain management (McCaffery and Ferrell, 1991). Other factors also include the type of surgery (Rai, 1993), patients gender, age, preoperative pain and mental factors (Bisgaard et al., 2001 Edwards et al., 2004 Granot and Ferber, 2005).Potentially, technical difficulties with intravenous (I.V.) access lines and patient- cut backled analgesia (PCA) devices also divine service as contributory factors (Wickstrom, Nordberg and Johansson, 2005). Pharmacokinetic and pharmacodynamic factors whitethorn also affect postoperative analgesia (). *A meta-analysis comparing the incidence of pain following three analgesic techniques I.M. analgesia, PCA, and extradural analgesia after surgery was conducted by Dolin et al. (2002). Data stratification establish on the drug administration route revealed that the proportion of patients with moderate-to-severe postoperative pain was highest in I.M. opioid administration group era this was lowest in the epidural anesthesia opioid group.In recent times, pain management is gaining increasing attention among healthcare providers and professional bodies (Hutchison, 2007). Thus, January 1, 2001 was declared during a United States congress as the commencement of a decade of pain control and research (American honorary society of Pain Medicine, 2010). Furthermore, the American Pain smart set (APS) presently urges clinicians to consider pain as the fifth vital sign (Loeser, 2003). This initiative has stimulated more interest and attention to the management of pain. As a consequence of that, several professional and regulatory bodies have recently produced guidelines for managing postoperative pain (American Society of Anaesthesiologists, 2004 American Pain Society, 2003 European Association of Urology, 2003 Veterans Health Administration and section of Defense, 2002 Joint Commission on Accreditation of Healthcare Organisations, 2001).Definition of Postoperative PainThe concept of pain has been a subject for discussion since antiquity. A universally accepted definition of pain is an unpleasant sensory and emotional experience associa ted with material or potential tissue damage described in ground of such damage (IASP, 1979 250). This definition emphasises on the subjective nature of the pain experience which can be twined by multiple factors (IASP, 2003). As a result of this, McCaffery (1983 14) defines pain as whatever the experiencing person says it is, existing whenever she says it does.Postoperative pain is thusly, defined as an acute form of pain which is experienced after surgery (Fine and Portenoy, 2007).Impact of Inadequate Postoperative Pain abatementUnrelieved postoperative pain can be detrimental to the physiological, psychological and sociological health of patients (Reyes-Gibby, 2002 Strassels, 2000 Vaughn et al., 2007). These negative consequences are derived from various body systems such as the cardiovascular, respiratory, gastrointestinal, renal, neuroendocrine and the autonomic nervous systems (Duggleby and Lander, 2004 Tulay, 2010).Physically, longer periods of unrelieved postoperative p ain can result in physiologic alterations which include the arousal of the pituitary-adrenal system (Yeager et al., 1987), sympathetic nervous system (Pasero, Paice and McCaffery, 1999) and restricted mobility (Yeager et al., 1987 Murray, 1990) which may result in cardiovascular, gastrointestinal and renal changes (Puntillo and Weiss, 1994 McCaffery and Pasero, 1999). All these changes in a postoperative may serve as a risk factor for the training of adverse effects such as deep vein thrombosis, pulmonary embolism, pneumonia (APMGP, 1992), coronary ischaemia, myocardial infarction (APMGP, 1992 Jacox et al., 1994 Puntillo and Weiss, 1994 Staats, 1998 McCaffery and Pasero, 1999), reduced immunity (Ikonomidou et al., 2004), poor wound improve (Shang and Gan, 2003) and chronic pain. Psychologically, unrelieved postoperative pain may result in stress, anxiety, depression and demoralisation (Murray, 1990).In addition, the under sermon of postoperative pain has potential negative conse quences for health systems (Hutchison, 2007). This includes extended periods of hospitalisation (Heiser et al, 1997 Miaskowski, 1993), readmissions (Ikonomidou et al., 2004) and patient dissatisfaction (Shang, 2003). As a result of this, additional responsibilities are placed on the healthcare provider which may lead to staff exhaustion and its resultant put leaves (Wilmore and Kehlet, 2001). Subsequently, these may increase the boilers suit costs of hospitalisation and place health systems at a deprived position, especially in todays competitive healthcare environment (Henry, 1995). Ultimately, these negative consequences have a enormous impact on the patients family, society and the nation at with child(p) (Vaughn et al., 2007).Pain ManagementThe importance of addressing the complex issues of pain management cannot be overemphasized (Botti, Bucknall and Manias, 2004). Apart from lessen unnecessary suffering, effective pain control improves patient outcomes (Wasylak et al., 199 0 Watwill, 1989 Sydow, 1989) and enhances their quality of life (Goudas, 2001 Reyes-Gibby, Aday and Cleeland, 2002 Rogers et al., 2000a Rogers et al., 2000b Strassels, Cynn and Carr, 2000). It is generally accepted that needless suffering from pain in any patient is unethical (Sderhamn and Idwall, 2003) and illustrates a betrayal of the healthcare professionals commitment to serve valetity (Ikonomidou et al., 2004). This is because patients are entitled to good quality care (Rawal, 1999 Idwall, 2004). Important goals for postoperative pain management are in that locationfore to hike up comfort, quicken recovery and avoid complications (Ready and Edwards, 1992).Pharmacological interventions have been utilise as the mainstay in managing postoperative pain (Dolin, 2002). Nevertheless, these interventions are not without unwanted adverse effects such as nausea, vomiting, dizziness, drowsiness, and allergic reactions (Koch et al., 1998). Thus, nonpharmacological methods have been ut ilise as adjuncts in the treatment of postoperative pain (Ready and Edwards, 1992).*corporate trust pharmacologic and nonpharmacologic methods of pain provides effective pain relief for the patient (McCaffery, 1990). Thus, the carry may make a significant contribution to postoperative pain management by offering the patient various non-drug techniques that can be used concurrently with analgesics (McCaffery, 1990 McCaffery and Beebe, 1989).Nonpharmacologic interventions have been known to be valuable, simple and nickel-and-dime(prenominal) adjuvants to analgesic techniques (Hyman et al., 1989). As a result, several non-drug techniques can also be used as adjuncts in managing postoperative pain (Good et al., 2005). Specifically, the use of euphony as a nonpharmacological technique has prompted various research studies in this area (Ikonomidou et al., 2004), leading to the publication of numerous studies (Anderson et al., 2005 Good et al., 2001, 2002, 2005 Heiser et al., 1997 Heit z et al., 1992 Nilsson et al., 2001, 2003 Taylor et al., 1998) and reviews (Cepeda et al., 2006 Dunn, 2004 Engwall and Duppils, 2009 Evans, 2002 Nilsson, 2008).History of Music TherapyMusic, as a remedy for wildness is a prehistoric concept (Todres, 2006) that has been used to influence piece health (Bunt, 1994 Nilsson, 2003 White 2000).It is the art of listening to safes that commonly have rhythm, pitch (Funk and Wagnall, 1998), melody and harmony (Steckler, 1998). Throughout history, harmony has been used as an alternative therapy to publicize the social welfare of patients (Guzzetta 1988). Thus, music therapy can be defined as the act of using melodic sounds to defend the physical, psychological and social needs of an individual during illness or disability (Aluede, 2006 sake and Mount, 1978). Its main goal is to promote comfort by serving as a diversionary measure from an unpleasant occurrence (Nwokenna, 2006).Archaelogical findings reveal that the sick primitive man u sed music as a modality of pacifying the idols (Henry 1995). Also, the Egyptians of 1500 BC used music to enhance their fruitfulness while the Greeks and Romans strove for human body and soul integration using music (Buckwalter, Hartsock and Gaffney, 1985). Thus, Apollo, the Greek god of mythology, was considered as the giver of medicine and music (Todres, 2006).There is anecdotal evidence from contemporary writings that music was used by Hippocrates to promote wellbeing (Storr, 1994). The sixth century Greek philosopher, Pythagoras, who is considered as the founder of music therapy and geometry, believed that music greatly influenced human health (Olson 1998). As a result, he often prescribed music and diet to reinstate and sustain the integration human body and soul (Bunt, 2001 White 2001).Also, it was demonstrated by the Renaissance tendency group that different types of music affected digestion, blood pressure, respiratory and amount of money rates (Cook, 1986). In a nameles s article that appeared in the Columbian Magazine in 1789, a case was made for the use of musical experiences to influence and regulate emotional conditions (White 2000). Subsequently, a book entitled the influence of music on health and life, which describes the use of music in healing, was write by Chomat in 1846 (Biley, 2000).From a nurse perspective, music has been used to promote patients health and well-being (Chlan, 2002). In the early 1800s, Florence Nightingale noticed the forcefulness of music as a vital part of the healing process for injured Crimean soldiers (Nightingale, 1992). After observing different types of music, she remarked that wind instruments with continuous sound or air created a positive effect on patients while those that lacked continuous harmony produced negative effects (Nightingale 1992, McCaffrey and Locsin 2002). Nightingale believed that, it was the nurses responsibility to control the environment for healing to take place (Nilsson, 2003 White, 2 001 McCaffrey and Locsin, 2002 Nightingale, 1992).After the invention of the record player in the late 1800s, recorded music was used in hospitals to promote sleep and relieve perioperative anxiety (Taylor, 1981). An extensive account of this occurred when healthcare professionals concurrently used music with analgesia and anaesthesia (ibid).In 1914, music was used for the prototypal time in the intraoperative environment to distract patients from the horror of surgery (Kane, 1914 p.1829). Afterwards, the National Association for Music in Hospitals was established in 1926 by a nurse named, Isa Maud Ilsen (Ilsen, 1926). After identifying rhythm as the basic therapeutic element, she advocated for the slaying of specific musical prescriptions (Ilsen 1926).An extensive study on music was made by Hunter, in 1892, after playing a piano in the Helensburg Hospital, Scotland. He noticed that there was a reduction in the patients report of pain and temperature following musical exposure (Hun ter, 1892). An observation made by Coring (1899) and Tarchanoff (1903) also revealed that different types of music had an effect on the patients heart rate, external respiration and bodily secretions (Light et al 1949). Also, a group of surgeons in 1949 studied the use of music together with psychosomatic factors. They discovered that music had a tranquilize effect on those patients who were anxious and unresponsive to routine medication (ibid).With the orgasm of the technological advancements of the twentieth century, the link among health and music declined (Heitz, Symreng and Scamman, 1992). However, there has been an upsurge interest in music therapy due to its prominence in pain management (McCaffery, 1979) Thus, it is considered as a vital aspect of the nursing discipline (Paterson and Zderad, 1988).The Analgesic Properties of MusicThe mechanism by which music affects pain responses appears to be as varied as the research paradigms (Pricket and Standley, 1994). Music has be en shown to affect the physical, emotional, cognitive and social aspects of the pain experience (Todres, 2006). *Thus, the question is how does music defend its analgesic properties? In the search for answers to this query, various theories and hypotheses have been proposed (Gagner-Tjellesen et al., 2001).The auditory stimulus of music produces a biological effect on human demeanor by engaging specific brain functions (Thaut 1990). The effect of music is comprehend in the right hemisphere of the brain (Thaut 1990, Ligeois-Chauvel et al., 1998, Myskaja and Lindbaeck, 2000), whereas a greater portion of interpretation occurs in the left hemisphere (Thaut 1990, Myskaja and Lindbaeck, 2000).Music stimuli serve as a distraction (Good et al., 2000 McCaffery and Good, 2000) and cause the prefrontal cortex to be conditioned to the music, which is more pleasant, (Nilsson, 2008), familiar, relaxing (Mok and Wong, 2003) and preferred (Siegele, 1974 McCaffery, 1992 Mok and Wong, 2003). Pati ents can thus, focus their sense from the noxious input unto the music (Fernandes and Turk, 1989 Good et al., 1999 Willis, 1985) to aid relaxation (Beck, 1991 White, 2000 White, 2001 Thorgaard, 2005). Although patients are often in a transitional zone between instinct and sleep during the perioperative period, the sense of hearing still persists amidst the impairment of former(a) senses (Nilsson, 2003). As a result, music may be of immense benefit to this population.The ban of the afferent noxious impulses causes the activation of *endogenous opiates, descending nerve impulses, and neuropeptides in the in the central nervous system (Andy, 1983 Yezierski et al., 1983). Subsequently, excitatory neurotransmitters such as substance P, prostaglandins, bradykinins are inhibited leading to reduced muscle and mental tension (Good, 1995 OCallaghan, 1996 Taylor et al., 1998).On the contrary, it has also been demonstrated that music, which is inappropriately used, can exasperate pain sensa tion and thus can increasing pain knowledge and experience (OCallaghan, 1996).The Ghanaian ContextDespite the fact that 3.5% of the worlds surgical trading operations are performed in developing countries (Weiser, Regenbogen, Thompson et al., 2008), the management of postoperative pain is poor in Ghana (Clegg-Lamptey and Hodasi, 2005 Murthy, Antwi-Kusi, Jabir et al., 2010). This may be due to factors such as inadequate knowledge, negative attitudes (Hall-Lord and Larsson, 2006), discrepancies between healthcare professionals and patients assessment of postoperative pain and the lack of relatively efficient analgesic techniques such as PCAs and epidural analgesia (Murthy et al., 2010). Moreover, the use of non-invasive, safe and cheap nonpharmacological interventions such as music is also underutilised.Music plays a vital role in the life of an African however, the origin of music therapy in African societies remains a stir up due to the lack of indigenous written records (Aluede, 2006). Although, many Ghanaians love music (FGMSA, 2010), music therapy in Ghana is currently at its embryonic re-create (Kofie, 2004).Music, as the *stock-in-trade of traditional healers is used in the Ghanaian society. It accompanies their set of dances until they get the semi-conscious state whereby they begin their communication with ancestral spirits. During this enterprise, music stimulates their ecstasy and they are being offered concoctions that may be used in healing the sick (Kofie, 2004). Music is also an effective form of therapy for patients who believe their ailments is a form of misdemeanour towards others and for that manner receiving punishment from the ancestral spirits (ibid).Rationale for the Proposed look backThe use of music as a postoperative pain intervention has prompted various research studies (Ikonomidou et al., 2004), leading to the publication of numerous articles (Anderson et al., 2005 Good et al., 2001, 2002, 2005 Heiser et al., 1997 Heitz et al., 1992 Ikonomidou et al., 2004 Nilsson et al., 2001, 2003 Taylor et al., 1998). Nevertheless, these studies have reported mixed/ contradictory/ conflicting findings. While some show improved pain relief (Anderson et al., 2005 Good, 1999 Good et al., 2001 Good et al., 2002 Good et al., 2005 Heitz et al., 1992 Laurion and Fetzer, 2003 Masuda, Miyamoto, and Shimizu, 2005 McCraty et al., 1998 Mullooly et al., 1988 Nilsson et al., 2001 Nilsson et al., 2003), others showed no difference in pain management among study participants (Blankfield et al., 1995 Good, 1995 Heiser et al., 1997 Ikonomidou et al., 2004 Taylor et al., 1998). The approaches used in these studies have mainly been experimental, however, most of them lack strict control with various outcome measures ranging from psychological (pain, anxiety), physical (sleep) to physiological parameters (heart rate, respiratiory rate, blood pressure).In an seek to find solutions to the efficiency of music as a pain management interventio n, an increasing number of systematic reviews (Cepeda et al., 2006 Dunn, 2004 Engwall and Duppils, 2009 Evans, 2002 Nilsson, 2008) have been published during the past years. Nonetheless, the conclusions from these studies may not be fully support for various reasons such as poor methodological quality of included studies, limited search strategies, inclusion of studies from only unquestionable countries and being out erad.Evans (2002) conducted a systematic review on the efficacy of music as an intervention for hospitalised patients. This review included postoperative pain as well as pain occurring after certain procedures. Of the four eligible studies, three of them found no difference in pain scores and analgesic consumption (Blankfield et al., 1995 Good, 1995 Taylor et al., 1998) while the remaining study (Koch et al., 1998) reported a reduction in analgesic consumption among the music intervention group. On this basis, he reason out that music may be an effective diversion in treating pain. This assumption may be obstructive due to limited evidence as at that time and its resultant myopic inference.A systematic review conducted on the efficiency of music in reducing postoperative pain (Dunn, 2004) was also inconclusive due to the poor methodological quality of the included studies. Moreover, it was also restricted to developed countries such as the United Kingdom and the United States of America. For this reason, such findings may not be applicable to other developing countries such as Ghana, where the clinical settings and management may be different.Cepeda et al. (2006) systematically reviewed the literature on the use of music for relieving pain. This review included all types of pain ranging from acute, procedural, crab louse and chronic pain. It was concluded that music listening reduces pain and analgesic consumption, but the magnitude of these effects is small and thus, had vague clinical significance. Based on this premise, it was recommended t hat music should not be used as a origin line management option for pain. Although the conclusions are quiet reasonable, this review is outdated (Kaveh et al., 2007) due to the publication of new studies that specifically report on the use of music in patients experiencing postoperative pain.Another systematic review (Nilsson, 2008) was also conducted on the efficacy of music in relieving postoperative pain and other parameters such as anxiety and stress. This review limited the inclusion criteria to studies conducted between 1995 and 2007. The review concluded that approximately half of the reviewed randomised controlled trials favoured the pain reducing effects of music while the rest were not in support of this. In the light of this, the author recommended some additional studies to be conducted in this area ibid.A recently published article in 2009 concluded that music can be used as an adjuvant for pain relief (Engwall and Duppils, 2009). This conclusion may not be fully suppo rted considering the fact that the review included other non-randomised controlled trials (which are subject to biases). Moreover, the review included the combined use of music with other nonpharmacological interventions (such as claver relaxation, therapeutic suggestion, guided imagery and so on) which creates difficulties in determining whether the outcomes is totally due to music or the other interventions. The review also used few databases (Blackwell Synergy, CINAHL, PubMed and Elsevier/ Science Direct) and restricted the review to studies conducted between 1998 and 2007.Considering the publication of new randomised controlled trials that have reported conflicting findings (Allred, Boyers and Sole, 2009 Cooke et al., 2010 Ebneshahidi and Mohseni, 2008 Good and Ahn, 2008 Hook, Sonwathana and Petpichetchian, 2008 Sen et al., 2009) and the limitations identified in previous reviews, an updated version of a systematic review conducted on this way out will be of immense benefit. My review, thereof intends to include randomised controlled trials disregardless of the location, and will include only music as the nonpharmacological pain intervention. I will also expand my search strategy to include other databases and will not limit it to any year range since music is not an intervention that becomes outmoded with time and largely depends on an individuals preferences. sum-upIn this section the background information and literature on the use of music in relieving postoperative pain has been provided. Moreover, the rationale for the systematic has been well explained as well as the justification for the review question.Chapter Two methodologyOnce a research question has been shaped, it is useful to think about its type, as this will have an effect on what kind of research would provide us with the greatest quality evidence. The review question concentrates on music as a postoperative epain management intervention for patients after all kinds of surgery.In pr oviding the best evidence of effectiveness of an intervention, a systematic review is considered the most suitable way. This is because it summarises or draw conclusions from primary research on a specific subject, therefore increasing the number of subjects and enhancing the superpower to detect an intervention effect (Dickson, 2003).This chapter will discuss the systematic review approach and evaluate its role in evidence-based practice. It then outlines the strengths and limitations of systematic reviews. Following this, a description of the procedural steps is given. Finally, the method used to conduct this review is discussed.lDefinition of doctrinal ReviewsTypes of Systematic ReviewsSystematic Reviews growthThe Role of Systematic Reviews in Evidence-based PracticeIn an era of evidence-based nursing, care providers need to base their clinical decisions on the preferences of patients, their clinical expertise, as well as the current best available research evidence relevant f or practice (Beaven and McHugh, 2003 Mulhall, 1998 Sackett and Rosenberg, 1995).Implications from the ever expanding volumes of healthcare literature (Beaven and McHugh, 2003) means that, it is impossible for a clinician to access, let alone understand, the primary evidence that informs practice (Glasziou, Irwig and Colditz, 2001 Handoll et al., 2008). As a result of this, useful research studies and valuable findings are concealed and creaky as a whole (Beaven and McHugh, 2003). Systematic reviews of primary studies are therefore an essential aspect of evidence-based healthcare for practitioners who want to keep up to date with evidence in making informed clinical decisions (Lipp, 2005 Glasziou et al., 2001 Handoll et al., 2008 Schlosser/ FOCUS, 2010).Commencing with a unclouded research question, such reviews utilise explicit methods to systematically identify, select, critically appraise, extract, study and synthesise data from relevant studies on a particular musical theme ( Handoll et al., 2008 Petticrew and Roberts, 2006 Wright et al., 2007 Sackett et al., 2000). This process helps to minimise bias (Cook, Mulrow and Haynes, 1997), eliminate poorly conducted studies, confers power to the results that may not be given to individual studies (Lipp, 2005) and thus provide practitioners with reliable, effectual and condensed evidence (Glasziou et al., 2001) in a considerably shorter period of time (Mulrow, Langhorne, and Grimshaw, 1997). Systematic reviews may involve the use of statistical methods (meta-analysis) (Handoll et al., 2008) in estimating the precision of treatment effects (Egger, Smith and ORourke, 2001).Unlike traditional narrative reviews, systematic reviews part with for a more objective appraisal of the evidence and may thus contribute to resolving uncertainty when original research, and reviews disagree (Egger et al., 2001). By using an efficient scientific technique, systematic reviews also can counteract the need for further research s tudies and stimulate the timelier implementation of findings into practice (Lipp, 2005). They can also inform the research agenda by identifying gaps in the evidence and generating research questions that will shape future research (Eagly and Wood, 1994 Handoll et al., 2008 Lipp, 2005).