Developing An Evidence Based Study Into Postoperative Pain

Developing An Evidence Based Study Into Postoperative Pain In spite of recent advances in pain management, postoperative pain still remains a major clinical problem (Gilmartin and Wright, 2007; Manias et al., 2005; Singer et al., 2010) with about 69% of patients experiencing moderate to severe pain after surgery (Apfelbaum et al., 2003). Postoperative pain, although expected is an undesirable experience after surgery (Good, 1995; Rosenquist and Rosenberg, 2003). When left untreated or inadequately managed, it can negatively affect an individuals physical, psychological and social well being (Vaughn, Wichowski and Bosworth, 2007). Thus, it generates additional responsibilities for the healthcare provider (Wilmore and Kehlet, 2001) as well as creating economic difficulties for ones family, society and the nation at large (Vaughn et al., 2007). Pharmacological interventions have been used as the mainstay in the management of postoperative pain (Dolin, 2002). However, these interventions are not without undesirable effects such as nausea, vomiting, dizziness, drowsiness and allergic reactions (Koch et al., 1998). Analgesic techniques for perioperative pain relief are therefore, being challenged by an ever-increasing demand for complementary and holistic therapies (McCaffrey and Locsin, 2002). Thus, several non-drug techniques can be used as adjuncts in managing postoperative pain (Good et al., 2005). The use of music as a nonpharmacological technique has prompted various research studies in the area of postoperative pain management (Ikonomidou et al., 2004). Resultantly, several studies have been published on this issue; hitherto, these have 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 attempt to find solutions to the efficiency of music as a pain management intervention, 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 be questionable for various reasons such as poor methodological quality of included studies, limited search strategies, inclusion of studies from only developed countries and being outdated. With the evolvement of recent studies (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) which continuously report conflicting findings and the flaws identified in previous reviews, this issue needs to be addressed in a more rigorous manner. The aim of this dissertation is to ascertain the efficacy of music as a postoperative pain management intervention by systematically reviewing the available literature. With the aid of the evidence from already existing literature, this dissertation will commence with the rationale for the proposed systematic review and justification of the review question. In the subsequent chapter, the systematic review methodology will be explored together with the justification for the main decisions of the review. Following this, the results 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 process and the implications of the study findings for clinical practice, research and education. Literature Review A review of the literature identifies the trends, strengths and limitations of the methodological approaches of a study (Dunn, 2004). Thus, it provides an orientation to the known and unknown aspects of a subject area (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 following the background information and literature on the use of music in managing postoperative pain. Epidemiology of Postoperative Pain It has been estimated that more than 73 million surgeries are per ­formed every year in the United States (Apfelbaum et al., 2003). Apparently, the tissue damage and trauma caused during surgery results in acute postoperative pain which may vary in intensity from mild to excruciating pain (Hutchison, 2007). Recent studies indicate that effective pain management 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 unrelieved postoperative pain (Backstrom and Rawal, 2008) despite years of research into pain and its management (Botti, Bucknall and Manias, 2004; Hutchison, 2007). This may be partly due to the insufficient training received by healthcare professionals on pain management (American Medical Association, 2010). In addition, many patients have accepted the notion that acute postoperative pain is to be expected during hospitalisation. Thus, the resultant 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 conducted by Oates et al. (1994) revealed that 34% of the 206 patients experienced moderate to severe pain postoperatively. Conclusions from the National Health and Medical Research Councils (1999) report also depicted that about 75% of patients experienced moderate to severe postoperative pain. An inquiry made by Watt-Watson and colleagues also showed 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 attention to the inadequacies in pain management (McCaffer y Ferrell, 1997). This is because patients often underestimate their pain due to their high expectations regarding postoperative pain experience (Hutchison, 2007). Some clinicians and patients also have misconceptions about the use of opioid analgesics which contribute 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 psychological factors (Bisgaard et al., 2001; Edwards et al., 2004; Granot and Ferber, 2005). Potentially, technical difficulties with intravenous (I.V.) access lines and patient-controlled analgesia (PCA) devices also serve as contributory factors (Wickstrom, Nordberg and Johansson, 2005). Pharmacokinetic and pharmaco ­dynamic factors may also affect postoperative analgesia (). *A meta-analysis comparing the incidence of pain following three analgesic techniques: I.M. analgesia, PCA, and epidural anal ­gesia after surgery was conducted by Dolin et al. (2002). Data stratification based on the drug administration route revealed that the pro ­portion of patients with moderate-to-severe postoperative pain was highest in I.M. opioid administration group while this was lowest in the epidural 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 Academy of Pain Medicine, 2010). Furthermore, the Ameri ­can Pain Society (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 As ­sociation of Urology, 2003; Veterans Health Administration and Department of Defense, 2002; Joint Commis ­sion on Accreditation of Healthcare Organisations, 2001). Definition of Postoperative Pain The concept of pain has been a subject for discussion since antiquity. A universally accepted definition of pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage described in terms of such damage (IASP, 1979: 250). This definition emphasises on the subjective nature of the pain experience which can be influenced 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 thus, defined as an acute form of pain which is experienced after surgery (Fine and Portenoy, 2007). Impact of Inadequate Postoperative Pain Relief Unrelieved 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 pain can result in physiologic alterations which include the stimulation 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 development of adverse effects such as deep vein thrombosis, pul ­monary embolism, pneu ­monia (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 healing (Shang and Gan, 2003) and chronic pain. Psychologically, unrelieved postoperative pain may result in stress, anxiety, depression and demoralisa ­tion (Murray, 1990). In addition, the undertreatment of postoperative pain has potential negative consequences 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 sick leaves (Wilmore and Kehlet, 2001). Subsequently, these may increase the overall costs of hospitalisation and place health systems at a disadvantaged position, especially in todays competi ­tive healthcare environment (Henry, 1995). Ultimately, these negative consequences have a enormous impact on the patients family, society and the nation at large (Vaughn et al., 2007). Pain Management The importance of addressing the complex issues of pain management cannot be overemphasized (Botti, Bucknall and Manias, 2004). Apart from reducing unnecessary suffering, effective pain control improves patient outcomes (Wasylak et al., 1990; 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 (Sà ¶derhamn and Idwall, 2003) and illustrates a betrayal of the healthcare professionals commitment to serve humanity (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 therefore to promote comfort, quicken recovery and avoid complications (Ready and Edwards, 1992). Pharmacological interventions have been used 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 used as adjuncts in the treatment of postoperative pain (Ready and Edwards, 1992). *Combining pharmacologic and nonpharmacologic methods of pain provides effective pain relief for the patient (McCaffery, 1990). Thus, the nurse 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 inexpensive 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 music 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; Heitz 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 Therapy Music, as a remedy for sickness is a prehistoric concept (Todres, 2006) that has been used to influence human health (Bunt, 1994; Nilsson, 2003; White 2000). It is the art of listening to sounds that usually have rhythm, pitch (Funk and Wagnall, 1998), melody and harmony (Steckler, 1998). Throughout history, music has been used as an alternative therapy to promote the wellbeing of patients (Guzzetta 1988). Thus, music therapy can be defined as the act of using musical sounds to support the physical, psychological and social needs of an individual during illness or disability (Aluede, 2006; Munro 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 used music as a way of pacifying the gods (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 movement group that different types of music affected digestion, blood pressure, respiratory and heart rates (Cook, 1986). In a nameless 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 written by Chomat in 1846 (Biley, 2000). From a nursing perspective, music has been used to promote patients health and well-being (Chlan, 2002). In the early 1800s, Florence Nightingale noticed the power 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, 2001; McCaffrey and Locsin, 2002; Nightingale, 1992). After the invention of the phonograph 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 first 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 implementation 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 (Hunter, 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, 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 calming effect on those patients who were anxious and unresponsive to routine medication (ibid). With the advent of the technological advancements of the twentieth century, the link between 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 Music The mechanism by which music affects pain responses appears to be as varied as the research paradigms (Pricket and Standley, 1994). Music has been shown to affect the physical, emotional, cognitive and social aspects of the pain experience (Todres, 2006). *Thus, the question is: how does music exert 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 stimulation of music produces a biological effect on human behaviour by engaging specific brain functions (Thaut 1990). The effect of music is perceived in the right hemisphere of the brain (Thaut 1990, Lià ©geois-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). Patients can thus, focus their awareness 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 consciousness and sleep during the perioperative period, the sense of hearing still persists amidst the impairment of other senses (Nilsson, 2003). As a result, music may be of immense benefit to this population. The inhibition 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 aggravate pain sensation and thus can increasing pain perception and experience (OCallaghan, 1996). The Ghanaian Context Despite the fact that 3.5% of the worlds surgical 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 puzzle 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 stage (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 reach 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 Review The 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 lac k strict control with various outcome measures ranging from psychological (pain, anxiety), physical (sleep) to physiological parameters (heart rate, respiratiory rate, blood pressure). In an attempt to find solutions to the efficiency of music as a pain management intervention, 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 supported for various reasons such as poor methodological quality of included studies, limited search strategies, inclusion of studies from only developed countries and being outdated. 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 concluded 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, cancer 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 that music should not be used as a first 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 supported 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 jaw relaxation, therapeutic suggestion, guided imagery and so on) which creates difficulties in determining whether the outcomes is solely 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 topic will be of immense benefit. My review, therefore intends to include randomised controlled trials irrespective 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. Summary In 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 thoroughly explained as well as the justification for the review question. Chapter Two Methodology Once 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 providing 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 power 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. l Definition of Systematic Reviews Types of Systematic Reviews Systematic Reviews Process The Role of Systematic Reviews in Evidence-based Practice In 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 for 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 abandoned 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 well-defined research question, such reviews utilise explicit methods to systematically identify, select, critically appraise, extract, analyse and synthesise data from relevant studies on a particular topic (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, valid 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 allow 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 studies 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).

The Supernatural in Hamlet and Macbeth Essay -- GCSE English Literatur

The Supernatural in Hamlet and Macbeth  Ã‚        Ã‚   In both Hamlet and Macbeth, the supernatural plays a very important role. Supernatural elements are crucial to the plot and they also have a more thematic part as well. Shakespeare presents the ghost in Hamlet, and the witches and ghost in Macbeth, as disrupting elements that not only enhance drama, but also tear apart the existing order of things. They force the title character of each play to undergo their own internal struggle that grows from their insecurity of living up to the image of a man.       First, let us consider Hamlet. The presence of the supernatural takes center stage at the beginning with a dramatic appearance of the ghost of Hamlet's father. Although the ghost does not speak, his presence is seen and already disrupts. It is in later in this first act where the ghost plays it's first and most crucial part. In Scene V of act I, Hamlet and his father's Ghost appear together and alone. The ghost says, "A serpent stung me, so the whole ear of Denmark/Is by a forged process of my death/Rankly abus'd"(I.v.36-38). The first seed of disrupting things (both Hamlet's identity and Denmark) is planted here. The ghost's words make it clear that his murder was not only a crime against him, but also a crime against the land.       The core of the play then unfolds from the actions and words of this ghost. Hamlet's revenge against his uncle is certainly fueled by the ghost's words, but the ghost seems to serve a more subtle and internal part here. In the famous "To be or not to be" soliloquy (III.i.55-88), Hamlet makes it clear his is not only unsure of what action to take, but unsure of himself as well. It seems his father's aberration confuses Hamlet ... ...e serves as ghosts in the machine of the character's life. And it is that which really kills them or drives them to their death in the end.    Works Cited and Consulted: Bloom, Harold. "Introduction." Modern Critical Interpretations: Hamlet. Ed. Harold Bloom. New York City: Chelsea House Publishers, 1986. 1-10. Bradley, A.C. "The Witch Scenes in Macbeth." England in Literature. Ed. John Pfordesher, Gladys V. Veidemanis, and Helen McDonnell. Illinois: Scott, Foresman, 1989. 232-233 Goldman, Michael. Critical Essays on Shakespeare's Hamlet. Ed. David Scott Kaston. New York City: Prentice Hall International. 1995. The Riverside Shakespeare: Second Edition Houghtom Mifflin Company Boston/New York   G. Blakemore Evans and J.J.M Tobin eds. Shakespeare, William. Macbeth. Edited by Norman Sanders. Cambridge: Cambridge University Press, 1984      

Chapter 2 Quiz + Answers Essay

1. When companies adopt the strategy-making and strategy execution process it requires they start by developing a strategic vision, mission and values 2. The strategic management process is shaped by external factors such as the industry’s economic and competitive conditions and internal factors such as the company’s collection of resources and capabilities 3. When a company is confronted with significant industry change that mandates radical revision of its strategic course, the company is said to have encountered a strategic inflection point 4. A company’s strategic plan consists of a vision of where it is headed, a set of performance targets, and a strategy to achieve them 5. Top management’s views about where the company is headed and what its future product-customer-market-technology will be constitutes the strategic vision for the company 6. Well-conceived visions are distinctive specific to a particular organization free of generic, feel-good statements not innocuous one-sentence statements All of these 7. Effectively communicating the strategic vision down the line to lower-level managers and employees has the value of  not only explaining â€Å"where we are going and why† but, more importantly, also inspiring and energizing company personnel to unite to get the company moving in the intended direction 8. A company’s mission statement typically addresses which of the following questions Who we are, what we do, and why we are here 9. A company’s values relate to such things as  fair treatment, integrity, ethical behavior, innovativeness, teamwork, top-notch quality, superior customer service, social responsibility, and community citizenship 10. The managerial purpose of setting objectives includes  converting the strategic vision into specific performance targets  using the objectives as yardsticks for tracking the company’s progress and performance  challenging the organization to perform at its full potential and deliver the best possible results  establishing deadlines for achieving performance results 11. A company needs financial objectives  because without adequate profitability and financial strength, the company’s ultimate survival is jeopardized 12. Strategic objectives  relate to strengthening a company’s overall market standing and competitive vitality 13. A balanced scorecard for measuring company performance entails striking a balance between financial objectives and strategic objectives 14. A balanced scorecard that includes both strategic and financial performance targets is a conceptually strong approach for judging a company’s overall performance because financial performance measures are lagging indicators that reflect the results of past decisions and organizational activities whereas strategic performance measures are leading indicators of a company’s future financial performance 15. A company needs performance targets or objectives for its operations as a whole and also for each of its separate businesses, product lines, functional departments, and individual work units 16. Business strategy concerns ensuring consistency in strategic approach among the businesses of a diversified company 17. In a single-business company, the strategy-making hierarchy consists of business strategy, functional strategies, and operating strategies 18. Functional strategies concern the actions, approaches, and practices related to particular functions or processes within a business 19. Operating strategies concern the relatively narrow strategic initiatives and approaches for managing key operating units within a business and for performing strategically significant operating tasks 20. Management is obligated to monitor new external developments, evaluate the company’s progress, and make corrective adjustments in order to decide whether to continue or change the company’s strategic vision, objectives, strategy and/or strategy execution methods

Reliable Help for Anyone Applying for a Scholarship Program

Reliable Help for Anyone Applying for a Scholarship Program There are several types of supports, but the scholarship you will get depends on how well your essay will persuade the reader. Use the wrong words, and your paper might end up in the rejection pile. But not everyone can naturally write a high-quality text that showcases your uniqueness or ability. However, if you are going to apply for an aid program, you must increase your chances of your application getting accepted by submitting flawless content. Rarely an application process will require transcripts only. You will also need a well-written content, which means that you must know how to write a good scholarship essay. One of the best ways to help your application to stand out is to understand what is a scholarship essay and read successful examples. We have been writing these types of tasks for many years hence know what to include to help your document make a lasting first impression. While we will craft the text according to your specifications, our proficient writer will include all the necessary information that will showcase who you are, what you are most passionate about and your goals. As our customer, you will also get access to various samples. Apart from crafting top-notch content, we also give tips to clients who want to craft the scholarship papers by themselves so that they can submit texts with the correct format, structure and standards. With the right online writer by your side, you will send a unique custom paper. Easy Way on How to Write a Scholarship Essay You are likely to need financial help once you join college. Some people prefer to get a part-time job to help pay for tuition. However, in most cases, sponsorship can help eradicate the burden. If you are going to apply for funding, then you have two options: either write the application yourself or hire a reputable online site to help you submit a high-quality document. If you want to do the task yourself, we can help you know how to write a scholarship essay step by step. Read the instructions Your application can be quickly denied if the reader finds that you did not follow all the given instructions. Follow the format and structure and stick to the required word count. Let the introduction capture the attention of the reader Always start your paper with a captivating introduction. Use a personal anecdote or a funny story as it helps the reader to relate to the message you are trying to convey. Keep your intro short and interesting. Use the body to stay focused on the topic The sentences in your body should be clear and straightforward to understand. Avoid complicated words as they can result in misunderstanding. Remember to include some of the goals of the institution sponsoring the grant and try to relate their values with yours. Have a compelling conclusion Do not let your ending paragraph be a summary of what you have written. Instead, summarize the main points to ensure the readers take away the right message. You can also ask a thought-provoking question to stimulate critical thinking. How to Start a Scholarship Essay That Will Capture the Attention Do you want to know how to begin a scholarship essay? So many students are also sending their applications, which means that if you are to get the aid you need, your documents must stand out. The first few sentences of your content must grab the attention of the reader and motivate them to read from start to finish. It should also clearly explain the purpose of the document. Therefore, create a context that will give the reader the right information to understand the body. You also need to set them for what they should expect when reading and whats to come. The structure of a scholarship essay will have an introduction, body or conclusion. Before you start to begin jotting down words, make sure you have structured your main points and know where they will appear. In your introduction, include a thesis statement that will act as your central argument. For this type of paper, your case will be giving reasons why you should get financial aid. Be honest and tell your audience what makes you unique. Tips for Writing a Scholarship Essay That Will Impress Your Reader With so many applications received every year, the committee tends to select those that stand out and meet all requirements. Here are some tips that our experts have used over the years to write successful content. Start Working on Your Application Before the Deadline Writing a scholarship application is not easy. You will need ample time to ensure you send out a quality document. Waiting until a few hours or days before the deadline will cause you to rush and end up submitting substandard work. 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Premarital Sex Essay Example

Premarital Sex Essay Example Premarital Sex Essay Premarital Sex Essay There is no social issue more difficult to address than premarital sex. Even in the 21st century, after decades of convincing the world that truth can be subjective, modern man still could not get rid off that uneasy feeling when confronted with the accusation that he or she is engaging in sex outside the bounds of marriage. This feeling is arguably more intense with teenagers than with adults but nevertheless most would rather hide the truth than openly acknowledge that they are practicing premarital sex. This paper will show the dangers of premarital sex. This can be done without having to resort to overly simplistic rhetoric. For instance when someone opposed to the idea of sex before marriage is interviewed about his opinion about premarital sex; the common reply is that such behavior is unacceptable without being able to fully explain rationally why it is forbidden. Background Before going into details it is important to get an overview of this social problem. Those who practice premarital sex can be broadly categorized into three major groups. The first one is composed of couples who were already engaged and set to marry soon. The emotional depth of their relationship is evident and the kind of premarital sex practiced can be also called engagement sex (Luker, p. 89). The second group is composed of adults who are not yet married, not engaged, no plans of marrying their current sexual partners, and yet engaging in sexual intercourse. Those belonging to this group can be strongly attracted to their sexual partner but there is no immediate desire to bring the relationship a notch higher by becoming engaged. Kung akin ang mundo, Ang lahat ng itoy iaalay ko sayo Kung ako ang hari ng puso Lagi kitang pababantay kay kupido, Hindi na luluha ang yong mga mata, Mananatiling may ngiti sa Yong lab, Para sayo, para sayo, REPEAT CHORUS Geode morgen iedereen Edgar Allan Poe He was born Edgar Poe in Boston, Massachusetts, on January 19, 1809, the second child of actress Elizabeth Arnold Hopkins Poe and actor David Poe, Jr. He had an elder brother, William Henry Leonard Poe, and a younger sister, Rosalie Poe. Edgar may have been named after a character in William Shakespeares King Lear, a play the ouple was performing in 1809. His father abandoned their family in 1810, and his mother died a year later from consumption (pulmonary tuberculosis). Poe was then taken into the home of John Allan, a successful Scottish merchant in Richmond, Virginia, who dealt in a variety of goods including tobacco, cloth, wheat, tombstones, and slaves. The Allans served as a foster family and gave him the name Edgar Allan Poe, though they never formally adopted him. l Said to Love By: Thomas Hardy I said to Love, It is not now as in old days When men adored thee and thy ways All else above; Named thee the Boy, the Bright, the One Who spread a heaven beneath the sun, I said to Love. I said to him, We now know more of thee than then; We were but weak in Judgment when, With hearts abrim, We clamoured thee that thou wouldst please Inflict on us thine agonies, I said to him. Thou art not young, thou art not fair, No faery darts, no cherub air, Nor swan, nor dove Are thine; but features pitiless, And iron daggers of distress, Depart then, Love! .. Mans race shall end, dost threaten thou? The age to come the man of now Know nothing of? We fear not such a threat from thee; We are too old in apathy! Mankind shall cease. So let it be, O Captain! My Captain! by Walt Whitman . 0 CAPTAIN! my Captain, our fearful trip is done, The ship has weatherd every rack, the prize we sought is won, The port is near, the bells I hear, the people all exulting, While follow eyes the steady keel, the vessel grim and daring; But O heart! heart! heart! O the bleeding drops of red, Where on the deck my Captain lies, Fallen cold and dead. O Captain! my Captain! ise up and hear the bells; Rise upfor you the flag is flungfor you the bugle trills, For you bouquets and ibbond wreathsfor you the shores a-crowding, For you they call, the swaying mass, their eager faces turning; Here Captain! dear father! The arm beneath your head! It is some dream that on the deck, Youve fallen cold and dead. My Captain does not answer, his lips are pale and still, My father does not feel my arm, he has no pulse nor will, The ship is anchord safe and sound, its voyage closed and done, From fearful trip the victor ship comes in with object won; Exult O shores and ring O bells! But I with mournful tread, Walk the deck my Captain lies, Fallen Cold and Dead My name is Alyssa Marie P. Suarez. I am 14 years old. I was born on March 6,1999 in Bacolod City. I am currently living at Canlaon View Subd. Murcia, Negros Occidental. I am currently studying at Bacolod City National High School. I live with my mom, May; and my dad, Arthur. I have two siblings namely Alliah Nicole P. Suarez and Art Joseph P. Suarez. Life to me means friends and family who you can trust and who trusts you. I am pretty much on the happy side of life, but like all teens I do I have my days of. That means I do have some sad days or depressed days. I have a few friends here that sort of look out for me and when I am having a bad day, I have someone here at school to talk to. I make my school days go by thinking of either the next hour or what I will do when I get home or on the weekend. My hobbies are singing, dancing and playing badminton. I am good in dancing, quite in singing. Friends are l ike sisters to me. They are always there in good times and in bad times. They are always being there every step of the way. I can share my secrets to them and as well as my problems. I am lucky to have them.

Arts and Politics - China, Germany, and the Soviet Union Essay

Arts and Politics - China, Germany, and the Soviet Union - Essay Example China, Germany, and the Soviet Union have been used as the target examples. This end of the article analyses the three choices, looks at their relationship and the reason as to why they were chosen as great choices for this report. In the 19th century, the Russian Tsars were clear in their articulation that revolutions stood in the offing, in the presence if outstanding masterpieces. There are situations in Russia where great artists of various forms were regarded as a threat to the government’ existence through their works of art. Pushkin, for example, as a great author who could express his thoughts in an articulate manner that was deemed as arrogant, with some freedom that made him make fun of official figures. His work, as per the governments, would rather have been used in public service. Art and politics have been closely related from past to present. There are some aspects that clearly point out the relationship between the two. The institutions of art, schemes in ideol ogy and some artists’ political dominance are just but a few. Over years, some authorities have tried to impose controls on ideologies in order to tame artists. Other governments have even attempted to thwart the freedom of expression as rolled out by artists. In China, the communist party pushed at gaining legitimacy in order to win cooperation from artists. The party tried to woo the artists to join in socialist constructions. The Chinese movements and the various notable interactions between the governments and artists place the country as one worthy of analysis for the purpose of this research. The artistic influence has grown in stages in China, with a recent period starting in the 1980’s after Mao’s death. This is a period that saw individual subjectivity on the rise and artists expressing themselves in minimal social reform. Germany has had its issues in the interactions between arts and politics as well. There were early attacks by the government to the artists, some of which indicate the magnitude that the artists had on the political arena. A good situation is in the 1940s when the national socialists banned all art that was in existence prior to 1933. There are examples of artists being forced to join certain groups, with those who refused being frustrated with professional dismissals. Looking at the mentioned issues, their effects and the reasons that led to their occurrence, art is an indispensable weapon in politics despite its autonomy, there is some coexistence that cannot be refuted. Looking at the Soviet Union, there is some inseparability between art and politics. According to Fox (1977), aesthetics and the style of art are led by the political exigencies. The politics of the day in the USSR dictate the Russian art. The styles of art in this country follow the trends that are in accord with the government. The links between art and politics in the Soviet can be traced from Karl Marx to Frederick Engels who asserted the i mportance of realistic representations to the state. The three countries have been able to showcase the tight bond between art and politics clearly as outlined b the examples stated above. A distinct relation is first evident in the manner in which the government controls the works of art. This may be represented vaguely, but political icons have treated artists with great suspicion from the word go, in all situations. In the USSR, the government dictated the styles; in Germany, the â€Å"degenerate art† exhibition indicated the government’s perception towards art and culture. In China, the government literally controlled the artistic movements.     

What is the Role of Ethnicity in Africa Essay Example | Topics and Well Written Essays - 750 words

What is the Role of Ethnicity in Africa - Essay Example 138). In a simple way, ethnicity refers to a group of people who share same ancestral background, language, lifestyles and culture. From the above definition, enmity among Hutu, Tutsi and Twa relates to the above definition. Ethnicity led to a political divide in Rwanda (Scott, 2007). By 1959, the Tutsis were keen to liberate Rwanda from colonial oppression. This however led to massive killings for the sake of finding this freedom. This liberation made Tutsis dominant thus the forming of the one party state, which was powerful enough to penetrate the whole Rwandan society. To ensure dominance, they came up with ideologies that were against education and the press. To define ethnic boundaries, they came up with a system that involves the use of identity cards to show where individuals belonged. Between 1958 and 1962, there was massive campaign against the Tutsis, which claimed close to 200,000 Hutus as revenge from the Tutsi. Due to the indirect rule, Rwandans came to define their identities due to the idea that a society that everyone must belong to an ethnic group. This led to political divide in that they believed power was a key item in ethnic identity. This evident when in 1990, there emerged real enmity between supporters of then the Rwandan President Juvenal Habyarimana who was a Hutu and the Rwandan Patriotic Front led by Paul Kagame who was a Tutsi. Due to this rivalry, Juvenal’s plane was shot while in the air and none of the people on board survived. This led to a blame game with the Tutsis being blamed for the assassination. The blame game left women and children at risk since they were the easiest to attack and kill in the name of revenge. Ethnicity played a key role in control of resources during and before genocide. Since independence, the Tutsis enjoyed the monopoly of being the only ones with the power to control the country’s natural