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quality of included studies, limited search strategies, inclusion of studies from only developed countries and being outdated.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).

Employee Law

Project Summary Employment Law The employment relationship Is a contractual one between an employer and a worker. The worker may be either an employee or an Independent contractor. Distinguishing between the two is very important. It has an effect on compensation, benefits, harassment, family leave, workers' compensation, unemployment insurance, and discrimination, (Moran, 2008, p. 3). In an employment relationship, authority is conveyed by an employer to an employee. Deciding what kinds of authority and how much authority to grant are important issues for employers to resolve, (Moran, 2008, . ). Inherent in every employment relationship is the employee's duties of loyalty and good faith and the employer's duties to compensate and maintain a safe working environment. Violations of these duties give rise to contractual and tort liability. A contract Is a legally enforceable agreement. A tort Is a private civil wrong. Tort liability encompasses assault and battery, defamation, Invasion of privacy, and negligence. The key to an employers responsibility Is whether the tort was committed within the scope of employment?in other words, â€Å"on the Job,† (Moran, 2008, p. 3)Employers may attempt to employ restrictive covenants, also known as nincompoop or nondisclosure agreements. These agreements are used to protect the employer's business against theft of trade secrets, stealing clients, and competing against the former employer. Courts generally do not like to restrict people from working, but the courts will enforce these agreements where they are voluntarily signed and designed to protect the business from unfair competition, (Moran, 2008, p. 3). The purpose of recruitment and selection is to obtain the best possible workers for a business.Discrimination is permissible with respect to selecting candidates based on interpersonal relations, communication skills, training, and education. It Is not permissible with respect to suspect classification such as race , religion, gender, age, disability, and national origin,† (Moran, 2008, p. 37). Because employees are valuable assets to a business, employers must be able to choose those employees who will perform the best work for the business. Education, training, communication skills, and interpersonal relations are key qualities that employees must possess to help a business be more successful, (Moran, 2008, p. ). The easiest way to discriminate against individuals is to do so in the recruitment and selection process. Employers may use a myriad of methods to evaluate an individual and his or her particular traits. Testing, interviews, writing samples, demonstrations, and role-playing are a few examples, (Moran, 2008, p. 37). If these methods are job-related, then the employer has every right to use them. â€Å"What an employer may not do is discourage potential candidates who belong to a particular suspect classification as defined by Title VII of the Call Rights Act, the Age Delimitat ion In Employment Act, and theAmericans with Deliverables Act,† (Moran, 2008, p. 37). The selection process has become a complicated procedure for employers, (Moran, 2008, p. 67). They must inappropriate questions that can be inferred as being discriminatory. Employers must recruit from a diverse pool of candidates. Employers must keep accurate records of these candidates, such as who applied and who was hired. Employers must establish Job-related criteria necessary for promotions. Employers must perform background checks on employees to guard themselves against negligent hiring, but these checks are limited to activities or criminal convictions that are Job elated,† (Moran, 2008, p. 67). Policies with regard to nepotism and promoting from within should also be drafted by the employer. The selection process is a daunting but necessary undertaking for the employer. As most of us know, it is an equally stressful experience for workers. Arbitration is a form of alternative dispute resolution where two sides look outside the court system to resolve a conflict, (Moran, 2008, p. 157).In arbitration, an impartial arbitrator listens to claims, facts, and testimony from both sides, then issues a decision. By signing arbitration agreements, employees typically waive their right to file lawsuits when they have a dispute with their employers. However, the obligation to arbitrate can vary. Some employers require all disputes to go to arbitration, while others designate arbitration for only certain issues. â€Å"Binding† arbitration is most frequently used in employment agreements, where both sides agree ahead of time that the arbitrator's decision will be final, with very limited basis to appeal, (Moran, 2008, p. 58). However, an arbitration agreement alone does not mean that employers can never be sued over an employment issue. State and federal regulators can still sue employers when employees file complaints against companies for violating discriminat ion, pay, or other laws. Once employees or former employees decide to enter into arbitration, there are three basic steps in the proceedings: preheating briefs, the hearing, and the arbitrator's decision. Preheating briefs allow the company and employees to present their views and describe their evidence to the arbitrator.During the hearing, both sides present their case to the arbitrator, which can include calling witnesses. Then the arbitrator makes a decision. Generally, employers do not take termination as personally as do employees. However, it can be a difficult process for both sides, especially if the employee believes that the discharge is wrongful. â€Å"At-will termination protects the rights of employers to terminate employees,† (Moran, 2008, p. 153). Therefore, employees must evaluate the evidence to discern whether it meets one of the public policy exceptions to the at-will doctrine.Employers must guard against compromising their protection under the at-will emp loyment doctrine and should not stipulate that employees will be discharged only for cause or list explicit seasons for discharge in an employment handbook or in conversation with an applicant or an employee, (Moran, 2008, p. 153). Rather employers should state that employees may be discharged at any time for any reason. Shortly after the conclusion of the Civil War in 1865, the Thirteenth, Fourteenth, and Fifteenth Amendments to the U. S.Constitution were adopted, (Moran, 2008, p. 171). The Thirteenth Amendment abolished slavery. The Fifteenth Amendment gave black men the right to vote. But, it was the Equal Protection Clause of the Fourteenth Amendment that laid the basis for equal rights in employment, (Moran, 2008, p. 71). The Equal Protection Clause basically states that â€Å"all people are entitled to equal United States, in Please v. Ferguson, interpreted this to mean that separate but equal facilities would satisfy the Fourteenth Amendment requirement, (Moran, 2008, p. 171 ).Segregation persisted into the sass, but inroads began to be made in the mid-sass with the Brown v. Board of Education decision, which mandated integration in public schools, (Moran, 2008, p. 171). This decision had a reverberating effect throughout society. In 1964, Congress passed the Civil Rights Act to legislate integration in schools, housing, restaurants, transportation, shopping, and employment. Title VII of the Civil Rights Act speaks to employment, (Moran, 2008, p. 171). It prohibits discrimination because of religion, race, color, sex, and national origin, (Moran, 2008, p. 171).There are two main types of discrimination: disparate impact, which is discrimination against a class of people, and disparate treatment, which is discrimination against an individual, (Moran, 2008, p. 171). The key to establishing an affirmative action plan is to obtain the commitment of management, Moran, 2008, p. 199). Once committed, management can emphasize its importance and lead by example. An assessment must be made of the number of women and minorities and their current status within the organization. This data will prove invaluable as a benchmark against which the program's progress can be measured, (Moran, 2008, p. 99). Once the problem areas are identified, then recruitment and promotion issues must be addressed. A critical look at the current methods utilized must be taken, and a plan must be instituted to remedy its deficiencies. To bolster acquirement, notification should be sent to the placement office of schools with significant or exclusive women or minority populations. Women and minority organizations can also be advised of the need for prospective candidates. Advertisements in newspapers, magazines, radio, and television designed for women and minorities will enable a company to tap into that particular circle, (Moran, 2008, p. 99). Company tours for students and community groups are also beneficial. â€Å"Relying solely on referrals and traditional rec ruitment techniques will only reinforce discrimination,† (Moran, 2008, p. 199). Career counseling to direct women and minorities toward career paths and training programs to help them realize these accomplishments must be created or embellished. The fact that counseling and training programs exist is not sufficient. They must be made available or specifically developed with women and minorities in mind.Job descriptions must also be perused for possible barriers against women and minorities, (Moran, 2008, p. 199). If found, the descriptive narration must be rethought. All requirements must be Job- related. Any that are not should be eliminated, especially unnecessary education or experience; otherwise, discrimination will continue. Testing should also be restricted to when it is absolutely necessary and its reality and Job-relatedness can be proved, (Moran, 2008, p. 199). The assignment of grade levels to Jobs must also be reviewed for bias in favor of men, (Moran, 2008, p. 199 ).If discovered, such bias must be readjusted. Interviewers must be indoctrinated to no longer believe that women and minorities can perform only certain Jobs – those involving routine ministerial tasks, (Moran, 2008, p. 199). They must avoid asking women and minorities personal questions about marital status, other sources of income, number of children, criminal record, and other issues that are not Job-related and are not routinely asked of white and in-house rules and regulations must be redrafted to be gender-neutral, both in written communications and pictorials,† (Moran, 2008, p. 199). Sexual harassment is defined as (1) a sexual advance or request for sexual favor made by one employee to another that is unwelcome and not consented to; and (2) touching, Joking, commenting, or distributing material of a sexual nature that an employee has not consented to and finds offensive,† (Moran, 2008, p. 89). Although the court- appointed test for determining what consti tutes sexual harassment is a reasonable person standard and what is reasonable may vary depending on the work environment, it is the purpose of this policy on sexual harassment to avoid litigation, not to win lawsuits.Therefore, employees are forewarned that the use of certain terms may give rise to a woman's filing a sexual harassment complaint and are therefore prohibited, (Moran, 2008, p. 289). If a complaint is filed with the company's human resources department on any of these allegations, it will be investigated immediately, (Moran, 2008, p. 289). The investigation shall consist of questioning the complainant, alleged perpetrator, coworkers, superiors, and subordinates, (Moran, 2008, p. 89). If a determination is made that a valid complaint had been issued against an employee, that employee will be entitled to a hearing to which he or she may be assisted by outside counsel. If a conclusion is reached that the conduct complained of meets one of the aforementioned criteria, then the employee shall be dismissed forthwith, (Moran, 2008, p. 289). Furthermore, the victim will be afforded counseling services, if needed.Every effort will be made by the company to aid the victimized employee in overcoming the emotional trauma of the unfortunate ordeal, (Moran, 2008, p. 289). Finally, the company will sponsor in-house workshops explaining this policy on sexual harassment, warning employees against engaging in it, and encouraging those affected by sexual harassment to come forward with the details of their encounter with it in order for the company to investigate and resolve the dilemma and service the needs of the victimized employee, (Moran, 2008, p. 289).The Americans with Disabilities Act requires employers having 1 5 or more employees to refrain from administrating against any individual who has an impairment that limits major life activities, such as impairment to sight, speech, hearing, walking, and learning, (Moran, 2008, p. 389). Also included are people w ith cancer, heart conditions, AIDS, and disfigurement, as well as people recovering from substance abuse. The forerunner of the DAD was the Rehabilitation Act of 1 973. It prohibited disability discrimination in federal employment and with federal contractors.The percentage of disabled workers who are unemployed is much greater than that of the general population, (Moran, 2008, p. 08). Public access and specific Job accommodations have gone a long way to aid the gainful employment of many of the disabled. Encouraging a change in the mind-set of employers remains a formidable task. Many employers view disabled applicants as inferior to others. They represent an additional worry employers do not need. However, with reasonable accommodation, many disabled employees have proven to work as effectively as other workers because their disability has been alleviated, (Moran, 2008, p. 08). They are operating on a level playing surface with the rest of the work population. Collective bargainin g is the negotiation process undertaken by a union on behalf of a contract after the resolution of labor issues,† (Moran, 2008, p. 420). The contract, known as the collective bargaining agreement, is binding on all union members. The advantage of collective bargaining is that the union has greater bargaining strength than an individual employee would have in attempting to negotiate the best possible deal, (Moran, 2008, p. 420).The Occupational Safety and Health Act of 1 970 (OSHA) was designed to set forth a standard that would provide for the safety and health of employees while on the Job, (Moran, 2008, p. 450). Employers are required to provide a place of employment free from occupational hazards. Employees are required to follow rules and regulations established to promote their safety and to use equipment designed to ensure their safety, (Moran, 2008, p. 450). Permanent standards are the standards originally introduced when OSHA was created as well as standards promulgate d thereafter, (Moran, 2008, p. 452).The latter are referred to as National Consensus Standards. When OSHA develops a new standard, it is published in the Federal Register, (Moran, 2008, p. 452). The public, especially employees, has 30 days to request a hearing. If requested, notice of a public hearing will be made. After the hearing, OSHA must publish the standard incorporating the changes, if any, and the date of its commencement, within 60 days. The Secretary of Labor must explain the need for the new standard, or else it will be null and void. He or she may delay the date of its commencement. In one case, a delay of 4 years was imposed.

Different Country, Different Culture Essay

A country is just like an onion; the innermost skin is Culture. Culture is like the soul of a country. All countries have their own unique cultures to live by, which means that people who have grown up in different places will have different ways of behaving, different ways of thinking about things and different ways of expressing themselves. Each country has its own culture, and there are many differences between different countries in culture. Those differences make our world a more colorful and exciting place to live. We can have a better understanding of it if we compare the big cultural differences between America and China. According to my two years of study in America and Intercultural Communication Stumbling Blocks by LaRay M. Barna, which talked about the difference between different cultures, I find two big differences in friendship and education. First difference is friendship. Time is often the best way to test friendship and friends. For the Chinese, to know each other for a long time, the communication needs to be at a certain depth, finding out each other’s habits, temperament, similar interests and the common experience of â€Å"suffering†. Then they will make the recognition of each other as a friend in the heart, and they will value this friendship. Once friendship is established, it will be lifelong, and hard to break. Chinese can share almost everything with their friends, for example, when you are in China, at restaurant, you can actually see people fight for the bill. It’s not about showing off to their friends or someone else. It’s just because they want to show their appreciation for their friendship. On the other hand, for most Chinese, we think Americans are â€Å"superficial,† like what Barna said â€Å"They talk and smile too much† (67) and â€Å"Their friendship are, most of the time, so ephemeral compared to the friendship we have at home. Americans make friends very easily and leave their friends almost as quickly† (67). For Americans, in general it seems to them that Chinese and some other people from different countries are â€Å"not necessarily snobs but are very unfriendly,† (67) Because we don’t talk and smile a lot. The reason why Chinese and Americans have a different opinion on friendship is because  our cultures are different. We can’t tell which kind of friendship is right or wrong because there is no such a thing as wrong culture. There are all just different cultures. The second difference is in education.† What you make of your education will decide nothing less than the future of this country.† says a Chinese proverb. As we all know, American and Chinese education systems are different, which creates different culture in turn. American education focuses on the students’ creativity and practical ability. In their classes, the teachers just play a role as leaders. Students do lab homework, group work to find out the answer by themselves. However in China, the school is more like a concert hall. This means that students are completely listeners. Students all focus on the textbook, try to memorize everything from the book, and then get a good score. They hardly come up with their own ideas. That’s why Barna says, â€Å"U.S. students often complain that the international members of a discussion or project seem uncooperative or uninterested†. (66) But both of those two educations’ intentions are good. In my view, we should learn the academic knowledge well, but we should also take part in the school activities, improve our interpersonal skills, and creative thinking, so that, we can prepare well for the future challenges. In one word, each country has its own culture. Although there are many differences between different countries, we should respect them and learn from each other. Especially, in the modern century, each country has to communicate with other countries more than ever. So, we must understand the differences in different countries’ culture well, only in this way, we can get along with each other in peace.

In The Play Twelfth Night, Or What You Will By William

In the play Twelfth Night, or What You Will by William Shakespeare, the playwright presents the very real issues of gender roles in his time by using a light-hearted comedy full of love triangles and mischief. Gendered roles are a driving force in Twelfth Night that change all aspects of the characters’ lives. The roles that each gender is set to play function to define society: women do this and men do that. These stereotypes become so ingrained into culture that they become hard to get rid of and are often damaging and overall negative. These specific roles based upon gender define who â€Å"loves† who and factors into how the individual is viewed in their everyday life. Twelfth Night gives the reader a powerful insight into gendered culture†¦show more content†¦Viola implies with this line that she is not ready to reveal her virtue, possibly because she is an unchaperoned lady in a foreign land. She seems to think that Lady Oliva might have her and help her conceal her social status until she too is ready to face men again. However, the Captain finishes her sentence, â€Å"That were hard to compass, / Because she will admit no kind of suit,† (1.2.44—45). Viola quickly changes her mind, deciding at this moment to ask the Captain to â€Å"conceal [her]† for â€Å"what [she is]† so that she may serve under Orsino (1.2.52). She wishes for the Captain to present her as a eunuch, possibly to explain her feminine features and high pitched voice, so that she can prove herself â€Å"very worth his service† (1.2.58). Here, Viola may still be thinking of ways to conceal her virtue, since as a man no one would guess her true social status. Another thing to note from Viola’s choice to ultimately disguise herself as a man, are the gender role undertones of the whole passage. 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