Research Methodology, Design and Process: Dementia Care

Abstract The ability to critically analyse literature is an important skill for evidence-based practice. This literature review aimed to critically analysed literature on dementia care. A search of literature was conducted on academic databases such as Pubmed and CINAHL. Three studies were finally retrieved for this literature review. Each of these studies was critiqued using the Critical Appraisal Skills Programme (CASP) tool for qualitative studies and the critiquing framework of Long et al. (2002). Findings of this literature review could be used to inform current and future community nursing practice. Specifically, this review revealed that music therapy could improve the mood of individuals with dementia and show evidence in improving memory function. While findings could not be applicable to a wider population, nurses could utilise findings and tailor these to the individual needs of their patients. Introduction Evidence-based practice (EBP) is heavily promoted in the NHS since this helps nurses and other healthcare practitioners apply findings of recently published literature to one’s current and future practice. The Nursing and Midwifery Council’s (NMC, 2008) code of conduct also emphasises that healthcare decisions should be evidence-based and supported by published literature and current guidelines. Developing the ability to critically analyse literature is essential when developing evidence-based care (Greenhalgh, 2010; Aveyard, 2014). There is a wealth of information from published literature and current guidelines. Determining the relevance and quality of these findings will help inform nurses whether findings are credible and valid before they are applied to current practice. As part of community nursing, I am interested in improving my current practice in order to deliver quality care to my patients. The recent policy on community care from the Department of Health (2013a) emphasises the importance of allowing patients with chronic conditions and their carers to self-manage their conditions, achieve self-efficacy and lessen admissions in hospital settings. This policy, â€Å"Care in Local Communities-District Nurse Vision and Model’ (Department of Health, 2013a) emphasises the role of nurses in supporting patients and their carers to improve their health outcomes. While it is acknowledged that patients with chronic illnesses may never recover from their condition, nurses have the responsibility to help patients or their carers manage signs and symptoms of the chronic illness. As a nurse in community setting, I have cared for patients with dementia. I saw how this condition impacts the patient’s quality of life and even increase the risk of depression amongst their carers (Talbot and Verrinder, 2009). I always had an interest in caring for patients with dementia. However, I noticed that most pharmacologic treatments have little effect in delaying the progression of cognitive impairments amongst these patients (Miller, 2009). These treatments are also costly and place a considerable burden on the family members and the NHS (Department of Health, 2013b). Hence, I thought that familiarising myself with non-pharmacologic interventions and their effects on cognition or memory of the patient would be important in my role as a community nurse. A number of non-pharmacologic interventions to preserve memory or delay cognitive decline have been developed in the last two decades. Studies (Spector et al., 2010; Hansen et al., 2006; Vink et al., 2004; Teri et al., 2003) show that these interventions range from motor stimulation, exercise programmes, sensory stimulation and cognitive training. Amongst these interventions, music therapy has been suggested to be least harmful and relatively effective. Some investigators (Fornazzari et al., 2006; Cuddy and Duffin, 2005) have shown that even in patients with severe dementia, music memory seemed to be preserved. However, some studies (Menard and Belleville, 2009; Baird and Samsom, 2009) suggest otherwise and explain that some patients with Alzheimer’s disease (AD) suffer from impaired music memory. One study (Baird and Samson, 2009) however, explained that procedural memory, specifically for musical stimuli are not affected in persons with dementia. With the acknowledgement tha t most pharmacologic interventions have limited ability to treat the symptoms associated with dementia, it is essential to consider how non-pharmacologic interventions, such as music therapy, alleviate symptoms of this condition. In order to enhance my current and future nursing practice and to increase my understanding on the relevance of music therapy to dementia care, I have decided to research this topic further. Literature Search A search of literature from academic databases such as the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Pubmed was done to retrieve relevant studies. CINAHL indexes more than 5,000 nursing and allied health sciences journals and contains almost 4 million citations. The depth of research articles indexed in this database makes it a database of choice for research on the effects of music therapy on patients suffering from dementia. Meanwhile, Pubmed was also used to search for academic literature. This database also contains millions of citations and indexes nursing and allied health journals. A quick search for ‘music therapy AND dementia’ was done in Pubmed since this database focuses on nursing and allied health journals. This search yielded 20 articles, most of which were available as full text journals. The same keywords were entered in the CINAHL database. The search yielded 14 articles, with almost all articles available as full text articles. A review of the abstracts of all articles was done to select only primary research studies conducted in the last five years. Polit et al. (2013) state that retrieving journal articles in the last five years will ensure that the most recent evidence is used to inform current and future nursing practice. Literature older than five years old may be outdated. However, this also increases the risk of excluding landmark studies (Aveyard, 2014). For the present review, the selection of studies was only restricted to the last five years to ensure that more recent evidence on music therapy were evaluated and critiqued. The re was also no restriction on the place where the studies were conducted since dementia affects people of different ethnicities. Learning from the experiences of other nurses or healthcare practitioners on the use of music therapy for dementia patients would also help improve nursing practice in the UK. The following articles were chosen for critique and evaluation: Simmons-Stern et al. (2012) ‘Music-based memory enhancement in Alzheimer’s disease: promise and limitations’ Sakamoto et al. (2013) ‘Comparing the effects of different individualized music interventions for elderly individuals with severe dementia’, Dermot et al. (2014) ‘The importance of music for people with dementia: the perspectives of people with dementia, family carers, staff and music therapists’ As previously stated, I am interested in how music therapy could help me assist my patients delay the progression of dementia and help them and their carers self-manage the signs and symptoms of dementia. Hence, all articles are relevant my work as a community nurse. To critique these studies, the Critical Appraisal Skills Programme (CASP, 2013) tool for critiquing qualitative studies was utilised. For the quantitative studies, Long et al. (2002) critiquing framework for quantitative studies was used. Both critiquing frameworks are easy to use and help researchers investigate the quality and rigour of research articles. Study 1: Simmons-Stern et al. (2012 A review of the title of the study shows that it reflected the main aim and objectives of the study. The title was concise and provided information to the readers that the study aimed to present the limitations of music-based memory enhancement as well as its possible application to nursing practice. Polit et al. (2013) emphasise the importance of creating a concise and clear title in order not to mislead readers and to inform stakeholders if the article is worth reading. A review was also done on the author’s background and shows that all had extensive background on dementia research and healthcare. This was essential since credibility of the authors’ background could increase the reliability of the findings of the study (Long et al., 2002). However, Hek and Moule (2011) emphasise that the authors’ background is not the sole criterion in assessing the credibility of the findings of the study. The abstract of the study failed to mention the type of study design used. While the abstract summarises the aims and main findings of the study, it did not follow the usual structure of an abstract in a journal article where the methodology or methods used are explicitly stated. Ellis (2010) reiterates that an abstract should provide a brief summary of the study’s background, aims and objectives, methodology, results and conclusion. Although it was difficult to determine why the researchers of this study failed to present the methodology in the abstract, readers of the study could have benefited from an abstract that states the methodology of the study. Reading of the body of the article would show that the quantitative study design was used. The study aimed to investigate the effects of music on the memory of patients suffering from Alzheimer’s disease, one of the diseases grouped under dementia. Simmons-Stern et al. (2012) made excellent use of literature and related findings from previous studies with the current study. Apart from the excellent use of literature, there was also a very good review of the previous studies and a gap in literature was clearly presented. Hence, the literature review of the study was well written and provided the readers with good background on why there is a need to carry out the present study. Polit et al. (2013) emphasise that a well-written review of literature should be able to provide context to the study’s aims and objectives and argue why there is a need to address the gaps in literature. Importantly, Simmons-Stern et al. (2012) avoided the use of jargon when writing the paper. Burns and Grove (2013) explain that the use of jargon should be avoided since this excludes readers of the article that have no nursing or medical background. A good paper is one that is written for a general audience and not only for a scientific community (Burns and Grove, 2013). A total of 12 participants who were diagnosed with Alzheimer’s disease and 17 healthy controls g ave their informed consents to participate in the study. Brown (2009) states the importance of obtaining the informed consent of participants before commencing the study. This would not only protect the rights of the participants but also ensure that the nurse researchers are observing the Nursing and Midwifery Council’s (NMC, 2008) code of conduct in protecting the patients or participants from harm. Part of obtaining an informed consent is the presentation of the study’s aims and objectives, possible side effects or benefits when participating in the study (Brown, 2009). An informed consent will also ensure that debriefing is provided to the participants to avoid any harm and psychological distress to the participants (Oermann, 2010). Apart from getting the informed consent, it was also crucial that an ethics committee has evaluated and approved the study protocol. An evaluation of the study reveals that this was observed and an ethics committee approved the study. On reflection, the study has a very small sample size (n=12 experimental group; n=17 control group). This would have taken a randomised controlled study design since a control group was used to compare the effects of music therapy on the patients with a healthy control. However, the investigators specifically state that this study was comparative. An inclusion and exclusion criteria were used when recruiting the patients, suggesting that participants were not randomly selected. Since the study was quantitative and employed the experimental study design, random sampling of the participants who have been more applicable (Crookes and Davies, 2004). It should be noted that it would also be difficult to randomise participants since this study was only conduc ted in one healthcare setting and it was crucial that participants have developed AD. While randomisation of participants was not observed, it is noteworthy that the investigators stated how many of the participants were excluded from the study and the reasons of their exclusion. This was essential since failure to explain why participants who gave their informed consents to participate in the study but were later excluded in the actual experiment would make the data collection process unclear (Moule and Goodman, 2009). Despite the small sample size, the demographic characteristics of the two groups were not significantly different when t-test was done. There were no significant differences in prior musical training, formal or informal, years of education and age between the participants of the two groups. This allowed the investigators to determine if there were differences after the study, this might have been due to the intervention employed. After informed consents were taken, the authors of the study declared that they paid the participants for the hours spent during the study. Compensating the participants for the time is considered as ethical since considerable time has been taken away from the subjects for their participation in the study (Hek and Moule, 2011). The interventions were clearly stated. This increased the rigour of the study since a clearly stated research method would help other investigators replicate the methods in future studies and verify whether similar findings are obtain ed (Hek and Moule, 2011). Simmons-Stern et al. (2012) also specifically outlined the lyrics used and where these were obtained and how music memory of the participants was tested. Results section of the study clearly presented the main findings of the study. Appropriate statistical tests were also utilised to test the hypotheses of the research. Polit et al. (2013) emphasise that statistical tests should be appropriate to the study’s aims and objectives and should rule out any biases in interpretation of the findings. Despite having a small sample size, the researchers were able to establish that music in patients with AD enhances memory in terms of familiarisation of sung lyrics but not in spoken stimuli. This suggests that in patients with AD, they can enhance their memory when familiarising with the lyrics or listening to music but not when they hear spoken language. There were also no significant differences in the healthy control and experimental groups in terms of memory after hearing the lyrics of a song compared to hearing the lyrics as a spoken stimuli. Since this study has a small sample size, the applicability of the findings to a larger and more heterogeneous population would be difficult (Burns and Grove, 2013). Although a control was used, it should be noted that participants in the experimental group are in the early stages of AD. This could have affected the findings of the study since it is unclear if patients with severe dementia would also yield similar reactions and results. At present, the findings are applicable to the sample population of the study and importantly, only on individuals in the early stages of dementia. While there were several limitations of the study, findings are noteworthy since these show that music therapy is promising as a non-pharmacologic intervention for enhancing memory in individuals with early stage dementia. The conclusion of the study was clearly presented and summarises the key points presented in the study. Although the discussion states future areas of study, there were no clear recommendations in the conclusion. Specific recommendations could have been made at the end to help future researchers identify areas of investigation. There were also no implications for future nursing and other healthcare practitioners’ practices. Despite the lack of clear recommendations, readers can still read through the study and identify areas that need further investigation. For example, there is a need to replicate the study in a larger and randomly selected sample population to strengthen the validity and reliability of the findings. There is also a need to compare findings with patients suffering from moderate to severe dementia to determine if music still has similar effects on the memory of those in advanced stages of the illness. There are a number of implications of the study in nursing practice. Nurses can use music to help enhance memory or prevent deterioration of memory amongst individuals with early stages of the disease. It is essential to consider the acceptability of music therapy in those suffering from dementia. As a whole, the study was of high quality and effort was made to reduce bias within the study. Although the investigators failed to blind assessors to the study, findings were presented objectively. It is also difficult to blind assessors because of the very small sample size (Burns and Grove, 2013). All investigators were familiar with the background of the participants and blinding them to the intervention was difficult since these investigators were also responsible in implementing the interventions. Finally, there were no conflicts of interest (Polit et al., 2013), ensuring the readers that bias in presentation of findings was avoided. Study 2: Sakamoto et al. (2013) An evaluation of the study’s title reveals that it was concise and clearly reflects the study’s aims and objectives. This was essential (Long et al., 2002) since this would present to the readers the main aim of the study. The type of study design chosen to answer the study’s aims was also appropriate. A quantitative study design would help investigators answer the research aims and objectives through experimentation, surveys or a randomised controlled trial (RCT) (Brown, 2009). In Sakamoto et al. (2013), the randomised controlled study design was used. Compared to other quantitative study designs, a RCT reduces risk of selection bias and bias in interpretation of findings (Moule and Goodman, 2009). Selection bias occurs when participants are not randomly selected and do no have equal chances of being assigned to a control or experimental groups (Crookes and Davies, 2004). This is avoided in RCT since all participants are randomly assigned to an experimental or c ontrol group. On the other hand, bias in interpretation of findings is lessened especially if investigators and assessors are blinded to the interventions and standard treatment (Oermann, 2010). A critical analysis of the study shows all participants in the study were randomly assigned to the treatment and standard care groups. However, a major limitation of this study was its relatively small sample size (n=39). It would be difficult to transfer findings to a larger and more heterogeneous group due to the representativeness of the sample population (Ellis, 2010). While it is difficult to transfer findings to other settings due to the relatively small sample size, community nurses may consider the applicability of the findings to their own practice. It is noteworthy that it would be difficult to recruit participants in the advanced stages of dementia since their ability to give their informed consent is severely limited (Department of Health, 2009). Further, their participation requires that their carers or immediate family members are aware of the study’s aims and objectives and should be able to assist the participants during the the study. While an ethics board app roved the study and informed consents were taken from the respondents or their representatives (Burns and Grove, 2013), involving individuals who suffer from severe cognitive impairment would be difficult. This also carries some ethical issues since their ability to understand the procedures of the study is compromised (Hek and Moule, 2011). Although the Mental Health Act in the UK acknowledges that carers can act in behalf of the individual with mental health condition, ethics regarding their participation in research studies remains debatable (Department of Health, 2009). Despite the possible ethical issues surrounding the study, investigators of this study used other means of evaluation to assess the participants’ responses to the interventions. For example, they used the Faces Scale (Sakamoto et al., 2013) to determine the emotions of the participants. A review of the study’s aims and objective shows that these were clearly presented in the beginning of the study. The introduction and review of literature also made excellent use of previous studies. It is also important to note the gaps in practice in recent studies were highlighted in the literature review section (Ellis, 2010). A good literature also argues why there is a need for the new study and how this could be applied to current healthcare practices (Ross, 2012). Methodology and methods used were also appropriate for the research question. Since the study aimed to determine the effectiveness of music therapy, it is appropriate that a RCT is used to compare music therapy with st andard care. Comparing music therapy with standard care is ethical (Ross, 2012) since all patients in the study received interventions. It would be unethical to withdraw treatment or assign participants to a control group that would receive no intervention (Crookes and Daives, 2004). The evaluation tools used to measure the responses of the patients were appropriate and have been previously validated and standardised. This was necessary to convey to the readers that validated measurement tools were used in the study (Moule and Goodman, 2009). A clear description of the research methods was presented. This would allow future researchers to replicate the present study (Oermann, 2010) and determine if similar findings could be observed. This also increases rigour of the study (Burns and Grove, 2013) since it is essential for other researchers to also test the hypothesis of the study and ensure that results are consistent across different healthcare settings. Results of the study were well presented and appropriate statistical tests were used. The discussion section of the study presented the strengths and limitations of the study. Polit et al. (2013) emphasise that presenting the limitations of a study will help inform other researchers on areas that need further improvement and presents areas for further research. Since weaknesses of the study were presented, readers and other healthcare practitioners can determine the extent in which the findings can be applied to current and future nursing practice (Burns and Grove, 2013) . The conclusion of the study succinctly captures the main points raised in the research study. This helped the researchers identify the main highlights of the study (Ellis, 2010). However, recommendations for other researchers and areas of improvement of the study were not cited. While the discussion section presented these limitations and areas for future studies, brief recommendations at the end of the study could have added rigour to the research study. Importantly, there were no conflicts of interest. This assured the readers that bias in reporting of data was reduced (Ellis, 2010). Findings of this study have important implications in nursing practice. All participants received either the passive or interactive music intervention while the control group received no music intervention. There was careful choice of music in the interactive group. For example, healthcare workers assigned to the interactive group helped investigators choose music for the patient participants. Music played during the intervention all had special meaning to the participants. All interventions were given individually for 30 minutes per session at once a week for 10 weeks. Those in the interactive group were allowed to clap, sing or interact with the music. Meanwhile, those in the passive group only listened to the music. The music chosen for the passive group also had special meaning to the participants. Those in the control group sat in silence for 30 minutes during the once a week session. Interestingly, findings show that music associated with special memories led to significant cha nges in the parasympathetic nervous system of the participants. Investigators note that music significantly increased relaxation of the individuals immediately after intervention when compared to baseline data. However, these were not noted in the control group. Significant changes were also seen on the emotional states of the participants in the interactive and passive music intervention groups. Music appeared to elicit pleasant emotional states. However, when passive and interactive groups were compared, the latter was significantly more relaxed following the music intervention. It should be noted that patients with severe dementia are more sensitive to environmental stimuli and may experience stress when placed in a new environment (Morris and Morris, 2010). Further, patients with cognitive impairments may express feelings of stress and fear through disruptive behaviour (Morris and Morris, 2010). The difficulty in verbalising their emotional needs could aggravate their responses to their surroundings (Department of Health, 2009). Hence, the st udy of Sakamoto et al. (2013) may have important implications in nursing care for patients in community settings. Nurses can encourage family members to play music that have special meaning to their loved ones suffering from dementia to illicit positive emotional states. The calming effect of music could be an advantage for patients cared in home or care settings since this would not only prevent stress but also allow patients to enjoy quality of life. Study 3: Dermot et al. (2014) A review of the study’s title shows that it also reflects the main aims and objectives of the study. Readers could easily understand that the study explored the experiences of individuals with dementia, their carers, staff and music therapists when music interventions are employed. The CASP (2013) tool for qualitative studies contains three screening questions that should be used to determine if a study is worth reviewing. The study of Dermot et al. (2014) suggests that music can help maintain the person’s interconnectedness and their quality of life. Findings have important implications in nursing practice since music intervention (Miller, 2009) is not costly and could yield positive results for patients suffering from early to advanced stages of dementia. Further review of the study shows that aims and objectives of the research were clearly stated. The main aim of the study was to explore the meaning of music in the lives of individuals suffering from dementia. Inves tigators of this study state that there is limited knowledge on why or how individuals find music beneficial to their wellbeing. Understanding the role of music according to the perceptions of the patients and their carers will help inform nursing practice on the relevance of music in the lives of people with dementia. A qualitative research methodology was appropriate for the study’s aims since the research aims to interpret the subjective experiences of individuals with dementia. Parahoo (2006) emphasises that a qualitative study allows researchers to explore the experiences and perceptions of individuals in more detail and depth. Since open-ended questions are used, investigators can use probing questions (Burns and Grove, 2013) to help participants articulate their experiences. One of the strengths of this study was the inclusion of participants’ family members, care home staff and music therapists. Individuals suffering from dementia were recruited from care homes and those living in the community. This allowed Dermot et al. (2014) to compare the perceptions of people with dementia living in care homes or in the community and determine if settings of the individuals impact their experiences with music therapy. Recruitment strategy employed was also appropriate for the research ai ms. There was also a clear explanation on the methods of data collection. Semi-structured interviews and focus group discussions were done. In the former, this would allow researchers to investigate perceptions of participants in more detail (Parahoo, 2006). However, this requires more time to complete especially if there are many participants in a study. A focus group discussion, on the other hand, requires little resources and could be completed in one setting (Polit et al., 2013). However, if a dominant member would be included in a focus group discussion, interactions would be limited (Burns and Grove, 2013). This could be avoided with a facilitator who knows how to redirect the discussion to all members of the focus group. A stregnth of the study of Dermot et al. (2014) is the presentation of a rationalisation on why they used a combination of focus groups and in-depth interviews. It should also be noted that participants with dementia might display cognitive impairments, depending on the stage of their illness. Hence, requiring these patients to explain their experiences in more depth might be challenging. However, the investigators tried to mitigate this challenge by including carers of the patients as part of the study participants. Inclusion of carers could provide researchers with more detailed information on how music impacts the wellbeing and quality of life of the patients since these carers are more acquainted with the individuals suffering from dementia (Miranda-Castillo et al., 2010). It is also noteworthy that music therapy was individualised to the patients in the study. Thi s suggests that comparison of music therapy received by the patients was not done. Instead, investigators focused on the impact of music therapy on the patients’ wellbeing. In addition, the study did not take into account the differences in music interventions and whether this shaped the individual’s reaction to music therapy. Despite the differences in music intervention, it was common for the music therapists to use songs that were well-known to the patients. They also supported active music therapy with exploratory improvisation. Dermot et al. (2014), however, failed to explain what is exploratory improvisation or how this was done during music therapy. There was also an explanation on the content of the guides used for the in-depth interviews and focus group discussions. This was essential to demonstrate the coverage of the interview guides and whether each guide reflects the aims and objectives of the study (Moule and Goodman, 2009). However, the relationship between the researchers and the participants was not thoroughly discussed. If the participants knew the investigators, this might lead to potential bias especially if the researchers hold positions of power (Oermann, 2010). Despite this limitation, Dermot et al. (2014) emphasise that only one facilitator guided the focus group discussions. There were changes in the methods used during data collection. For instance, where a focus group discussion was initially decided, this was then changed to individual interviews in the second group of patients and healthcare workers. Dermot et al. (2014) explain that the severity of dementia of the patients was considered in the choice of d ata collection. In-depth interviews were used when patients had severe dementia. There were also sufficient details on how participants were recruited and whether ethical standards were observed. Polit et al. (2013) state that ethics in research is crucial to ensure that the rights of the participants were observed and they were not subjected to undue stress or negative experiences during data collection. Confidentiality was also observed in the study and all participants remained anonymous. Approval was also sought from an ethics board in the community settings. Data analysis of qualitative data could be extensive and time consuming (Parahoo, 2006). Informing readers how data was analysed would help increase the rigour of a qualitative study. Dermot et al. (2014) provided an in-depth description of how data was analysed. Thematic analysis was also used to present the main findings of the study. There was also a clear description on how categories and themes emerged. For instance, the long-table approach was used during analysis of data. Verbatim transcripts wer e used to support the main themes. This ensures validity and credibility of the main themes generated in the study (Polit et al., 2013). Contradictory data were also taken into account. The researchers also critically examined their own roles in the research process and the potential bias that might arise during analysis of research data. While respondent was not done, validity and credibility of the data were observed through constant comparison of categories and themes. More than one researcher was involved in the analysis of data. Professors and doctoral students of the Doctoral Programme in Music Therapy were also consulted during thematic analysis and were involved in identifying categories. Importantly, findings were discussed with reference to the original research question. A discussion was also made on the relevance of the study to dementia care. Findings of this study suggest that music is a medium that is readily accessible to patients with dementia. Many of the patients, their carers and healthcare staff admitted that music promotes mental stimulation and is an emotionally meaningful experience. Almost all participants also remarked that song lyrics with personal meanings helped patients remember their personal history. It is also perceived to reinforce personal and cultural identity. Music is also perceiv ed to promote connectedness and building and sustaining of relationships. In addition, music has immediate effects on the mood of the patients. Most of the staff members who participated in the focus group discussions remarked that agitation of the patients decreased as a result of music therapy. It is also shown to promote a relaxing environment in the care homes. On the other hand, listening to music in the lounge area could be challenging since care home residents might have different music preferences. Hence, it would be a challenge for healthcare workers to address all the music preferences of the patients. Since the study was qualitative, transferability of the findings to a larger and more heterogeneous population is impossible (Polit et al., 2013). However, other healthcare practitioners could use findings to help build a peaceful environment for patients suffering from dementia. A further review of the study also shows that the conclusion summarises the main points raised in the study and provides recommendations for other researchers to consider in similar studies in the future. Implications of Findings in Nursing Practice Findings of this literature review could be used to improve nursing practice when caring for patients with dementia. All three studies (Simmons-Stern et al., 2012; Sakamoto et al., 2013; Dermot et al., 2014) included in this literature review demonstrate the impact of music therapy on patients with dementia. Music therapy could improve health outcomes and quality of life of the patients from early to advanced stages of the disease. In the latter, patients who have difficulty communicating their needs, react positively to music therapy. Many of the patients with severe dementia show less agitation when exposed to music that was once relevant to them before they suffered from dementia. This suggests that music therapy could even not only promote positive mood of the patients but might even reconnect them to ‘who they are’ (Dermot et al., 2014). This holds important implications in nursing practice in community settings. Music therapy could be introduced to families caring for a loved one with dementia and could be used to calm the patient, reconnect with their family members and create an environment that is less stressful for the individual with dementia. The type of music therapy, however, will be dependent on the preferences of the individual (Sakamoto et al., 2013). This is consistent with patient-centred care (Department of Health, 2009) where patient preferences are considered when creating a care plan or introducing healthcare interventions. It is suggested that interactive music therapy (Simmons-Stern et al., 2012; Sakamoto et al., 2013) might be more effective than passive music therapy in improving memory and mood of the patients with dementia. As a community nurse, I need to be aware of the different non-pharmacologic interventions for people with dementia. I can use findings of this review when caring for patients suffering from dementia. Music therapy is relatively easy to carry out and entails very little cost. Importantly, it has positive short and long-term impacts on patient’s mood, memory and quality of life. Hence, considering this type of intervention could also help ease the burden of carers who provide care to these patients on a daily basis. I could use information from this literature when conducting patient education. I can inform my patients and their family members of the benefits of music therapy and the sustainability of this type of therapy over time. I can also encourage family members to consider music therapy to help alleviate the mood of the patients and provide a calm environment. Conclusion This literature review has shown the feasibility and promise of music therapy in promoting wellbeing, improving memory and quality of life of patients with dementia. As a community nurse, music therapy could be employed with the help of a music therapist in community settings. Families and carers could be taught on how to use this type of therapy to improve the mood of the patient or to calm the individual when agitated. This type of therapy holds some promise in long-term care for people with dementia. As shown in the review, individuals with severe dementia still have the ability to respond positively to music therapy. However, consideration should still be made on the applicability of the findings of the three studies to a larger and more heterogeneous population. All studies recruited a relatively small sample size that might not be representative of the experiences of a wider group of people with dementia. Although this limits applicability, findings can be tailored to the needs of individual patients. Considerations should also be made on the preferences of the patients and their family members on whether music therapy is acceptable to them. Since there is a need to practice patient-centred care, nurses have to determine if patients or their family members are willing to employ music therapy. It should ne noted that this literature review is only limited to reviewing three studies. Literature on the acceptability of music therapy was not evaluated. Despite this gap in the present literature review, the positive responses generated after music therapy should help patients and their family members consider music therapy. References Aveyard, H. (2014) Doing a literature review in health & social care: A practical guide. 2nd ed. Berkshire: Open University Press. Baird, A. & Samson, S. (2009) Memory for music in Alzheimer’s disease: unforgettableNeuropsychology Review. 19(1), p. 85–101. Brown, S. (2009) Evidence-based nursing: the research-practice connection. Sudbury Mass: Jones & Bartlett Publishers. Burns, N. & Grove, S. (2013) The practice of Nursing Research: Conduct. critique and utilisation. 7th ed., St. Louis: Elsevier Saunders. Critical Appraisal Skills Programme (2013) 10 questions to help you make sense of qualitative research. England: CASP. Crookes, P. & Davies, S. (2004) Research into practice. Essential skills for reading and applying research in nursing and healthcare. 2nd ed. Edinburgh: Bailliere Tindall. Cuddy, L. & Duffin, J. (2005) Music, memory, and Alzheimer’s disease: is music recognition spared in dementia, and how can it be assessedMedical Hypotheses. 64(2), p. 229–235. Department of Health (2013a) Care in local communities: A new vision and model for district nursing. London: Department of Health. Department of Health (2013b) Improving care for people with dementia [Online]. Available from: https://www.gov.uk/government/policies/improving-care-for-people-with-dementia (Accessed: 5 December, 2014). Department of Health (2009) Living Well with dementia: A National Dementia Strategy. London: Department of Health. Ellis, P. (2010) Understanding research for nursing students. Exeter: Learning Matters. Fornazzari, L, Castle, T. & Nadkarni, S. (2006) Preservation of episodic musical memory in a pianist with Alzheimer disease. Neurology. 66(4), p. 610–611. Greenhalgh, T. (2010) How to read a paper: the basics of evidence-based medicine. West Sussex, UK: John Wiley and Sons. Hansen, V., Jorgensen, T. & Ortenblad, L. (2006) Massage and touch for dementia. Cochrane Database of Systematic Reviews. 4, p. CD004989. Hek, G. & Moule, P. (2011) Making sense of research. 4th ed. London: Sage. Long, A., Godfrey, M., Randall, T., Brettle, A. & Grant, M. (2002) Developing evidence based social care policy and practice. Part 3: Feasibility of undertaking systematic reviews in social care. Leeds: Nuffield Institute for Health. McDermot, O., Orrell, M. & Ridder, H. (2014) The importance of music for people with dementia: the perspectives of people with dementia, family carers, staff and music therapists. Aging & Mental Health. 18(6), p. 706-716. Menard, M. & Belleville, S. (2009) Musical and verbal memory in Alzheimer’s disease: a study of long-term and short-term memory. Brain and Cognition. 71(1), p. 38–45. Miller, C. (2009) Nursing for wellness in older adults. Philadelphia: Lippincott Williams and Wilkins. Miranda-Castillo, C., Woods, B., Galboda, K., Oomman, S., Olojugba, C. & Orrell, M. (2010) Unmet needs, quality of life and support networks of people with dementia living at home. Health and Quality of Life Outcomes. 8:132 doi: 10.1186/1477-7525-8-132. Morris, G. & Morris, J. (2010) The dementia care workbook. London: McGraw-Hill International. Moule, P & Goodman, M. (2009) Nursing Research: An Introduction, London: Sage Publishers. National Institute for Health and Clinical Excellence (NICE) (2009) Depression: The treatment and management of depression in adults. London: NICE. Nursing and Midwifery Council (NMC) (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. London: NMC. Oermann, M. (2010) Writing for publication in nursing. 2nd ed., Philadelphia: Lippincott Williams & Wilkins. Parahoo, K. (2006) Nursing Research: Principles, Process and Issues. 2nd ed. New York: Palgrave Macmillan. Polit, D., Beck, C. & Hungler, B. (2013) Essentials of nursing research, methods, appraisal and utilization. 8th ed., Philadelphia: Lippincott Williams & Wilkins. Ross, T. (2012) A survival guide for health research methods. Maidenhead: OUP. Sakamoto, M., Ando, H. & Tsutou, A. (2013) Comparing the effects of different individualized music interventions for elderly indivduals with severe dementia. International Psychogeriatrics. 25(5), p. 775-784. Simmons-Stern, N., Deason, R., Brandler, B., Frustace, B., O’Connor, M., Ally, B. & Budson, A. (2012) Music-based memory enhancement in Alzheimer’s disease: promise and limitations. Neuropsychologia. 50(14), p. 3295-3303. Spector, A., Orrell, M. & Woods B. (2010) Cognitive Stimulation Therapy (CST): effects on different areas of cognitive function for people with dementia. International Journal of Geriatric Psychiatry. 25(12), p. 1253–1258. Talbot, L. & Verrinder, G. (2009) Promoting Health: The Primary Health Care Approach. Australia: Elsevier Australia. Teri, L., Gibbons, L., McCurry, S., Logsdon, R., Buchner, D., Barlow, W., Kukull, W., LaCroix, A. McCormick, W. & Larson, E. (2003) Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial. Journal of the American Medical Association. 290(15), p. 2015–2022. Vink, A., Birks, J., Bruinsma, M. & Scholten, R (2004) Music therapy for people with dementia. Cochrane Database of Systematic Reviews. 4, p. CD003477.