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Running Head: CRITIQUE OF COMPLEMENTARY MUSIC THERAPY

Critique of the effect of complementary music therapy on the patients postoperative state
anxiety, pain control, and environmental noise satisfaction
Andrew Adlaon
Southwestern Adventist University

NURSING RESEARCH
NURS 421
Lenora D. Follett, PhD, RN
July 21, 2014
Information about the Authors
Tressa Comeaux, APRN, FNP-C, CEN is a CICU Staff Nurse and part of Patient Care
Services at Our Lady of the Lake Regional Medical Center in Baton Rouge, LA.
Susan Steele-Moses, DNS, APRN-CNS, AOCN, is the Research Director of Academic
Affairs in Our Lady of the Lake Regional Medical Center in Baton Rouge, LA.
Brief Summary of the Article
The purpose of the study was to determine the effect of music therapy on state anxiety,
pain management, and environmental noise perception on postoperative patients in addition to
traditional analgesics. A quasi-experimental non-equivalent control group design was used in this
study with participants assigned based on room assignment rather than randomly. Participants in

CRITIQUE OF COMPLEMENTARY MUSIC THERAPY

A hallway were the control group and received the standard of care. Those in B hallway received
the intervention of complementary music therapy in addition to the standard of care. Each
participant was enrolled for a total of 3 days or until discharge, whichever came first. Data was
collected upon enrollment (Time One) and for the next 2 consecutive days (Time Two and Time
Three). The intervention was instructed listen to non-lyrical low decibel (less than 60 db) preprogrammed music, for at least 30 minutes after their prescribed analgesia was given.
State trait anxiety, pain, and environmental noise satisfaction were assessed using the StateTrait Anxiety Inventory and two standardized questionnaires. The findings
suggest music therapy may decrease pain and environmental noise perception, but may have no
effect on state anxiety. Use of music therapy could improve patients' postoperative experience by
increasing their pain management and white noise satisfaction.

Critique of the effect of complementary music therapy on the patients postoperative state
anxiety, pain control, and environmental noise satisfaction

Introduction
Research Problem
The overriding problem this article addressed in the very first sentence was unrelieved
postoperative pain. The first paragraph points out that while analgesics can mitigate many
instances of pain, postoperative pain is often present with drug therapy alone (Comeaux &
Steele-Moses, 2013, p. 313). The article builds a very persuasive argument that music therapy, in
addition to traditional analgesics, can alleviate some of that pain by lowering anxiety levels,
providing a distractor from hospital environmental noise, and promoting relaxation.

CRITIQUE OF COMPLEMENTARY MUSIC THERAPY

The research problem is of great significance to nursing because any method that can
possibly reduce patient pain will only enhance the patient experience since a patients
postoperative comfort and well-being will increase as pain level decreases. Complementary
music therapy for pain management could make substantial contributions to nursing practice and
policy because it is a relatively inexpensive and easy treatment to apply. The research problem
and the way the research was conducted fits well within the boundaries of the positivist
paradigm.
Purpose and Hypothesis
The research article had a very clear heading which labeled the purpose and the hypothesis, but
did not have an obvious research question. The purpose of the study was to determine the effect
of music therapy on state anxiety, postoperative pain, and environmental noise perception, and
the hypothesis was: Music therapy will decrease state anxiety, increase pain management
effectiveness, and increase environmental noise satisfaction in postoperative patients (Comeaux
& Steele-Moses, 2013, p. 315).
The hypothesis specified the variables being studied with music therapy (anxiety, pain,
and environmental noise), and properly identified the population as postoperative patients
(Comeaux & Steele-Moses, 2013, p. 315). The basis of the hypothesis flowed from other
research that found music therapy to be beneficial in promoting relaxation, decreasing anxiety,
and perceived pain. The hypothetical prediction was justifiable since it wished to see if the
analgesic effects of music translated to postoperative patients in a controlled environment. All in
all, the research hypothesis was plainly worded and clearly stated its prediction that music would
decrease anxiety, increase pain management, and increase environmental noise satisfaction in
postoperative patients.

CRITIQUE OF COMPLEMENTARY MUSIC THERAPY

Theoretical Framework and Definitions


The researchers used a theoretical delivery model called Relationship-Based Care (RBC)
that emphasize care of self, care of colleagues, and care of patients and families(Comeaux &
Steele-Moses, 2013, p. 313). This was an appropriate framework that helped link the study
purpose with the theoretical model since the study is focused on improving care of patients.
Literature Review
Review of the Literature
Comeaux and Steele-Moses literature review was up-to-date with the majority of articles
going back five years. The review included primary studies from sources like the American
Music Therapy Association and the Joanna Briggs Institute, though there was one source by
Binns-Turner, P.G. (2008) that was an unpublished dissertation (Comeaux & Steele-Moses, 2013,
p. 313). The review was not a simple summary, but compared various other studies to show the
relationship between music therapy, postoperative pain/anxiety, and environmental noise. It was
very well organized and had multiple headings throughout. The researchers state that music
therapy can promote relaxation and distraction from pain, but there is limited research that focus
on pain management in postoperative patients specifically (Comeaux & Steele-Moses, 2013, p.
314). This supports the reasoning behind the need for this study. The wording and language was
appropriate and objective, and the ideas were developed clearly.
Description of Sample
Sample
The study identified the population as those who have postoperative pain. The paper
outlined sample inclusion criteria as patients admitted to the surgical unit who: anticipated a 3day hospital stay, were alert/oriented, aged 18 or older, able to read/write English, and

CRITIQUE OF COMPLEMENTARY MUSIC THERAPY

hematology-oncology diagnosis. The researchers obtained a convenience sample total of 41


participants and split them into two groups. Group A contained 22 people and was to be the
control that received the standard of care. Group B contained 19 people who were to receive the
music therapy in addition to the standard of care (Comeaux & Steele-Moses, 2013, p. 315).
Since a convenience sampling design was used, the sampling plan can definitely be
improved. Using any form of the various probability-sampling methods (random, simple random,
stratified random, etc.) would be a stronger alternative to the convenience sampling used. The
design they used was not one that could yield a very good representative sample of the
population, and the sample size was very small with only 19 people receiving the intervention.
However, the small sample selection is probably due to the fact that this is a pilot experiment and
only a part of a larger study.
Pilot studies are usually small-scale studies that help evaluate the sample size, cost, and
time in order to improve the full-scale research study. The use of power analysis and sample
mortality was not mentioned. It is unclear whether vulnerable populations (economically
disadvantaged, pregnant, elderly, etc.) were used because only gender and race (Caucasian and
African American) were given in the demographic data (Comeaux & Steele-Moses, 2013, p.
315). However, the inclusion criteria included those 18 or older and those alert and oriented, so
vulnerable people like children and the mentally ill were not used.
Design and Procedures
Research Design
The design used in this study was a quasi-experimental non-equivalent control group
type. Patients in hallway A were in the control while the patients in hallway B were in the
intervention group. A total of three surveys that measured anxiety state, pain management

CRITIQUE OF COMPLEMENTARY MUSIC THERAPY

satisfaction, and environmental noise satisfaction were used. The first survey was to be filled by
the participants at enrollment (Time One), the second survey to be filled one day after (Time
Two), and the last survey to be filled on the third day or at discharge, whichever came first (Time
Three) (Comeaux & Steele-Moses, 2013, p. 315).
The intervention consisted of pre-programmed MP3 players, in addition to the usual
standard of care. The players contained non-lyrical low decibel (<60dB) music, and those in the
intervention group were encouraged to listen the songs for at least 30 minutes after the
prescribed analgesia was given. Patient anonymity was kept intact by placing surveys into
envelopes that contained hallway assignment, participant number, and day of completion.
This was not the most rigorous design that could have been used because the separation
of the control and intervention groups was not based on randomness, but on the hallway at which
they were admitted. Patient analgesia was not controlled and his may have influenced some of
the perceived pain levels in both groups. The study also reports that some patients may have
listened to their own music and skewed some findings. Data was collected at one-day intervals
for three consecutive days for a total of three data points. Since the study was looking at how
music affected pain, a few more data collection points may be useful because pain can change
fairly quickly and is not always constant over a three-day period.
To enhance statistical conclusion validity the researchers used a calculated probability
value of 0.001 (Comeaux & Steele-Moses, 2013, p. 316). In the world of statistics, a P<0.001 is
statistically highly significant (less than 1 in 1000 chance of being wrong). The intervention
effectiveness was analyzed over time, and the pain management and environmental noise
satisfaction t-scores were 7.385 and 4.371, respectively (Comeaux & Steele-Moses, 2013, p.
316). These results pointed to a dramatic improvement in both pain management and noise

CRITIQUE OF COMPLEMENTARY MUSIC THERAPY

satisfaction. However, there was no statistical evidence of a change in state anxiety (t=1.47;
p=0.159) (Comeaux & Steele-Moses, 2013, p. 316).
Data Collection
Patients were asked to complete a 20-item State-Trait Anxiety Inventory (STAI) Form Y1 that measured state anxiety feelings like calm or nervousness. Another 20-item STAI Form Y-2
was used to measure trait anxiety feelings like inadequacy or happiness. Two other standardized
questionnaires were implemented to measure satisfaction with pain management and
environmental noise. The questionnaires used a 4-point Liker scale to enhance data quality.
After the initial survey (Time One) and the two follow-up surveys (Time Two and Three) were
finished, all three questionnaires were placed in individual white envelopes. The three envelopes
were then placed into a manila envelope containing only the hallway assignment, participant
number, and day of completion to maintain patient anonymity.
All of the data used came from self-reports in questionnaires. Adding more methods like
observation and bio-physiologic measures would help strengthen the findings found because
self-reports do come with its own weaknesses. How can we be sure the participants really felt the
way they said they did? Did they report less pain in order to please or help the researchers?
While the questionnaires are easier to implement and replicate, the researchers state that
the questionnaire was tedious, and somewhat repetitive. This may have skewed some of the
results from patients just jotting down answers to get it over with. A stronger method of selfreport would have been face-to-face interviews. This would also allow the interviewer to observe
the participants behavior and facial expressions that could help interpret the responses of
participants. The procedures for data collection were effective in maintaining patient anonymity.

CRITIQUE OF COMPLEMENTARY MUSIC THERAPY

This study was provided exempt status by the Nursing Research Council and Clinical Research
Steering Committee of OLOL-RMC (Comeaux & Steele-Moses, 2013, p. 315)
Data Analysis and Results
Tool
There were a total of four surveys used to gather patient data: STAI Form Y-1, Stair Form
Y-2, a pain management questionnaire, and an environmental noise questionnaire. The StateTrait Anxiety Inventory (STAI) Form has two subscales: STAI Form Y-1 and STAI Form Y-2.
Form Y-1 had 20 questions that measured current feelings like calmness or nervousness at that
very moment, and had a Chronbachs alpha of 0.62. STAI Form Y-2 contained 20 questions that
measured the usual emotion feelings they felt all the time like inadequacy or happiness, and had
a Chronbachs alpha of 0.86. The pain management questionnaire contained a single item:
During the previous 24 hours, I am satisfied with my pain control. The environmental noise
questionnaire had one item as well: During the previous 24 hours, I am satisfied with the noise
level in and around my room (Comeaux & Steele-Moses, 2013, p. 315). Both questionnaires
used a 4-point Likert scale to rate the item from 1 (not at all) to 4 (very much so. The coefficient
of determination for the pain and noise questionnaire was 0.72 and 0.74, respectively (Comeaux
& Steele-Moses, 2013, p. 315).
Measurement
The paper offers measurement reliability by including the Cronbachs alpha values and
the coefficients of determination for the various surveys. The cited study for the STAI inventory
was based on a study from 1970, and forms Y-1 and Y-2 had alpha values of 0.62 and 0.86,
respectively. Cronbachs alpha values measure internal consistency, and the closer the values are
to 1.0, the better. Since the Y-1 form measuring current state feelings was below 0.7, the results

CRITIQUE OF COMPLEMENTARY MUSIC THERAPY

for that test should be taken with caution. The Y-2 form measuring usual emotional feelings
appears to have adequate reliability.
The pain and noise questionnaires were based on a study from 2010, and had coefficients
of determination of 0.72 and 0.74, respectively. A coefficient of determination measures how
much of the response variable can be explained by the explanatory variables. Both questionnaires
had over 70% correlation to the variables being tested (pain management and environmental
noise), with the other 28%-26% resulting from other factors. Since coefficients of determination
range from 0.00 to 1.00, the values of both questionnaires indicate fairly strong reliability in the
surveys.

Statistical Analysis
The paper outlined descriptive statistics to summarize the demographics of the sample
and showed all the different variables (state/trait anxiety, pain management/environmental noise
satisfaction) and the results of a comparative analysis together on a table. The researchers used a
paired t-test to compare the mean differences within groups, and an independent t-test to analyze
the groups themselves.
Both tests were appropriate tests since it was a comparison of only two groups. The
findings suggest a statistically significant improvement in pain management satisfaction and
environmental noise satisfaction. However, there was no statistically significant change in state
anxiety. The statistical information was organized clearly, and the table was easy to read. Overall,
the findings appear to support the hypothesis that musical therapy can aid postoperative patients
with pain and environmental noise management.

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Discussion
At Time One, environmental noise satisfaction was slightly higher in the control group
compared to the music group. The researchers attributed this discrepancy to renovations on the A
hallway. That hallway had the beds behind a double wall and further from the door, and acoustic
tiles in the room (Comeaux & Steele-Moses, 2013, p. 317). While this difference in experimental
atmosphere between the two groups can be a credible threat to the findings, the main outcome of
pain management is not affected by the different room layouts. In the end, the outcomes of the
study partly support the hypothesis that music therapy can aid traditional analgesics in managing
pain and environmental noise satisfaction.
However, the results did not support the theory that music would have an effect on state
anxiety. The article addresses the lack of supporting evidence for music therapy on state anxiety
by pointing out that most of the patients on the unit had surgical oncology diagnoses. If the
diagnoses were relatively new, it is understandable how music would have little affect on their
current anxiety.
Nursing Implications
The authors state that the nursing implications are profound because it provides evidence
that music, a relatively easy and inexpensive therapy, can be used to increase pain management
and environmental noise satisfaction in postoperative patients. The paper suggests the hospital
provide mp3 players with disposable ear buds to patients, or to simply encourage family
members to bring their own devices and play music for the patient.
While letting the family bring their own device to play music seems appropriate, the
selection of music should also be taken into account. The study used non-lyrical low decibel
music for at least 30 minutes after receiving analgesia. The paper does not mention any studies

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that used lyrical vs. non-lyrical music for music therapy, but it is something to consider since
patients may listen to popular lyrical music instead of instrumentals.
Limitations and Recommendations
The researchers do a very good job in pointing out specific study limitations and the
recommendations for future research. They point out the lack of randomness in patient
assignment, and included reports of patients in the control group who listened to their own music
or on the television. Since this was a pilot study, the researchers advocate duplicating the study
with a larger sample and various patient populations. Lastly, they admit the STAI Questionnaire
may have been tiresome and repetitive to some of the patients, especially the ones with new
oncological diagnoses. The researchers suggest implementing the intervention earlier in the
preoperative phase may give additional benefits.
Conclusion of Student
Overall, I think the study holds merit in showing the effect of music on managing pain
and environmental noise. The results are certainly relevant to me because Ive always noticed
that Im able to exercise and push through more pain when I listen to music, but thats just some
anecdotal evidence because I know people who prefer no music during exercise.
One advantage of the study is the relatively cheap cost. With the majority of phones being
able to play music, it would be very easy to supply patients with non-lyrical songs for therapy.
However, I feel that the results of this study should be found in more studies before the practice
is implemented everywhere.

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Reference

Comeaux, T., & Steele-Moses, S. (2013). The effect of complementary music therapy on the
patient.Medsurg Nursing, 22(5), 313-318. Retrieved from
http://proxy.swau.edu:2055/login.aspx?
direct=true&db=c8h&AN=2012328345&site=ehost-live