1
DESCRIPTIVE STUDY TO ASSESS THE EFFECTIVENESSOF CLASSICAL MUSICAL THERAPHY ON PSYCOLOGICAL AND BEHAVIOUR PARAMETERS AMONG PRETERM NEONATES ADMITTED IN NICUWITH RESPIRATORY DISTRESS
M.Sc. Nursing Dissertation Protocol submitted to
Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore.
By
Miss. DEEPTHIMOL K P
M.Sc. NURSING 1ST YEAR
2009-2011
Under the Guidance of
HOD, Department of Paediatric Nursing
Josco College of Nursing
Nelamngala,
Bangalore -562 123
Karnataka
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE,KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 / NAME OF THE CANDIDATE / Miss. DEEPTHIMOL K P2 / NAME OF THE INSTITUTE / JOSCO COLLEGE OF NURSING,
NELAMNGALA,BANGALORE
3 / COURSE OF STUDY AND SUBJECT / MSc NURSING 1st YEAR
PAEDITRIC NURSING
4 / DATE OF ADMISSION OF COURSE
5 / TITLE OF THE TOPIC / DESCRIPTIVE STUDY TO ASSESS THE EFFECTIVENESS OF CLASSICAL MUSICAL THERAPHY ON PSYCOLOGICAL AND BEHAVIOUR PARAMETERS AMONG PRETERM NEONATES ADMITTED IN NICUWITH RESPIRATORY DISTRESS
6 / BRIEF RESUME OF THE STUDY
6.0 INTRODUCTION
6.1 NEED FOR STUDY
6.2 REVIEW OF LITERATURE
6.3 STATEMENT OF THE PROBLEM
6.4 OBJECTIVES OF THE STUDY
6.5 OPERATIONAL DEFENITIONS
6.6 HYPOTHESIS
6.7 ASSUMPTION
6.8 LIMITATION
6.9 PROJECTED OUT COME / ENCLOSED
7 / MATERIALS AND METHODS
7.1 SOURCE OF DATA
7.2 METHODS OF DATA COLLECTION / ENCLOSED
8 / BIBILOGRAPHY / ENCLOSED
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE
PERFOMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1. / Name of the Candidate andAddress (in block letters) / Miss. DEEPTHIMOL K P
2. / Name of the Institution / JOSCO COLLEGE OF NURSING
NELAMANGALA,BANGALORE
3. / Course of Study And Subject / M. Sc. NURSING
PAEDIATRIC NURSING
4. / Date Of Admission of Course
5. / Title of the Topic /
DESCRIPTIVE STUDY TO ASSESS THE EFFECTIVENESS OF CLASSICAL MUSICAL THERAPHY ON PSYCOLOGICAL BEHAVIOUR PARAMETERS PRETERM NEONATES ADMITTED IN NICU WTTH RESPIRATORY DISTRESS.
6.0 BRIEF RESUME OF THE STUDY
INTRODUCTION
“Angels live in the heart of kids;
Music is well said to be the speech of angels."
Thomas Carlyle
In the present era of science and technology, where quality is the supreme priority, Quality Of Life can only be accredited by decreased morbidity and mortality rate of newborn. The UNICEF’s Flagship Publication, The State of World’s Children(15th Jan2009) reported that a million neonatal death occurs in India every year.
The popularity and credibility of alternative treatment modalities such as music therapy also have increased over the past decade. Support for the use of music with infants is not limited to music therapy literature; infact, authors in several other fields of study have written about the benefits of using music to create a nurturing environment for infants. Such articles have been published in journals intended for nurses(Hicks, 1995; Olson, 1998; Standley, 2002) physicians (Jones and Kassity, 2001; Marwick,2000)paediatric nurse practitioners (Klein and Winkelstein, 1996) and music educators (Fox, 2000). In this growing field of interest, current research has provided health care professional with many reasons to use music in their repertoire of treatment options for newborns.
6.1NEED FOR THE STUDY
Music benefits documented for full term newborns may also apply to the premature infants, that is, lullabies promote language development,familiar music is recognized, reinforcing and comforting and infants orient to and avidly attend to music more than other auditory stimuli. This burgeoning area of researches provides exciting possibilities for the practice of music therapy in the Neonatal Intensive Care Unit (NICU) and for music education in early childhood(Standley, 2008).
Preterm babies are also having some sort of anxiety and stress even though we are not taking care of.Several studies have shown how music therapy enhances the efficacy of nursing interventions that is the majority of NICU staff preferred live recorded music and music appears to be an acceptable intervention in Neonatal Intensive Care Unit (http//:web.mac.com).
Music therapy is an important intervention that is soothing for the infants. Music therapy can also encourage parental involvement, support infant development and optimize preterm infants’ neuro developmental outcomes (Nordoff and Robbins, 1997; Haselbeck, 2004).
Elena and Nick (2008) reported that music has an effect on the state of paediatric patients, potentially improving the physiological well being of long term hospitalized children when exposed to live music.
The highest mortality among infants is due to prematurity. Prematurely born infant emerges into a hectic, cold, noisy and bright environment filled with
Mysterious equipments and peopled by masked strangers who try to help. Thus the experience in Neonatal Intensive Care Unit contains frequent aversive procedures, excess handling and disturbance of rest, noxious oral medications, noise and bright light. These conditions are sources of stress and anomalous sensory stimulation (Zentner, 1996).
The holistic movement has become a challenge to health care professionals and music is one of the few interventions that can be considered truly holistic. Research and clinical findings support the uses of music in a variety of physical and psychological conditions (
Music alleviates both acute and chronic pain and found a 30% decrease in the use of pain medications with the use of therapeutic music (Herth, 1998).
Whipple and Glynn (1992) stated that soothing music resulted in a significant increase in the pain threshold of 10 healthy female volunteers.
The length of hospitalization was shorter and average daily weight gain was greater for infants, whose parents received training in music, although these differences were not significant. A one month post discharge follow up showed little difference between experimental and control group parent infant interaction in the home (Whipple, 2000).
6.2REVIEW OF LITERATURE
Searching the literature is the first and vital stage of a research. The purpose of literature review is to discover what has previously been done about the problem to be studied, what methods have been employed in other researches, suggestions for further studies etc. The most important types of information for a research review are finding from empirical investigations. Literature review is defined as a critical summary of research on a topic of interest, often prepared to put a research problem in context (Polit and Beck, 2008).
A brief account of various studies conducted by different investigators and a few citations from books, which are found to be relevant to the study are included in this chapter.
6.2.1PRETERM NEONATES AND RESPIRATORY DISTRESS
Preterm babies are babies born of less than 37 completed weeks (Singh, 2004;Kennerand Lott, 2003).
Preterm infants can be categorized by weight as well as gestational age. A child weighing less than1500 grams is considered as very low birth weight infantand 1501 to 2500 grams constitute a moderately low birth weight infant (Wong et al., 2006).
About 10 to 12 % of Indian babies are born preterm as compared to 5 to 7% incidence in the west (Singh, 2004). More than a half million babies in the
United States-that is 1 in every 8- are born premature every year (Centre for Disease control and Prevention, 2008).
The factors contribute to the preterm delivery are late initiation of prenatal care, lower socio economic status and substance abuse (Kenner and Lott, 2003).
Multiple pregnancies (twins, triplets) are another significant factor for preterm birth (March of Dimes, 2006).
Pregnant women exposed to passive smoking or those who smoked are at an increased risk of preterm delivery (Richard, 27 March 2009; Mc Cowan, 2009).
Parenting behaviours, particularly parent child synchrony were associated with neuro behavioural development of preterm infants (Treyvaud et al., 2009).
6.2.2AUDITORY SENSITIVITY OF NEONATES
While newborn human infants are immature beings in many ways, their sense of hearing is actually quite well developed at birth; they are able to detect changes in loudness of only 3 dB and to perceive timbre and pitch much like adults do (Fassbender, 1996).
The neonates often experience some auditory asymmetry in their perception of sound. Specifically, several studies have shown that the right ear is slightly more sensitive to auditory signals than the left ear (Bertoncini et al., 1989; Eldredge and Salamy, 1996; Kei, McPherson et al., 1997).
Typical newborns have immature but functional hearing ability and they are able to discriminate subtle differences between sounds soon after birth (Atkinson and Braddick, 1982).
Four day olds can distinguish between changes in consonant-vowel syllables presented dichotically (Bertoncini et al., 1989).
Even term newborns could be affected by noise in that it hinders their independent attempts to sleep, self-soothe and pay attention (Philbin and Klaas, 2000).
6.2.3NOISE LEVELS IN NEONATAL INTENSIVE CARE UNIT
Noise levels were found to be above the AmericanAcademy of Paediatrics recommended 45 dB levels and the recommended impulse maximum of 65dB was also exceeded inNeonatal Intensive Care Unit(Darcy and Hancock, 2008).
Zahr and De Traversay (1996) pointed out in their study to develop aggressive anti noise policies to substantially and consistently reduce the noise in the Neonatal Intensive Care Unit.
Excess noise in the NICU correlates with a decreased oxygen saturation and an increased heart rate and sleep disturbances (Kellman, 2002).
Exposure to aberrant noise levels in the NICU may cause sensorineural damage, induce stress and contribute to language or auditory processing disorders in the preterm neonates (Schulte, 1997).
One study found that loud noises in the Neonatal Intensive Care Unit significantlychanged the behavioural and physiological responses of infants (Zahr and Balian, 1995).
Exposure to noise in the NICU may result in cochlear damage and the noise may disrupt the normal growth and development of premature infants (American Academy of Paediatrics, 1997; White, 2005).
A study reported that existing NICU environment has very high sound pressure levels (SPL) and this can cause hearing impairment, sleep disturbances, somatic effect, impaired auditory perception and affect emotional development in babies (Gupta, 2005).
Music is credited to ensure autonomic stability, reduce stress and quieten the baby, increases oxygen saturation and reduces heart rate (Singh, 2004).
6.2.4 PRETERM NEONATES’STRESS IN NEONATALINTENSIVE CARE UNIT
Environmental factors in the Neonatal Intensive Care Unit have major implications for the care of the sick newborn infant. Broad evidence implicates the environment in the Neonatal Intensive Care Unitas a factor in neonatal morbidity.
Abnormal sensory input can be a source of potentially overwhelming stress and at a sensitive period during development can modify the developing brain. The NICU environment therefore assumes a crucial role in the care of the sick neonates (Mhairi et al.,2005).
Music has been found to reduce stress hormones and enhance the immune system, which allows healing to occur more rapidly in sick patients (Knight, 2001).
Classical music strengthens our natural regulatory and recovery processes and is particularly noticeable in the relief of the physical, mental and spiritual effects of stress (WHO stress conference, 1995).
6.2.5THERAPEUTIC USES OF CLASSICAL MUSIC THERAPY
The term classical music originates from the Latin term classicus, meaning taxpayer of the highest class. The origins of Indian classical music can be found from the oldest of scriptures, part of the Hindu tradition, the Vedas.
Haydn has been referred to as the “Father of classical music”. Indian classical music is monophonic in nature and based around a single melody line which is played over a fixed drone. The performance is based melodically on particular ragas and rhythmically on talas (
Many styles of music exist within classical music; the most recognizable being the symphony, opera, choral works, chamber music, Gregorian chant, the madrigal, and the Mass.
Music can enhance the immediate environment provide a diversion and lessen the impact of potentially disturbing sounds for paediatric patients (Barrera, Rykovet al., 2002; Klein and Winkelstein, 1996).
Classical music decreased the tension but had little effect on other feelings (Mc Craty, Barrios et al., 1998).
Music has been found to be an effective anxiolytic for patients undergoing anxiety-producing procedures and allows for less pain medications, less sedatives and an increased recovery time (Miluk, 1994).
Classical music can decrease patient’s perceptions of, and responses to pain, even in very young premature infants (Butt, Kisilevsky, 2000; Joyce, Keck et al., 2001).
Nursing pioneering leader Florence Nightingale (1860) recognized the healing power of music. Today nurses can use music in a variety of settings to benefit patients and neonates.
6.2.6EFFECT OF CLASSICAL MUSIC THERAPY ON PHYSIOLOGICALPARAMETERS
Classical music has an effect on the state of paediatric patients, potentially improving their physiological and psychological wellbeing (Elena and Nick, 2008).
When compared with recorded music or no music therapy; live music therapy is associated with a reduced heart rate at 30 minutes after music therapy in stable preterm neonates (Shmuel et al., 2006).
Taped intrauterine sounds combined with female vocal singing resulted in significant reduction in agitated behaviours and improved oxygenation in newborns (Collins, 2001).
Music listening increases oxygen saturation levels in neonates (Cassidy and Standley, 1995; Collins and Kuck, 1991; Standley and Moore, 1995).
Live music therapy is associated with a reduced heart rate at 30 minutes after music therapy (Staneslow et al., 2006).
6.2.6EFFECT OF CLASSICAL MUSIC THERAPY ON BEHAVIOURAL RESPONSES
When examining infant’s overt responses to stimuli, researchers must be wary of interpreting their movements as purposeful; newborns have undeveloped motor skills and thus, a limited capacity for deliberate movements. One way to consistently observe behaviours for an entire population of infants is to use a standard scale and that scores based on a general state of alertness. In studies using behaviour state as a dependent variable, music generally has a stabilizing effect on alertness. The incidence of stress and anxiety behaviours may be reduced when exposing the newborns to music therapy (Burke et al., 1995; Caine, 1991; Larson and Ayllon, 1990; Leonard, 1993; Whipple, 2000).
Listening to music can cause behaviour state to decrease overall(Burke, Walsh et al., 1995) return to normal following a stressful intervention (Butt and
Kisilevsky, 2000) or reduce lability (Collins andKuck, 1991; Kaminski and Hall, 1996).
Live music significantly reduced the behavioural distress and it was especially effective for children of one year old and younger who were receiving needle sticks (Malone, 1996).
Live music therapy is associated with a deeper sleep at the 30minutes after therapy (Staneslow et al., 2006).
Live music therapy is associated with a reduced heart rate and a deeper sleep at 30 minutes after therapy in stable preterm neonates(Shmuel et al., 2006).
Auditory stimulation in the form of heart beat lengthened the duration of quiet sleep period. Some NICUs have urged using sound as a protective window for the infant-when music is played, the infant will not be disturbed (Schulte, 1997).
6.2.7CLASSICAL MUSIC THERAPY AND ITS EFFECTS ON RESPIRATORY DISTRESS
The hospital care of premature and low birth weight infants requires expensive technology and experienced care. Many studies have looked at the institution of developmental care in the Neonatal Intensive Care Unit.
Significant increase in oxygen saturation was found with the use of classical music therapy in neonates (Malinova et al., 2004).
When lullaby music was played in theNeonatal Intensive Care Unit, there were less episodes of oxygen desideration in preterm neonates (Caine, 1991).
A study involving premature infants’ exposure to harp music resulted in overall a significantly lower salivary cortisol level and lowers the respiratory rate (Block and Jennings, 2003).
If a baby suffered from lack of oxygen during his prenatal development, no matter whether he is premature or not, his activity of cell ferments is lowered. After listening to classical music, activity of babies’ cell ferments rose. They took babies’ blood pressure, pulse, rhythm of breathing and they observed a classical reaction of adaptation and improved the oxygenation status (Mikheeva, 2006).
6.3STATEMENT OF THEPROBLEM
Study to assess the Effect of Classical Music Therapy on Physiological and Behavioural Parameters among Preterm neonates admitted in Newborn Nursery of selected Paediatric Hospitals in Bangalore city.
Preterm deliveries, 8 to 10% of live births in the United States account for roughly 75 to 80% of neonatal morbidity and death(Kennel and Lott, 2003; March of Dimes,2003).
Prematurity and low birth weight (LBW) contributes to more than 85% of neonatal mortality. Neonatal survival is a very sensitive indicatorof population growth and socio economic development. The issue of neonatal death is a serious national health concern especially in developing countries where 96% of the World’s approximate 5 million annual neonatal deaths occur (WHO 2006).
The global burden of neonatal deaths is estimated to be 5 million, of which 3.2 million deaths occur during the first week of life. Almost a quarter of these deaths are shared by India with three babies dying every minuteand every fourth baby born being a low birth weight(Nair, 2006).
The major problems that the newborn encountered are those of adaptation to the extra uterine environment. Premature infants will generally need maximal physiological support and should be cared for in a well equipped intensive care unit(Singh, 2004).
6.4OBJECTIVES OF THE STUDY
- Assess the effect of classical music therapy on physiological parameters in preterm neonates.
- Assess the effect of classical Music therapy on behaviouralparameters in preterm neonates.
- Assess the effect of classical music therapy on the respiratory distress in preterm neonates.
6.5OPERATIONAL DEFINITIONS
Effect
According to Oxford Dictionary “effect” means results of outcome or change produced by action.
In this study, effect is the difference in physiological and behavioural parameters in the preterm neonates during and after classical music therapy.
Classical Music Therapy
It is the use of classical music with a client or groups or in a process designed to facilitate and promote communication, relationship, mobilization, expression, organization and other relevant therapeutic objectives in order to meet physical, emotional, mental, social and cognitive needs.
Preterm neonates
Preterm neonate means babies born of less than 37 completed weeks. In this study, preterm neonates mean babies born of30 to 36 weeks.
Physiological parameters
Physiological parameters are Heart rate(HR), Respiratory rate(RR) and Oxygen saturation(SpO2).