The Use of Patient-Preferred Music to Improve Patient Experience During Interfacility Ambulance Transport Katie L

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Electronic Theses, Treatises and Dissertations The Graduate School

2013 The Use of Patient-Preferred Music to Improve Patient Experience during Interfacility Ambulance Transport Katie L. Myers

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COLLEGE OF MUSIC

THE USE OF PATIENT-PREFERRED MUSIC TO IMPROVE PATIENT EXPERIENCE

DURING INTERFACILITY AMBULANCE TRANSPORT

KATIE L. MYERS

A Thesis submitted to the Department of Music Therapy in partial fulfillment of the requirements for the degree of Master of Music

Degree Awarded: Fall Semester, 2013 Katie Myers defended this thesis on September 16, 2013. The members of the supervisory committee were:

Jayne Standley Professor Directing Thesis

Dianne Gregory Committee Member

Kimberly VanWeelden Committee Member

The Graduate School has verified and approved the above-named committee members, and certifies that the thesis has been approved in accordance with university requirements.

This thesis is dedicated to opening new avenues for the field of music therapy, and to improving the lives of many new clients through music therapy.

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ACKNOWLEDGMENTS

I would like to thank these people, whose support made this thesis possible: Leon County Emergency Medical Services, for being willing to take a risk in allowing me to incorporate music therapy services into an area of emergency medicine that has never provided music therapy services before.

The emergency medical technicians and paramedics of Leon County, for their dedication to their patients, and for willing to become more informed about music therapy in order to help improve patient care.

The patients who were willing to participate in this study, without whom, this study would not have been possible.

Dr. Standley, who was so patient with me, and always able to provide an answer to my every question throughout the research process.

Dr. VanWeelden for making research fun and exciting, and for serving on my thesis committee.

Professor Gregory, for her caring spirit and dedication to improving the field of music therapy, and for serving on my thesis committee.

My fellow music therapy grads, who inspire me to be better every day, and continue to be so eager to collaborate in order to make the field of music therapy the best that it can be.

Elaine, Emily, and Ellyn, for being incredibly supportive and reassuring throughout the thesis process, and for helping me navigate the most difficult parts of graduate school.

My sister Rachel, for being my best friend, and always giving me the encouragement I need to navigate the obstacles in life.

My family, for their constant love and support, and for taking an interest in my journey as a music therapist.

My parents, whose love and support has provided me with countless opportunities to do whatever I set my mind to, and who are the reason for everything I have accomplished.

TABLE OF CONTENTS

List of Tables ...... vi List of Figures ...... vii Abstract ...... viii INTRODUCTION ...... 1 REVIEW OF LITERATURE ...... 3 Interfacility Transport ...... 3 Transport Demographics ...... 3 Patient Experience During Interfacility Transport ...... 4 Ambulance Environment ...... 5 Music Therapy ...... 6 Beneficial Qualities of Music ...... 6 Effectiveness of Music Therapy in Emergency Medicine ...... 8 METHODS ...... 13 Case Study Approach ...... 13 Setting ...... 13 Design ...... 13 Case Study Participants...... 13 Case Study Procedure ...... 14 RESULTS AND DISCUSSION ...... 16 Case Study Results ...... 16 Participant Case Studies ...... 16 Summary Results ...... 18 Case Study Discussion ...... 23 Clinical Recommendations ...... 27 APPENDICES ...... 29

A. HUMAN SUBJECTS APPROVAL FROM FLORIDA STATE UNIVERSITY ...... 29

B. EMT CONSENT TO PARTICIPATION ...... 30

C. CONSENT TO PARTICPATION ...... 31

D. PATIENT SURVEY ...... 33

E. MUSICAL GENRE SELECTIONS ...... 36

REFEERENCES ...... 43

BIOGRAPHICAL SKETCH ...... 47

LIST OF TABLES

1 Table 1: Participant Demographics ...... 14

2 Table 2: Negative Mood Scale Changes ...... 20

3 Table 3: Positive Mood Scale Changes ...... 20

4 Table 4: Pain Scale Changes ...... 20

LIST OF FIGURES

1 Figure 1: Pulse ...... 21

2 Figure 2: Oxygen Saturation ...... 21

3 Figure 3: Systolic Blood Pressure ...... 22

4 Figure 4: Diastolic Blood Pressure ...... 22

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ABSTRACT

The aim of this study is to determine whether there is a significant difference between self- reported scores of anxiety, mood state, and pain levels and the physiological comparison of vital signs when patients are allowed to listen to preferred music during interfacility ambulance transport. The music therapist administered a mood scale prior to and following interfacility ambulance transport, and measured vital signs prior to, during, and following transport for all participants (N=5). In addition, the music therapy intervention of listening to self-selected music on an iPad was provided to the participants in the music condition (n=2). Results determined that music therapy was effective in increasing relaxation and comfort, and in positively impacting the experience of interfacility ambulance transport. Participant feedback on the study questionnaire indicated that 100% patients would prefer listening to their selected genre of music during ambulance transport.

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INTRODUCTION

There is limited research regarding interfacility ground transports, however, the number of interfacility transports has been rapidly increasing in recent years. The cause of recent increases is due to a decrease in the number of hospitals and an increase in the centralization of specialists in high-level hospitals (Koppenberg & Taeger, 2002). Additionally, changes in reimbursement for medical treatment may necessitate transfer to a designated facility that can provide services for payers (National Highway Traffic Safety Administration, 2006). The National Highway Traffic Safety Administration (2006) defines interfacility transfer as “any transfer, after initial assessment and stabilization, from and to a health care facility.” Transports may occur from hospital to hospital, clinic to hospital, hospital to rehabilitation facility, and hospital to long-term care facility (NHSTA, 2006). A wide variety of facilities use interfacility transport services for transfer of patient care, including skilled nursing facilities, physician offices, clinics, custodial care centers, acute care hospitals, home and hospice care facilities, board and care facilities, and urgent care centers (County of Santa Clara County Emergency Medical Services System, 2013). The interfacility transport experience may cause or increase patient stress and anxiety due to separation from family, lack of patient control in decision-making, and other unknown factors, such as an unfamiliar hospital, city, and length of transport (Brown, Tompkins, Chaney, & Donovan, 1998). In addition, patients may be critically ill and have underlying disease stressors (Stuhlmiller, Lamba, Rooney, Chait, & Dolan, 2009). These added disease stressors may manifest as anxiety, which is comprised of a physiological response in the arousal of the autonomic nervous system, in addition to the psychological component involving feelings of powerlessness, apprehension, and impending doom (Stuhlmiller et al., 2009). While there has been such an increase in numbers of interfacility transports, there is still little research about anxiety due to transport, and whether anti-anxiety interventions are successful (Stuhlmiller et al., 2009). The American Music Therapy Association (2013) defines music therapy as “the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program”. Berry (2013) provides a rationale for the necessity of having a music therapist

present to facilitate music therapy interventions, stating that “The key lies in finding the right melody at the appropriate time and place with those (patient or co-worker) to help motivate, inspire, relax, improve concentration or even process emotion.” Music therapy is proven to be highly effective in medical treatment, and has been successfully used with a variety of treatment needs, including respiratory, chronic pain, physical rehabilitation, diabetes, headaches, cardiac conditions, surgery, and obstetrics” (American Music Therapy Association, 2013). Additionally, evidence suggests music therapy may be anxiolytic for patients having dental procedures, cardiac catheterization, surgery, endoscopy, postoperative care, and in intensive care units, emergency departments, and outpatient settings (Stuhlmiller et al., 2009). Medical music therapy promotes anxiety and stress reduction, non-pharmacological management of pain and discomfort, positive changes in mood and emotional states, active and positive patient participation in treatment, and decreased length of stay (American Music Therapy Association, 2013). Music therapy is recognized as a “powerful motivating tool for the medical community”, as Emergency Medical Services personnel identify the benefits of using music to improve patient care during transport through objectives such as providing distraction, “maintaining social order”, facilitating bonding between patients and medical staff, improving patient environment and atmosphere, decreasing anxiety and pain, facilitating relaxation and increasing healing time, improving patient well-being, and maintaining patient circadian rhythms” (Berry, 2013). A study from the Air Medical Journal defines the role of music therapy in emergency medicine as the “the use of music to aid the physiologic, psychological, and emotional integration of the individual during illness.” This study demonstrated improved comfort and relaxation as a result of music listening during transport, as reported subjectively by patients. Results of this study indicated that patients would prefer to have music played during ambulance transports in the future and concluded that music is a “simple adjunct” that could be used during critical care transport to increase patient comfort and decrease anxiety (Stuhlmiller et al., 2009). Due to the success of music therapy in medical treatment and emergency medicine, music therapy is indicated as an ideal treatment adjunct in the ambulance environment. Since no studies have been conducted to address the effectiveness of music therapy in the pre-hospital environment, this study will examine the impact of patient-selected music on the perceived and physiological experience of interfacility ambulance transport.

REVIEW OF LITERATURE

Interfacility Transport Transport Demographics

The U.S. National Highway Traffic Safety Administration conducted a National EMS assessment in 2011 that found 9% of the 13.5 million patients transferred by ambulance required interfacility ambulance transport. Non-urgent medical transfers involved 994, 378 patients (7%), while 244, 543 patients (2%) required specialty care ground transfers, for a total of 1.2 million interfacility transports (Federal Interagency Committee on Emergency Medical Services, 2012). A large percentage of the interfacility transfers of critically ill patients are identified in the emergency department (Gray, Bush, & Whitely, 2004). Many patients report negative perceptions of emergency services, including a lack of explanation regarding wait times, inadequate information regarding care, unsatisfactory quality of care, and unpleasant staff-patient interactions (Wellstood, Wilson, & Eyles, 1982). Gordon and colleagues (2010) also cite negative patient experiences due to fragmentation of care, use of medical jargon, lack of patient advocates, and loss of autonomy and independence. Patients surveyed regarding their experience with emergency services indicated that there is a miscommunication with staff about what aspects of the experience are important: while staff emphasize clinical competence, patients value service delivery (Holden & Smart, 1999). The decision to transport a critically ill patient is made on the basis of several factors, such as assessment of risks and benefits, the need for additional care, and lack of diagnostic, procedural, or specialty services at the current location (Warren et al., 2004). Issues regarding interfacility transfer eligibility include: patient’s clinical stability, facility destination, negotiation of transfer protocol between facilities, availability, timeliness, efficiency, economy, skill level of the transport team, and dosage and medication conversion for the receiving facility (Bosk, Veinot, & Iwashyna, 2011; Nairn, Whotton, Marshal, Roberts, & Swann, 2004). Organizational stressors during the process of transfer, which are the result of an underdeveloped system, can jeopardize the patient’s clinical outcome and may put the patient at risk, prolong pain and suffering, cause dissatisfaction, decrease productivity, and create opportunities for miscommunication (Bosk et al., 2011; Nairn et al., 2004).

In recent years, controversy has ensued regarding patient use of health maintenance organizations (HMO), which dictate transfer to a facility within the HMO’s network in order for the provision of services to be reimbursed under the patient’s healthcare insurance (Selevan, Fields, Chen, Petitti, & Wolde-Tsadik, 1999). When a patient is critically ill, transfer to another facility increases the risk of complications and death, and is considered unnecessary unless the proper resources are non-existent at the current facility. While federal legislation has created quality control regulations that prevent the instances of inappropriate interfacility transport due to financial constraints, many transfers are still necessary to acquire appropriate care (Selevan et al., 1999).

Patient Experience During Interfacility Transport

Patients who are critically ill frequently require transition between multiple care settings, which presents the opportunity for poor transition of care and vulnerability due to lost information. Poorly executed care transitions can cause failure to adhere to treatment plans, misuse of medication, and failure to receive appropriate follow-up care. Additionally, it may result in increased health care spending as a result of adverse outcomes such as lengthened stay in heath care facilities, repeated admission, and negative side effects from medication errors (Jeffs et al., 2012). Because of the severity of their condition, there is an increased risk of morbidity and mortality for critically ill patients (Warren et al., 2004). Due to the critical status of many patients being transported during interfacility ambulance transfers, medical emergencies may arise during transfer, including arrhythmia, cardiac arrest, acute respiratory insufficiency, fits, and hypotension or hypertension (Waddell, Scott, Lees, & Ledingham, 1975). Complications such as tachycardia and septic shock often develop after the completion of transport, as a result of hypotension and hypertension that occur during the transfer (Waddell et al., 1975). Patients that are transported in an ambulance may experience a rise or fall in arterial blood gas and body temperature, which can affect the development of complications and survival rate post transport in critically ill patients. (Waddell et al., 1975). Research regarding ambulance transport states that the effects patients experience during the journey may be either direct or indirect, and patient condition may be influenced by discomfort, pain, and other stimuli, including the motion of the ambulance itself (Waddell et al.,

1975). The Joint Commission on Accreditation of Healthcare Organizations recognizes the critical nature of pain in identifying it as the third most common healthcare problem, and regulates its assessment and treatment by mandating its status as the fifth vital sign (Downey & Zun, 2010). Pain intensity directly correlates to the degree of anxiety a patient feels, as higher pain perception is reported as anxiety increases (Walworth, 2003). Patients believe that pain indicates how serious their condition is, and satisfaction with its management involves the degree and timeliness of relief achieved (Nairn et al., 2004). Successful pain management is associated with increased patient satisfaction as evidenced by decreased distress, improved rapport with healthcare professionals, compliance with medical advice, and in turn, provision of customer service and positive healthcare outcomes (Downey et al., 2010).

Ambulance Environment

The ambulance environment creates challenges that are not a factor inside of a hospital, such as limited space, power availability, and dynamic physical forces due to movement of the ambulance (Fromm & Varon, 2000). The limited medical facilities of an ambulance, and its unpredictable movement limit the capabilities of pre-hospital care staff to provide appropriate treatment to patients (Waddell et al., 1975). Factors affecting the ability of pre-hospital care staff to provide care also include: the increased complexity and acuity of patients requiring transport, potential necessity for intensive treatment, and language and cultural barriers (Nairn et al., 2004). Due to an increase in the number of psychiatric patients presenting for emergency services, personnel must be prepared to integrate services which meet their unique needs (Maclean & Andrew-Starkey, 2009). Patients surveyed identified the emergency care environment as “uncomfortable”, “frightening”, “oppressive”, “claustrophobic”, and lacking in privacy (Gordon, Sheppard, & Anaf, 2010). Patients also stated that they felt vulnerable, anxious, stressed, and fearful regarding their experience with emergency care (Gordon et al., 2010). Patients in several studies reported anxiety regarding the nature of their illness, the perception of its life-threatening indications, the treatment it would require, and unknown outcomes from treatment (Walworth, 2003; Gordon et al., 2010). Stress is a causal aspect of physical and psychological illness, and

5 involves a complex reaction comprised of physiological, cognitive, and behavioral elements (Burns, Labbe, Arke, Capeless, Cooksey, & Steadman, 2002). Knight and Rickard (2001) state that the degree to which a physiological stress response is demonstrated is dependent upon the level of control one feels they have over the stressful stimuli. Continual stressful environments create a risk for the development of stress system dysregulation in patients, possibly inhibiting recovery and healing, lengthening hospitalization, and increasing negative physiological manifestations and postoperative distress in patients undergoing surgery (Walworth, 2003). Increased exposure to noise in the ambulance may trigger a negative response from the sympathetic nervous system, increasing the burden on the cardiovascular system in patients with cardiac conditions (Byers & Smyth, 1997). Anxiety levels are affected by an individual’s stress response, which encompasses perceived stressors, and guided by personality traits, coping strategies, perceived ability to control the situation, and past experiences (Walworth, 2003). Reduction in anxiety levels correlates with increased patient satisfaction in emergency care (Ekwall, Gerdtz, & Manias, 2009).

Music Therapy

Beneficial Qualities of Music

Music is a pleasant, everyday stimulus that captures and maintains attention, and whose universal, cross-cultural nature makes it an accessible treatment for patients of any age, sex, race, religion, nationality, income level, social class, and education. Evidence demonstrates the success of music interactions in affecting measurements of physiological, affective, behavioral, and psychological states in the human body. Established research documents the positive influence of music on physiological signs and symptoms, such as pulse, heart rate and rhythm, arterial blood pressure, and electroencephalograph and galvanic skin responses (Powers, 2002; Biley, 2000). Both the cardiac and pulmonary systems are stabilized by music, and regular, rhythmic breathing occurs deeply and slowly, which promotes increased oxygenation (Powers, 2002). Music enhances the emotional and aesthetic dimensions of communication, expands human expression of emotion, and provides nonverbal access to thoughts and feelings (Taylor, Lin, Snyder, & Eggleston, 1998). Several studies prove music’s ability to successfully decrease

anxiety, recovery period, length of hospitalization, the amount of analgesics, sedatives, and medications in recovery, and to assist in eliminating confusion during hospital stay (Walworth, 2003). During times of acute distress, stress hormones such as catecholamines, adrenocorticotrophic hormones, and cortisol are released into the bloodstream. With the addition of music, endorphins are released, which decreases the number of stress hormones present in the blood, in turn decreasing pain levels (Powers, 2002). Music addresses the total stress response, decreasing anxiety, and physiological measures such as blood pressure, heart rate, and plasma stress hormone levels (Clark, Isaaks-Downton, Wells, Redline-Frazier, Eck, Hepworth, & Chakravarthy, 2006). Research involving music and anxiety indicates that effectiveness in reducing anxiety and pain results from the human body’s vibratory response to music and its ability to produce relaxation and distraction (Taylor et al., 1998). In an experiment investigating the effects of classical music on the well being of critical care patients in a Maryland hospital, results demonstrated that half an hour of music could be equated to a 10-milligram dose of Valium (Powers, 2002). Music also addresses the behavioral components of stress, which allows patients to return to a state of calm more quickly prior to surgery, as evidenced by physiological signs including arterial pressure, heart rate, cardiac output, skin temperature, and glucose count (Burns, Labbe, Arke, Capeless, Cooksey, & Steadman, 2002). Personal preference is an influential factor in music selection during music therapy interventions as greater efficacy has been demonstrated when subject-selected music is used. A meta-analysis of music research in medical treatment completed by Jayne Standley (2000) demonstrated that preferred music had the greatest effects on study participants, producing an effect size of 1.40. Increased pain relief, decreased pain perception, and a decrease in self- reported anxiety were found when subjects in a research study were allowed to select their music of choice (Clark et al., 2006). This physiologic response to music is enhanced by familiarity and the degree of liking for particular selections of music (Knight & Rickard, 2001). Selecting preferred music also allowed patients to feel a greater sense of control, have greater expectations for pain reduction, and experience more significant pain reduction (Mitchell & MacDonald, 2006). A research study conducted by Walworth (2003) determined that a significant decrease in anxiety was displayed in several studies regardless of whether the subject chose a specific

artist, song, or a musical genre, and validated that patient-preferred genre selection was as effective as specific songs. The efficacy of generating a state of relaxation is more closely related to the degree of liking for the music as opposed to musical style, and is influenced by factors such as familiarity, past associations, and personal meaning (Mitchell and MacDonald, 2006). Researchers discovered that subject-selected music was a significant factor in eliciting beneficial physiological effects because of personal interest and appreciation for the music, regardless of musical type (Burns et al., 2002). Males and females were significantly more able to tolerate pain stimuli when given the opportunity to listen to their preferred music (Mitchell & MacDonald, 2006). Patients hospitalized for surgical procedures on the brain also evidenced improved quality of life as indicated by lowered anxiety and stress, increased perception of the hospital and surgical procedure, and increased relaxation (Walworth, Rumana, Nguyen, & Jarred, 2008).

Effectiveness of Music Therapy in Emergency Medicine

A powerful rationale for music therapy in emergency medicine is the lack of negative side effects that would prevent its use during ambulance transport, and as such, has been identified as a safer and less liable option than any existing pre-hospital treatment (Powers, 2002). Music therapy is recognized as a simple, inexpensive way to increase patient comfort in a variety of medical settings and has already been identified as an effective clinical intervention in the emergency department (Dubois, Bartter, & Pratter, 1995; Clark, et al., 2006, Negrete, 2011). According to Powers (2002), music therapy classifies as at least an “IIa treatment” on the American Heart Association’s treatment classification scale, signifying an acceptable and probably helpful treatment. Because of the noise, space limitations, hyperactivity and urgency in care, Powers (2002) states that the ambulance is an ideal venue for music therapy. In terms of medical evaluation, music therapy has been proven to be effective in eliciting improved cognitive responses with less anxiety and restlessness when combined with typical examinations and day-to-day activities (Powers, 2002). Speed of assessment is a significant factor in patient perception, and the psychological component that influences the perception of waiting can be positively altered by music interventions. Music therapy interventions that address the communication skills of patients can positively enhance the assessment process in

pre-hospital care, especially for uncooperative patients (Powers, 2002). Because a significant percentage of transports involve adults with Dementia, Alzheimer’s, or nursing home residents, music therapy is a rational treatment adjunct because of its proven efficacy with these populations (Powers, 2002). Music therapy also effectively addresses the additional sensory and physical needs of elderly patients and enhances the holistic care approach required for such patients. Neurological benefits of music therapy include the deceleration and regulation of brain waves, and the induction of alpha wave activity, which promotes a relaxed, wakeful state (Powers, 2002; Biley, 2000). Due to music’s ability to release endorphins into the blood stream, music therapy has the power to alter mood state (Mornhinweg, 1992). Mood states have been improved with a variety of populations using music therapy interventions, including traumatic brain injury, and chronic neurological disabilities. In patients with traumatic brain injuries and chronic neurological disabilities, music therapy possesses the ability to address negative mood state, elevate general mood state, and decrease feelings of anxiety and depression (Magee & Davidson, 2002). A systematic nursing review established music therapy as an effective treatment to improve mood in hospital patients (Evans, 2002). Additionally, a randomized controlled trial in which patients with Alzheimer’s type dementia were allowed to choose the musical style of the session resulted in decreased anxiety and depression (Guetin, Portet, Picot, Pommie, Messaoudi, Djabelkir, Olsen, Cano, Lecourt, & Touchon, 2009). For patients diagnosed with terminal cancer, music therapy increased quality of life, and maintained continuous improvement over time (Hilliard, 2003). The element of musical tempo may be used in conjunction with preferred music to bring patients to a more positive state through the Iso principle. Using this technique, a trained music therapist will select music that matches the patient’s current mood and energy in terms of tempo, and progressively move the patient to a more desirable state of relaxation by gradually slowing or increasing the tempo of the music. The implications of using music to alter mood are that music can further be used to decrease pain and promote control of pain perception, induce deep sleep, decrease nausea, and decrease anxiety levels and fear (Mornhinweg, 1992). Music therapy is an effective anxiolytic treatment that has been proven to increase salivary IgA levels while decreasing the levels of stress hormones, cortisol and ACTH (Knight & Rickard, 2001). Pelletier (2005) conducted a meta-analysis of music therapy literature

documenting the effects of music on decreasing arousal due to stress. Results showed that music therapy strongly increased relaxation in conditions of high arousal caused by stress. Data indicated success across a variety of stress-inducing conditions, including surgery, a traumatic diagnosis, medical procedures, labor, and occupational stress. All measures of report, physiological, behavioral observation, and self-assessment produced similar effects in reduction of anxiety, stress, and tension (Pelletier, 2005). Data taken during a study involving myocardial infarctions indicated that listening to music lowered heart and respiratory rates and decreased anxiety levels, suggesting the effectiveness of music therapy to improve treatment outcomes (Powers, 2002). Music therapy is a valuable treatment option for preventing increases in physiological measures of stress, including heart rate and systolic blood pressure, as well as subjective report of anxiety levels (Knight & Rickard, 2001). Music therapy also includes non-invasive techniques for pain management, and when used in conjunction with less effective treatment and medication or as an adjunct treatment, affect both the physical sensation of pain and the emotional components that accompany it (Mitchell & MacDonald, 2006). This concept of “audioanalgesia” involves the use of music to distract attention away from the pain stimulus, emotionally engaging the patient in a more positive stimulus, promoting relaxation, and increasing coping skills (Mitchell & MacDonald, 2006). Subjects reported lower pain intensity following hernia and varicose vein surgery, in addition to a perceived increase in their ability to control the experience of pain by using music as a coping strategy for distraction (Mitchell & MacDonald, 2006). A reduction in sedation use has also been demonstrated during procedures when music therapy is used in conjunction with typical pharmacological measures (Evans, 2002). Music therapy interventions have successfully been used in the emergency department with both children and adults experiencing a variety of medical emergencies and conditions. Barton (2008) conducted a study with children receiving medical procedures in the hospital and the emergency room, and found that music therapy interventions that supported the child during the procedure decreased pain and anxiety for both invasive and noninvasive procedures. Music therapy provided during IV starts, finger pricks, incisions and draining, suturing, the removal of foreign material from the skin, X-rays, CT scans, and breathing treatments showed less aversive and anxiety-related behavior in children receiving these procedures. Patient satisfaction with

music therapy services during the study was 100%, and hospital perception was greatly improved. When music therapy interventions were provided to adults in the emergency room, Negrete (2011) discovered a significant decrease in pain correlated with an increase in comfort. Pre and post-test scores of self-report indicated an increase in the quality of care received and a decreased sense of anxiety. All of the patients who received music therapy would request music therapy services again if they returned to the emergency department. Documented effects of music therapy include masking of unpleasant sounds and feelings, the instillation of a sense of safety and well being, and the ability to influence perception of time and space (Powers, 2002). Research documents increased tolerance of environmental noise annoyance and a positive decrease from baseline vital signs during music interventions (Byers & Smyth, 1997). In the context of ambulance transport, music therapy might be beneficial in improving the environment inside the ambulance, creating a less stressful and confining space for treatment. Research indicates that pre-hospital care providers would also benefit from the inclusion of music therapy services. In a study conducted using ambient recorded music in the work environment, emergency services personnel reported a noticeable alteration in the environment, in addition to a positive change in their performance. Researchers believe that playing recorded music in an emergency services work environment improves the atmosphere, increasing organization and decreasing stress (Gatti & Silva, 2007). Data collected at the University of Virginia demonstrated that music is one of the top three most frequently used treatment adjuncts for enhancing conventional therapies in the emergency department. Clinicians surveyed expressed a desire to acquire greater knowledge and training regarding referrals to such services for patient care, in addition to recognizing the benefits for their own personal well-being and relaxation (Taylor, Lin, Snyder, & Eddleston, 1998). Benefits such as decreased anxiety, stabilized respiratory and heart rates, and decreased levels of stress hormones that occur in patients, might augment pre-hospital care providers’ ability to provide services. It was theorized that because music enhances spatial-temporal reasoning and improves spatial task performance, it would enhance providers’ ability to think and act faster with confidence and assurance, making fewer mistakes (Powers, 2002). This in turn, would benefit the patient, as the provision of pre-hospital care would be greatly improved.

The addition of music therapy intervention to pre-hospital care might improve multidimensional customer satisfaction with services by exceeding expectations, maintaining and increasing business for ambulance transport (Powers, 2002). With a successful transfer of care, this improved perception of the pre-hospital experience may even help to create a positive experience in the emergency department, raising satisfaction with hospital services. If evidence of clinical effectiveness in music therapy is demonstrated after a brief period of intervention, then it’s use in the ambulance would be a cost-effective treatment adjunct (Magee et al., 2002). There are no experimental controlled studies of music therapy use in ambulance transport. The aim of this study is to determine whether there is a significant difference between self-reported scores of anxiety, mood state, and pain levels and the physiological comparison of vital signs when patients are allowed to listen to preferred music during interfacility ambulance transport. The results will be analyzed to determine the impact of the musical intervention on the perceived and physiological experience of being transported by ambulance.

METHODS

Case Study Approach

Setting

Data were collected inside of five different paramedic ambulances used in interfacility transport in North Florida. Adult patients from the age of 18 and higher with a variety of medical conditions were provided transportation between medical facilities. This included patients with leukemia, acute respiratory failure, muscular sclerosis, chronic obstructive pulmonary disorder, multiple strokes, and abdominal pain. Leon County Emergency Medical Services is a 9-1-1 ambulance service that provided emergency medical and transport services to the residents of Leon County, Florida. Leon County EMS is the primary pre-hospital healthcare provider for Leon County and provided interfacility transportation from hospitals, nursing homes, physician offices, specialty hospitals, assisted living facilities, and rehab centers (Interfacility Transports, N.d.). Leon County paramedic ambulances contained a front compartment for the driver, and a back compartment for the purpose of patient care. The patient care component was considered a mobile intensive care unit (MICU) and included a seat for the treating paramedic, a bench seat for other crew members or riders, area for the stretcher, and storage for all medical equipment and supplies.

Design

This study was a case study approach to evaluate the effects of no music vs. patient- preferred musical genre selection on the dependent variables of vital signs and self-reported mood states as indicators of patient experience during interfacility ambulance transport (N=5). Data were taken pre, during, and post transport.

Case Study Participants

Five adult patients (N=5), including women (n=2) and men (n=3) who were being transported by ambulance between two medical facilities participated in this study. The

researcher obtained Florida State University Institutional Review Board approval (Appendix A). Participants were referred to the music therapist via telephone call from the operations department of Leon County Emergency Medical Services upon receiving a request for transport. Criteria for inclusion specified that participants be adults who were age 18 and older and who were awake, alert, and able to understand their medical diagnosis and reason for being transported between facilities in an ambulance. Participants who had a significant psychopathology that would not allow them to understand their reason for being transported as determined by orientation questionnaire were excluded from the study. In addition, patients who could not make their own healthcare decisions due to debilitating illness or psychopathology were excluded. Potential participants that were receiving medication that altered alertness, memory, or vital signs were also excluded. Participants were transported to a location that was within 10 to 45 minutes distance from their original destination.

The following table identifies the demographic information regarding study participants:

Table 1: Participant Demographics

Age (in years) Gender Diagnosis(es)

60 Female Leukemia

42 Male Acute Respiratory Failure (Muscular Sclerosis)

65 Male COPD

41 Male Multiple strokes

65 Female Abdominal Pain

Case Study Procedure

The principal investigator received notification from Leon County Emergency Medical Services when eligible participants were going to be transported between facilities with a travel 14

time between 10 and 45 minutes. The principal investigator met Leon County Emergency Medical Services (EMS) providers at the location from which the transport was departing. An emergency medical technician or paramedic from Leon County EMS approached the patient to obtain his or her consent (Appendix B). The principal investigator then made contact with the patient once he or she was loaded into the ambulance and again obtained consent to participate (Appendix C). Participants were assigned to the music condition or no music condition prior to participation in alternating order. The principal investigator sat alongside the stretcher on the ambulance’s bench seat and had limited interaction with participants during transport. Participants in both the music condition and the no music condition were asked by the principal investigator to complete the survey instrument once loaded into the ambulance (Appendix D), and at the completion, of transport. The survey instrument was completed while Leon County EMS staff prepared the patient for transport and attached all necessary medical equipment. Following the survey instrument, vital signs (pulse, oxygen saturation level, and systolic and diastolic blood pressure) were recorded by EMS staff at the beginning of the transport, during transport, and at the final transport destination for patients in both conditions. After completing the initial survey instrument, participants in the music condition were presented with an iPad with a menu of several genre categories of music, and were asked to select which genre (Appendix E) of music they would like to listen to during their transport. Genre lists were generated using music therapy genre repertoire recommendations as well as popularly selected top hits charts (Billboard, 2013, Drop.fm, 2013, Kickass Classical, N.d., Nexus Radio, N.d., Song Lyrics, N.d., Standley & Jones, 2007). Participants in the music condition were then allowed to listen, for the remainder of their transport, to a selection of songs from their selected genre, which were arranged in order of decreasing tempo, according to the Iso principle of music therapy. Participants in the no music condition received no musical intervention and proceeded with their transport according to standard procedure. The principal investigator had limited interaction with participant outside of administering the patient survey. Participants in the music condition were also asked to complete the questionnaire in the patient survey upon completion of transport (Appendix D).

RESULTS AND DISCUSSION

Case Study Results

Data were collected from five (N=5) participants. Data were analyzed for all five participants, and results were determined through evaluation of vital signs and mood scales for both groups (N=5), in addition to questionnaire feedback from the music group (n=2). Vital signs taken prior to, during, and at the completion of transport were compared in graph format using an excel spreadsheet. The original fifth vital sign, respirations per minute was not included in the graphed results because it was not measured by Leon County EMS paramedics and emergency medical technicians, therefore, four vital signs were measured (pulse, oxygen saturation, systolic blood pressure, and diastolic blood pressure).

Participant Case Studies

Case Study #1 (Music)

Patient was a 60-year-old woman with a diagnosis of Leukemia pending. The patient was being transported back to Archibald Medical Center from Tallahassee Memorial Hospital after receiving specialized care.

This patient was said to have moments of altered consciousness, however, she passed the orientation questionnaire necessary to participate in the study. She selected the gospel genre as her preferred music for the transport. Behavioral observations made by the principal investigator indicated an increased state of relaxation, as evidenced by a smile during the song “In the Garden”, and with closed eyes for several minutes. While the patient occasionally teared up towards the beginning of the transport, her facial affect appeared more peaceful following the transport.

The patient’s vital signs demonstrated a slight positive decrease in heart rate and blood pressure, while respirations per minute and oxygen saturation remained consistent. Her pulse prior to transport was recorded at 99 beats per minute (bpm), increased to 102 bpm during transport, and decreased to 98 bpm following transport. The paramedic explained that she was experiencing

16 tachycardia and an irregular heartbeat due to her medical condition. Respirations measured by the paramedic remained consistent at 24 breaths per minute, which is slightly above the normal range of 12-20 per minute. The patient’s oxygen saturation level was 97% prior to transport, and remained consistent throughout the transport even when given supplemental oxygen via nasal cannula at two liters per minute, and subsequently, four liters per minute. The paramedic explained that she had sleep apnea, which caused her oxygen levels to drop when the stretcher was laid back to increase comfort. The patient’s blood pressure prior to transport was 160/86, decreased to 151/93, and remained fairly consistent at 152/82 post-transport.

The patient’s negative mood scale scores increased in two out of the six categories (anxiety and uncomfortable), remained constant in three categories (anger, discontent, and stressed), and decreased in one category (depressed). The patient’s positive mood scale scores decreased in only one category (relaxed), remained constant in two categories (happy and comfortable), and increased in three categories (excited, calm, and content). The patient’s pain score increased slightly from 0.

Case Study #2 (Music)

Patient was a 41-year-old male who had a second stroke due to elevated blood pressure. The patient was being transported to a Taylor County Hospital from Tallahassee Memorial Hospital after receiving specialized care.

The patient selected R&B as his preferred music for the transport. Behavioral observations made by the principal investigator during the transport demonstrated evidence of increased relaxation, as he closed his eyes at several points.

The patient’s vital signs remained mostly constant, with the exception of blood pressure, which increased slightly. However, the patient was being treated for high blood pressure and was given medication for the transport in the event that his blood pressure became too high and put him at risk for another stroke. His pulse was recorded at 76 beats per minute (bpm) prior to transport, and remained consistent for the remainder of the transport. The patient’s oxygen saturation level was 96% prior to transport, remained steady during transport, and decreased to 95% following

17 the transport. The patient’s blood pressure was 134/103 prior to transport, decreased to 130/89 during transport, and increased slightly to 136/96 following the transport.

The patient’s negative mood scale scores did not increase in any categories, remained constant in four categories (angry, anxiety, discomfort, and stressed), and decreased in two categories (depressed and uncomfortable). His positive mood scale scores only decreased in one category (content), remained constant in two categories (excited and calm), and increased in three categories (happy, relaxed, and comfortable). The patient’s pain score remained constant at 0.

Case Study #3 (No Music 1)

Patient was a 65-year-old male who had Chronic Obstructive Pulmonary Disorder. The patient was being transported from Specialty Select to Tallahassee Memorial Hospital in order to receive specialized care.

The change in the patient’s vital signs was minimal. The patient’s pulse was recorded as 94 beats per minute (bpm) prior to transport, decreased to 90 bpm during transport, and increased to 93 bpm post-transport. His oxygen saturation level was measured at 90% prior to transport. The patient was placed on oxygen via nasal cannula at two liters per minute, which increased his oxygen saturation to 95% for the remainder of the transport. The patient’s blood pressure prior to transport was 132/72, and increased to 136/85 for the remainder of the transport.

The patient’s negative mood scale scores increased in one category (stressed), remained constant in three categories (angry, anxiety, and discontent), and decreased in two categories (depressed and uncomfortable). His positive mood scale scores decreased in 100% of the categories. The patient’s pain score increased approximately 17% from his initial score.

Case Study #4 (No Music 2)

Patient was a 65-year-old female who had abdominal pain. The patient was being transported from Tallahassee Memorial Hospital to Specialty Select after surgery and advanced care.

The change in the patient’s vital signs was moderate. The patient’s pulse was recorded as 101 beats per minute (bpm) prior to transport, decreased to 95 bpm during transport, and increased to 96 bpm post-transport. Her oxygen saturation level was measured at 99% prior to transport, and 18 remained stable throughout the remainder of the transport. The patient’s blood pressure prior to transport was 134/51 prior to transport, became 141/63 during transport, and changed to 118/72 following transport.

The patient’s negative mood scale scores increased in one category (anxiety), remained constant in four categories (angry, depressed, discontent, and stressed), and decreased in one category (uncomfortable). Her positive mood scale scores decreased in one category (comfortable), remained constant in four categories (excited, calm, happy, and relaxed), and were unknown in the sixth category (content). The patient’s pain score increased almost 20% from 0.

Case Study #5 (No Music 3)

Patient was a 42-year-old male who had acute respiratory failure as a complication of muscular sclerosis. The patient was being transported from Tallahassee Memorial to Archibald Medical Center after receiving specialized pulmonary care.

The change in the patient’s vital signs was minimal. The patient’s pulse was recorded as 88 beats per minute (bpm) prior to transport, decreased to 86 bpm during transport, and increased to 89 bpm post-transport. His oxygen saturation level remained stable at 98% throughout the transport, as he was receiving humidified oxygen at six liters per minute through his tracheostomy tube. The patient’s blood pressure prior to transport was 91/57 prior to transport, increased to 95/60 during transport, and changed to 96/50 following transport.

The patient’s negative mood scale scores increased in one category (discontent), and remained constant in the remaining five categories (angry, anxiety, depressed, stressed and uncomfortable). His positive mood scale scores decreased in one category (content), and remained constant in the remaining five categories (excited, calm, happy, relaxed, and comfortable). The patient’s pain score remained stable at 0.

Table 2: Negative Mood Scale Changes

Anger Anxious Depressed Discontent Stressed Uncomfortable Music 0 +4 -4 0 0 +4 1/8 0 0 -1.25 0 0 -0.25 No 0 0 -1 7/8 0 +0.5 -1.25 Music 0 +6 0 0 0 -6 0 0 0 +6 0 0 Note: Positive changes are indicated in blue.

Table 3: Positive Mood Scale Changes Excited Calm Happy Content Relaxed Comfortable Music +6 +1 0 +2 -0.5 0 0 0 +3 -3 +2 7/8 +2 7/8 No Music -5/8 -1/8 -2 -0.25 -0.25 -1.25 0 0 0 Unknown 0 -2 7/8 0 0 0 -6 0 0 Note: Positive changes are indicated in blue.

Table 4: Pain Scale Changes Pain Music +1 7/8 0 No Music +1 +1 5/8 0 Note: Positive changes are indicated in blue.

Figure 1: Pulse

105

100

95 Patient 1 90 Patient 2 Patient 3 85 Patient 4

80 Patient 5

70 0 0.5 1 1.5 2 2.5 3 3.5

Figure 2: Oxygen Saturation

100 99 98 97

96 Patient 1 95 Patient 2 94 Patient 3 93 Patient 4 Patient 5 92 91 90 89 0 1 2 3

Figure 3: Systolic Blood Pressureure

165 160 155 150 145 140 135 Patient 1 130 125 Patient 2 120 Patient 3 115 Patient 4 110 105 Patient 5 100 95 90 85 80 0 1 2 3

Figure 4: Diastolic Blood Pressursure

105

85 Patient 1 Patient 2 75 Patient 3 Patient 4 65 Patient 5

45 0 1 2 3

Summary Results

Vital signs from the two participants (n=2) in the music condition remained consistent or showed a slight positive decrease. Vital signs measured for the three participants in the no music condition showed a slightly negative increase. However, these results are not medically significant. Subjective mood state was evaluated by comparing numerical measurements (in inches) in each of the thirteen categories on the pre-test and post-test surveys. Categories included negative moods (angry, anxious, depressed, discontent, stressed, and uncomfortable), positive moods (excited, calm, happy, content, relaxed, and comfortable), and pain. Mood scale scores for participants in the music condition indicate that negative mood scores were maintained or decreased in nearly all categories, positive mood scores were maintained or increased in almost all of the categories, and pain scores were only slightly increased for one participant while the other participant’s score remained the same. Mood scale scores did not demonstrate the same trends in the no music condition. Negative mood scores were maintained and even increased in some instances. Positive scores decreased in every category for one participant, and did not show any increase for other participants. Finally, pain scores were increased for two participants, and remained unchanged for the third. Questionnaire feedback from participants in the music condition indicated a positive response to music therapy. While both participants disagreed that being transported in ambulance was stressful, they reported that listening to music decreased their anxiety and made them feel more comfortable and relaxed during the transport. Of all participants in the music condition, 100% were satisfied with their musical selection, and stated that listening to any kind of music would be helpful.

Case Study Discussion

The effectiveness of music therapy was evident in the findings of decreased negative scores and increased positive mood scores on the mood scale. Since mood can have a large influence on how patients perceive their illness and in turn, the care they receive, positive changes in this score reflect the impact of music therapy. Questionnaire feedback also demonstrated the effectiveness of music therapy as participants reported that it positively 23

impacted their experience by increasing relaxation and comfort. Because anxiety, relaxation and comfort can directly influence a patient’s vital signs and medical condition, a strong, positive patient report in this area is evidence that music therapy is effective in the pre-hospital setting. Participant feedback on study questionnaire signifies that listening to self-selected musical genres has a positive impact on the experience of interfacility ambulance transport. While there was no significant difference in vital signs, results do indicate that listening to music caused a slight positive reduction in pulse and diastolic blood pressure. This was not medically significant, however. The fact that findings in this area were not significant could be a result of many factors. The varying length of transports may not have allowed enough time for vitals to change. Environmental noise also could have impacted the listening experience, and prevented participants from fully focusing on the music. Finally, the participants’ medical conditions caused changes in vital signs that were not necessarily related to the music therapy intervention. Some aspects of the pre-hospital environment created difficulties during this study. Obtaining study participants was very difficult because the transporting EMS service was located in city in which the largest hospital was a regional facility, and transported most patients’ hours across the state to other larger hospitals. As a result, there were a limited number of patients there were alert and met inclusion criteria for the study. In order to obtain participants for the study, the principal investigator needed to be able to meet the transporting ambulance at a moment’s notice, and a variety of locations. Additionally, transports that were shorter in length posed a challenge in completing the mood scale before departure and upon arrival. There was often a significant amount of time spent waiting for the hospital to discharge a patient when the EMS crew arrived, creating a wait that was potentially longer than the transport itself. Finally, the constant movement in the back of the ambulance, and the equipment used to obtain vital signs, in addition to the confinement of being strapped on a stretcher made it difficult for the participants to complete the subjective mood scale on their own, therefore, the principal investigator physically marked the survey with direction from the participant. A few of the patients had difficulty identifying which of the moods and to which degree on the scale they felt these moods. A revised mood scale for this environment may correlate more closely with hospital scales or pre-hospital documentation, and rated on a scale of 1 to 10 to better allow the patient to quantify their feelings.

When asked if they would like to have music therapy services in the ambulance if they were to require one in the future, 100% of participants in the music condition strongly indicated they would. None of the participants who were approached to participate in the study refused, and all participants who were offered a musical general selection chose their preferred music. Even one patient who did not receive music therapy expressed an interest in having music therapy if transport by ambulance was necessary in the future. This unanimous desire for music therapy services during ambulance transport indicates that there is a significant interest in music therapy services in the pre-hospital environment. Furthermore, this fact supports future research into the many new applications for music therapy in this field. Comments received regarding music therapy services in the music condition indicated that listening to music strongly decreased anxiety, and was “calming”. Both participants in the music condition often closed their eyes while listening to their chosen musical genre. One participant smiled upon hearing a particular song, and teared up. Paramedics treating participants in the music condition noted a change in mood and atmosphere. One participant in the no music condition, after hearing the principal investigator explain the study remarked, “Of course it (music) works, it changes mood”. Paramedic feedback during the study offered insight into future applications for music therapy in pre-hospital emergency medicine. Several paramedics that transported study participants suggested that music therapy may be more effective on transports that were several hours in length because “patients have more time to think about their situation” and become anxious. In addition, a transporting paramedic discussed the challenge of interacting therapeutically with such patients for hours, and thought that music therapy may enhance this interaction. This paramedic also shared that music therapy could improve the transport experience for paramedics and emergency medical technicians that respond to trauma calls, because these can be very stressful for pre-hospital care providers. Paramedic affect visually changed during the experimental condition, as the music appeared to increase interaction with the patient, brighten affect and mood, and increase a sense of relaxation, as evidenced by comments made to the principal investigator. Many paramedics expressed nostalgia for having “good time radios” in the patient care compartment of the ambulance, explaining that it was relaxing to both them and the patients.

Overall, music therapy was an effective intervention for the pre-hospital environment because it improved the experience of interfacility ambulance transport. Data collected during this study indicates that providing music therapy interventions in ambulances may improve patient experience, potentially improving the patient’s medical condition and the process of transferring care to a new facility. While the results of this study demonstrate a positive impact on the relaxation and comfort levels of the participants in the music condition, further research with larger numbers of patients needs to be conducted. This research could provide statistical significance regarding changes in vital signs and scores on mood scales in addition to an increased focus on behavioral observations. Because music therapy is a brand new service in the pre-hospital environment, there are many research questions for further study. Music therapy in-services for pre-hospital staff could be used to gain insight from pre-hospital care providers about potential appropriate applications for music therapy, and to better understand the needs of providers and patients. Music therapists could function as a consultant to EMS crews and provide advice regarding the appropriate selection for patient listening during transport. Since music therapy has been found to be highly effective in the emergency room, research could examine whether providing music therapy in the ambulance before arriving at the emergency room would improve the transfer of care, and further, the perception of care received in the emergency room. Because current research displays high rates of burnout and medical emergencies due to stress in EMS providers, music therapy could be used to reduce stress levels and teach positive coping strategies. The use of music therapy on different types of ambulance transports could be explored; music therapy could be provided on emergency transports, on fixed wing and air ambulance transports, and during neonatal and pediatric transports. The effects of live music could be studied using smaller instruments such as a ukulele or Qchord. Paramedic and author David Powers (2002) proposed many new applications for music therapy in the pre-hospital setting. Standard 12-lead EKG’s could be attached to patients while listening to certain types of music to examine the effects on heart rhythm. The beats per minute and regularity of classical music would be used with the intention of decreasing stress and positively impacting EKG rhythm. Contrarily, techno or electronica could be used to increase heart rate when medically necessary. Additionally, Powers and his partner used music with the appropriate number of beats per minute to assist them in staying on task when doing CPR

compressions, to maintain rhythmic regularity. Powers states that this was especially effective in reducing stress for new pre-hospital care providers during cardiac arrest transports.

Clinical Recommendations

After riding ambulances during interfacility transport, I feel that there is a need for greater research into the applications of music therapy in pre-hospital emergency medicine. Although this study focused on patient-preferred music during interfacility transport, there are many other contexts in this setting where music therapy could be highly effective. Additional functions of music therapy in the pre-hospital setting are included in the discussion section along with recommendations from study paramedics and a consulting paramedic who provided research on the subject. If one is thinking about providing music therapy services on an ambulance, the following are some considerations for the implementation of services. The most important step would be to first develop a positive relationship with the EMS service and it’s deputy of operations. This will provide access to communication with paramedics and emergency medical technicians, and allows the music therapist to structure the referral system in the most efficient and effective manner. Defining the referral system is a significant component of pre-hospital care music therapy because of the unpredictable nature of emergency medicine. The most effective way to obtain referrals in this study was for the deputy of operations to send staff and supervisors an email with the music therapist’s contact information and for the music therapist to call in to the dispatch center at the beginning of each day. Additionally, the music therapist must understand the requirements of the EMS service before riding along, as they may require a uniform, specific confidentiality training or riding along for a certain number of hours. While the principal investigator in this study did not perform an in-service for the pre- hospital care providers, it may be helpful to do so before implementing services, so that staff are educated about the goals and benefits of music therapy, in addition to current research in the field. Because music therapy in the pre-hospital setting is brand new application, this in-service could also be used to gain insight from pre-hospital care providers about potential applications for music therapy. However, the principal investigator in this study noticed no doubts about the effectiveness of music therapy from pre-hospital care providers, and sensed a general understanding and appreciation for music therapy services. Continued communication with the 27

deputy of operations and other pre-hospital care supervisors is recommended for improving the referral system and to ensure satisfaction with services or inquire about any additional areas that music therapy could assist or benefit staff or patients. Care must be taken to respect pre-hospital care providers need to treat patients at any given moment. While music therapy interventions would often not interfere with this ability, the music therapist should understand that music therapy may need to be paused for life-saving care to occur. One other concern, as in any other hospital or medical facility, would be for music therapists to follow universal precautions for their own safety and the safety of their patients. Any equipment used should be cleaned with the appropriate cleaning solution, and gloves might be appropriate to prevent the spread of infectious disease. The documentation used in this study was created by the principal investigator in order to measure the dependent variable of vital signs and mood states because this was a brand new application of music therapy. Formal documentation in this setting may be difficult to complete because of unpredictable and mobile nature of the setting. However, music therapy goals and objectives could be obtained from EMS electronic documentation at the departing hospital, and documented effects of the music therapy interventions could potentially be included in the EMS report after the transport is completed. From the principal investigator’s experience during this study, scheduling a music therapist full-time may pose some difficulty. Due to the unpredictable nature of emergency medicine, it is hard to define a “typical” or regular schedule. There may not be a specific section of the day that would guarantee high numbers of transports. However, a music therapist in a specific locale may be able to determine what hours are busiest in the location, therefore implementing services at a time that would benefit the greatest number of patients. It may be useful for a music therapist in this capacity to have an office that is located at an ambulance dispatch center, so as to avoid having to coordinate a meeting location or time with the departing EMS crew. Another possible alternative would be for a music therapist to ride along as a third crew member on ambulances that are stationed at posts.

APPENDIX A

HUMAN SUBJECTS APPROVAL FROM FLORIDA STATE UNIVERSITY

APPENDIX B

EMT CONSENT TO PARTICIPATION

EMT/Paramedic Verbal Consent Script

The Use of Patient-Preferred Music to Improve Patient Experience During Interfacility Ambulance Transport

Hello, my name is ______, and I am an EMT/Paramedic with Leon County Emergency Medical Services. You have been recommended to participate in a research study called The Use of Patient-Preferred Music to Improve Patient Experience During Inter- facility Ambulance Transport at Florida State University. You were recommended for participation in this study because you are because you are 18 or older, are awake and alert, are not taking any medications that alter your mental status or vital signs, and understand your diagnosis and why you are being transported to another facility.

Do I have your permission to bring the researcher in to explain the study to you and obtain your consent for participation?

Yes______No______

Patient Name______Date______

Medic Name______

Medic Signature______

APPENDIX C

CONSENT TO PARTICIPATION

APPENDIX D

PATIENT SURVEY

Negative Mood States: None Great I feel ANGRY

I feel ANXIOUS

I feel DEPRESSED

I feel DISCONTENTED

I feel STRESSED

I feel UNCOMFORTABLE

Positive Mood States: None Great I feel EXCITED

I feel CALM

I feel HAPPY

I feel CONTENT

I feel RELAXED

I feel COMFORTABLE

Pain: None Great

Patient Vital Signs:

Gender ______Age ______Diagnosis(es) ______

Before Transport: Pulse: _____ Respirations per minute: _____ Oxygen Saturation Level: _____ Systolic Blood Pressure: _____ Diastolic Blood Pressure: _____

During Transport: Pulse: _____ Respirations per minute: _____ Oxygen Saturation Level: _____ Systolic Blood Pressure: _____ Diastolic Blood Pressure: _____

At Transport Destination: Pulse: _____ Respirations per minute: _____ Oxygen Saturation Level: _____ Systolic Blood Pressure: _____ Diastolic Blood Pressure: _____

Patient Genre Selection: ______

Transport Questionnaire: Please Circle One Number Only

Being transported by an ambulance was a stressful experience: strongly disagree disagree neutral agree strongly agree 1 2 3 4 5 Listening to music had the following impact on my transport: strongly negative negative no effect positive strongly positive 1 2 3 4 5 Listening to music affected my anxiety level during the transport. My anxiety was: strongly decreased decreased unchanged increased strongly increased 1 2 3 4 5 Listening to music helped me to feel more comfortable and relaxed during the transport: strongly disagree disagree neutral agree strongly agree 1 2 3 4 5 I would have preferred to listen to other types of music during the transport: strongly disagree disagree neutral agree strongly agree 1 2 3 4 5 If you agree or strongly agree, please state your preferred type of music: ______

In the future, if I had to be transported by ambulance, I would prefer to have music played: strongly disagree disagree neutral agree strongly agree 1 2 3 4 5

Please add any comments or suggestions in the space provided below: ______

APPENDIX E

MUSICAL GENRE SELECTIONS

Alternative Blues Up in the Air – 30 Seconds to Mars Rockin’ Robin – Michael Jackson Stubborn Love – The Lumineers Rock Around the Clock – Bill Haley Diane Young – Vampire Weekend I Got You (I Feel Good) – James Brown Get Lucky – Daft Punk Them There Eyes – Billy Holiday My Songs Know What You Did in the Dark– Fall Out Rhymes – Beth Hart & Joe Bonamassa Boy Close to My Fire - Beth Hart & Joe Bonamassa Harlem – New Politics Miss Lady - Beth Hart & Joe Bonamassa Sweater Weather – The Neighborhood Jailhouse Rock – Elvis Castle of Glass – Linkin Park The Creeper – James Cotton Mountain Sound – Of Monsters and Men If I Tell You I Love You - Beth Hart & Joe Holding on to You – Twenty One Pilots Bonamassa Panic Station - Muse Gone Baby Gone – Boz Scaggs Demons – Imagine Dragons Hound Dog – Elvis Safe and Sound – Capital Cities Can I Change My Mind – Boz Scaggs Breezeblocks – Alt-J At Last – Etta James My God is the Sun – Queens of the Stone Age A Sunday Kind of Love – Etta James Radioactive – Imagine Dragons Bluegrass Classical Women Like to Slow Dance – Steep Canyon Rangers & Flight of the Bumblebee Steve Martin Trepak (Nutcracker) Old Joe Clark – Barrage Overture Solenelle “1812” Shawnee – Steve Martin & Edie Brickell The Toreadors – Carmen When it Rains – Ryan Holladay Introduction to Act III from Lohengrin Old Home Place – Russell Moore and IIIrd Tyme Out Bach Cello Suite No. 1 – Prelude Sarah Jane and the Iron Mountain Baby – Steve Martin & 2001 A Space Odyssey Opening Edie Brickell Habenera – Carmen Big Spike Hammer – Russell Moore & IIIrd Tyme Out Dance of the Sugar Plum Fairy Pretty Little Girl from Galax – Russell Moore & IIIrd Canon in D - The O’Neill Brothers Tyme Out Jesu, Joy of Man’s Desiring Kaymoor Mine – Ryan Holladay Brahms Lullaby Atheists Don’t Have No Songs – Sleep Canyon Rangers Fanfare for the Common Man & Steve Martin The Swan Gonna Lay Down My Old Guitar - Doc & Merle Watson Adagio for Strings Hurry Sundown – Ryan Holladay The Road to Donnelaith – Ryan Holladay Shady Grove – The Avett Brothers Wildwood Flower – The Carter Family Remember Me This Way – Steve Martin & Edie Brickell You – Steep Canyon Rangers & Steve Martin

Amazing Grace – Rose Bell

Contemporary Christian Country (Old) Come to the River – Rhett Walker Band I Walk the Line – Johnny Cash Every Good Thing – The Afters Rocky Top – Chet Atkins Gold – Britt Nicole Jolene – Dolly Parton Strangely Dim – Francesca Battistelli On the Road Again – Willie Nelson Steal My Show – TobyMac Hey Good Lookin’ – Hank Williams One Thing Remains – Kristian Stanfill Move it on Over – Hank Williams Hello, My Name Is – Matthew West Swingin’ – John Anderson We Won’t Be Shaken – Building 429 To All the Girls I’ve Loved Before – Willie Nelson Words – Hawk Nelson Take These Chains From My Heart – Hank Williams All I Can Do – Mikeschair Blue – LeAnn Rimes Restore – Chris August Always on My Mind – Willie Nelson Don’t Try So Hard – Amy Grant & James Honky Tonk Blues – Hank Williams Taylor Crazy – Patsy Cline The Lord Our God – Kristian Stanfill Could I Have This Dance – Anne Murray Help Me Find It – Sidewalk Prophets Georgia on My Mind – Ray Charles Whom Shall I Fear – Chris Tomlin Your Cheatin’ Heart – Hank Williams Need You Now – Plumb Blue Eyes Crying in the Rain – Willie Nelson Worn – Tenth Ave. North You Needed Me – Anne Murray King of the Road - Roger Miller I Fall to Pieces – Patsy Cline Lucille – Kenny Rogers Country (New) Folk Jump Right In – Zac Brown Band I Love Your Smile – Charlie Winston I Want Crazy – Hunter Hayes Baby – Devandra Banhart Done – The Band Perry Low Rising – The Swell Season Hey Pretty Girl – Kip Moore Honey Won’t You Let Me In – The Tallest Man on Get Your Shine On – Florida Georgia Line Earth Wagon Wheel – Darius Rucker The Gardener – The Tallest Man on Earth Downtown – Lady Antebellum Eet – Regina Spektor Runnin’ Outta Moonlight – Randy Houser Tree By the River – Iron & Wine Boys ‘Round Here – Blake Shelton Beautifully – Jay Brannan Beat This Summer – Brad Paisley Mykonos – Fleet Foxes Like Jesus Does – Eric Church Heart of My Own – Basia Bulat Crash My Party – Luke Bryan Tongue Tied – Charlie Winston Cruise – Florida Georgia Line Blue Skies – Noah and the Whale Sure Be Cool If You Did – Blake Shelton The Freshman – Jay Brannan Give it All We Got Tonight – George Strait First Days of Spring – Noah and the Whale In These Arms – The Swell Season

Gospel Jazz Swing Low, Sweet Chariot I Got Rhythm – Judy Garland Are You Washed in the Blood/I’ll Fly Away Goody Goody – Frankie Lymon This Little Light Don’t Get Around Much Anymore – Rod Stewart Because He Lives Chattanooga Choo Choo – Glenn Miller I Saw the Light Swing on a Star – Bing Crosby Old Time Religion It’s Only a Paper Moon – Nat King Cole Precious Lord Take My Hand/Just a Closer Come Fly With Me – Frank Sinatra Walk L-O-V-E – Nat King Cole In the Garden Strangers in the Night – Frank Sinatra Old Rugged Cross Ain’t Misbehavin’ – Joe Sample Trio & Randy Crawford What a Friend We Have in Jesus Sentimental Journey – Glenn Miller Amazing Grace Fly Me to the Moon – Frank Sinatra Wade in the Water At Last – Etta James Shall We Gather at the River It Had to Be You – Frank Sinatra How Great Thou Art Moon River – Frank Sinatra His Eye is on the Sparrow Bewitched, Bothered, and Bewildered – Ella Fitzgerald I Want Jesus to Walk With Me Someone to Watch Over Me – Ella Fitzgerald My Way – Elvis Presley

Hip Hop Motown Starships – Nicki Minaj I Got You (I Feel Good) – James Brown Titanium – David Guetta You Can’t Hurry Love – The Supremes She Doesn’t Mind – Sean Paul I Say a Little Prayer – Dionne Warwick Make it Out This Town – Eve I Heard it Through the Grapevine – Marvin Gaye Party on Fifth – Mac Miller Save the Last Dance for Me – The Drifters God Bless Amerika – Lil Wayne This Magic Moment – The Drifters In the Meantime – King Baby Love – The Supremes No Guns Allowed – Snoop Lion In the Still of the Night – Boyz II Men Immortal – Kid Cudi The Way You Do the Things You Do – The Temptations Mirror – Lil Wayne ft. Bruno Mars Ain’t No Mountain High Enough – Michael McDonald Enemies All Around Me – Ghostface Killah Ain’t Too Proud to Beg – The Temptations Pusher Love Girl – Justin Timberlake Reach Out I’ll Be There – The Four Tops Let it Go – Wiz Kahlifa ft. Akon My Girl – The Temptations Pour it Up – Rihanna Happy Together – The Turtles Stand By Me – Ben E. King Under the Boardwalk – The Drifters When a Man Loves a Woman – Percy Sledge Dock of the Bay – Otis Redding My Guy – Mary Wells Blueberry Hill – Fats Domino

Oldies Pop Oh Susana I Love It – Icona Pop Tie a Ribbon ‘Round the Old Oak Tree Treasure – Bruno Mars On a Bicycle Built for Two – Nat King Cole Love Somebody – Maroon 5 Five Foot Two 22 – Taylor Swift Catch a Falling Star Brave – Sara Bareilles By the Light of the Silvery Moon Here’s to Never Growing Up – Avril Lavigne You Are My Sunshine Gone, Gone, Gone – Phillip Phillips My Wild Irish Rose Cups – Anna Kendrick A Bicycle Built for Two – Daisy Bell Rebel Beat – Goo Goo Dolls Good Old Summer Time Heart Attack – Demi Lovato I’m Forever Blowing Bubbles Mirrors – Justin Timberlake My Bonnie Lies Over the Ocean When I Was Your Man – Bruno Mars It’s Only a Paper Moon Radioactive – Imagine Dragons He’s Got the Whole World in His Hands Lego House – Ed Sheeran Olds Folks at Home (Swanee) Cruise (Remix) – Florida Georgia Line ft. Nelly Home on the Range Stay – Rihanna Danny Boy Beautiful Dreamer Let Me Call You Sweetheart Greensleeves Patriotic R&B Anchors Aweigh #Beautiful – Mariah Carey ft. Miguel Over There Suit & Tie – Justin Timberlake The Stars and Stripes Forever Fine China – Chris Brown Yankee Doodle Blurred Lines – Robin Thicke ft. TI, Pharrel You’re a Grand Old Flag Beat It – Sean Kingston ft. Chris Brown & Wiz Khalifa The Caisson Song Lose to Win – Fantasia The Marines’ Hymn Next to Me – Emeli Sande Washington Post March Girl on Fire – Alicia Keys The Land is Your Land Diamonds – Rihanna When Johnny Comes Marching Home Adorn – Miguel The Star Spangled Banner How Many Drinks? – Miguel Overture Solenelle “1812” Gangsta – Kat Dahlia God Bless America Body Party – Ciara Battle Hymn of the Republic Fire We Make – Alicia Keys ft. Maxwell America (My Country ‘Tis of Thee) Pour it Up - Rihanna America the Beautiful Taps

Rap Rock Gangnam Style – Psy I Want You to Want Me – Cheap Trick Gentleman – Psy Bad Moon Rising – CCR Imma Boss – Meek Mill Good Riddance – Greenday Thrift Shop – Mackelmore Call Your Girlfriend – Robyn I’m Different – 2 Chainz It’s My Life – Bon Jovi Make it Nasty – Tyga That’s Just the Way It Is – Bruce Hornsby Rack City – Dukey ft. phildizzle Livin’ on a Prayer – Bon Jovi Wobble – V.I.C. More Than a Feeling – Boston Hall of Fame – The Script ft. Will.I.Am My Songs Know What You Did in the Dark – Fall Out Started from the Bottom – Drake Boy We Own It – Wiz Khalifa ft. 2 Chainz How You Remind Me – Nickelback 2 Step Remix Highway to Hell – AC/DC Can’t Hold Us – Mackelmore Pour Some Sugar on Me – Def Leppard Power Trip – J Cole Take Me Home Tonight – Eddie Money Bad – Wale ft. Tiara Thomas Hotel California – The Eagles Desperado – The Eagles

Reggae Showtunes Temperature – Sean Paul Give My Regards to Broadway Fire Burning – Sean Paul I Could Have Danced All Night Love is wicked – Brick & Lace Put on a Happy Face I Shot the Sheriff – Bob Marley & The Wailers Accentuate the Positive Gimme the Light – Sean Paul My Favorite Things Simmer Down – Bob Marley Oklahoma! Beautiful Girls – Sean Kingston Singin’ in the Rain Got to Love Ya – Sean Paul Seventy-Six Trombones Love From a Distance – Beres Hammond Oh, What a Beautiful Mornin’ Get Up Stand Up – Bob Marley & The Wailers The Surrey With the Fringe on Top Redemption Song - Bob Marley & The Wailers Getting to Know You One Love/People Get Ready - Bob Marley & Somewhere Over the Rainbow The Wailers Wouldn’t it be Loverly? Three Little Birds - Bob Marley & The Wailers Climb Every Mountain No One (Reggae Mix) – Damian Marley/Alicia Impossible Dream Keys Try to Remember Buffalo Soldier - Bob Marley & The Wailers Edelweiss No Woman No Cry - Bob Marley & The Memory Wailers Some Enchanted Evening One Day – Matisyahu

World 1960’s Danza Kudoro – Don Omar ft. Lucenzo At the Hop – Danny & The Juniors Bamboleo – Gipsy Kings Can’t Buy Me Love – Beatles Iko Iko – The Belle Stars Blowing in the Wind – Bob Dylan Sheebeg, and Sheemore – Lorinda Jones Against the Wind – Bob Seger Say Hey (I Love You) – Michael Franti & Brown Eyed Girl – Can Morrison Spearhead I Saw Her Standing There – The Beatles Hotaru Koi (Ho, Firefly) I Want to Hold Your Hand – The Beatles Baba Yetu – And I Love Her – The Beatles Rain Dance – Karl Jenkins Eight Days a Week – The Beatles Wavin Flag FIFA World Cup – Knaan Yellow Submarine – The Beatles Shewane – Soweto Gospel Choir House of the Rising Sun – The Animals Somewhere Over the Rainbow/What a Hey Jude – The Beatles Wonderful World – Iz With a Little Help From My Friends – The Beatles Reel Around the Sun – Riverdance Love Me Do – The Beatles O Schone Nacht Return to Sender – Elvis Mahatma – Barrage Twist and Shout – The Beatles Highland Visions – Johnny Gonzales Puff the Magic Dragon – Peter, Paul, & Mary Spanseniye Sodelal Yesterday – The Beatles Incan Pan Pipes Imagine – The Beatles Let it Be – The Beatles 1950’s 1970’s Blue Suede Shoes – Elvis American Pie – Don McLean Rock Around the Clock – Bill Haley Bad Moon Rising – CCR Chantilly Lace – The Big Bopper Down on the Corner – CCR Great Balls of Fire – Jerry Lee Lewis Gimme Three Steps – Lynyrd Skynyrd Splish Splash – Bobby Darin Peaceful Easy Feeling – The Eagles Bye Bye Love – The Everly Brothers I Can See Clearly Now – Jimmy Cliff I Could Have Danced All Night – Julie Sweet Home Alabama – Lynyrd Skynyrd Andrews Proud Mary – CCR Hound Dog – Elvis Leaving on a Jet Plane – John Denver Teddy Bear – Elvis Piano Man – Billy Joel This Land is Your Land – Woody Guthrie The Sound of Silence – Simon and Garfunkel Getting to Know You – Julie Andrews Tequila Sunrise – The Eagles Kansas City Take it Easy – The Eagles Singing in the Rain – Gene Kelly Free Bird – Lynyrd Skynyrd Let There Be Peace on Earth Annie’s Song – John Denver Suspicious Minds – Elvis All I Have to Do is Dream – The Everly Brothers Earth Angel – The Penguins How Great Thou Art – Carrie Underwood Unchained Melody – Righteous Brothers Can’t Help Falling in Love – Elvis Blue Moon – Mel Torme

1980’s 2000’s Walkin’ on Sunshine – Katrina and the Waves I Love It – Icona Pop Papa Don’t Preach – Madonna Beautiful Soul – Jesse McCartney You Give Love a Bad Name – Bon Jovi Hanging By a Moment – Lifehouse Summer of ’69 – Bryan Adams This Love – Maroon 5 Uptown Girl – Billy Joel Mirrors – Justin Timberlake Livin’ on a Prayer – Bon Jovi Boulevard of Broken Dreams – Greenday Look Away – Chicago Unwell – Matchbox Twenty Don’t Worry, Be Happy – Bobby McFerrin Beautiful – Christina Aguilera Margaritaville – Jimmy Buffet Breakaway – Kelly Clarkson Just the Way You Are – Billy Joel The Reason – Hoobastank All I Wanna Do is Make Love to You – Heart Everytime – Britney Spears The Rose – Bette Midler My Immortal – Evanescence Baby I Love Your Way – Peter Frampton Bad Day – Daniel Powter Wind Beneath My Wings – Bette Midler I’ll Be – Edwin McCain Wonderful Tonight – Eric Clapton

1990’s Come to My Window – Melissa Etheridge Strong Enough – Sheryl Crow Heaven – Bryan Adams Give Me One Reason – Tracy Chapman Head Over Feet – Alanis Morisette All My Life – KCI and JoJo Free Fallin’ – Tom Petty Without You – Mariah Carey I Will Remember You – Sarah McLachlan I Believe I Can Fly – R Kelly Everything I Do – Bryan Adams When a Man Loves a Woman – Michael Bolton Angel – Sarah McLachlan

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BIOGRAPHICAL SKETCH

Name: Katie Louise Myers Date of Birth: August 11, 1989 Place: Fairfax, Virginia

Education: Duquesne University Pittsburgh, Pennsylvania Bachelor of Science in Music Therapy Degree Awarded May 2011

Florida State University Tallahassee, Florida Master of Music in Music Therapy Degree Awarded December 2013

Experience: Music Therapy Internship, University of Pittsburgh Medical Center January 2012-June 2012

Credentials: MT-BC (2012), NICU-MT (2013), EMT-B (2012)