Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka s21
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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 NAME OF THE CANDIDATE AND Ms. SUNITHA SANIVADA ADDRESS GOLDFINCH COLLEGE OF NURSING
NO: 150/24, KODIGEHALLI MAIN ROAD
MARUTHINAGAR
BANGALORE-560092
2 NAME OF THE INSTITUTION GOLDFINCH COLLEGE OF NURSING
MARUTHINAGAR
BANGALORE-560092
3 COURSE OF STUDY AND SUBJECT M.SC NURSING
OBSTETRICS AND GYNECOLOGICAL
NURSING
4 DATE OF ADMISSION TO COURSE 30-06-2012
5.TITLE OF THE STUDY
“A STUDY TO ASSESS THE EFFECTIVENESS OF SELF INSTRUCTIONAL MODULE ON
KNOWLEDGE REGARDING THE EFFECTIVENESS OF MUSIC THERAPY IN RELIEVING
LABOUR PAIN AMONG STAFF NURSES IN A SELECTED HOSPITAL AT BANGALORE”
6.0 BRIEF RESUME OF THE INTENDED WORK
1 INTRODUCTION
"Take a moment now, and experience A Music Therapy Moment… ".
- Anonymous
In the early 1980's, Music Therapists began to explore the use of "audio analgesia" (sound
for pain relief) in the music therapy process in working with labor and delivery patients. Music
therapists assist patients in the clinical application of music in suppressing the pain response, but
can also work with patients in deeper psychological and emotional ways. The process of "music
therapy" differs from "music medicine" based on the establishment of a relationship between
therapist and patient. Music therapists specifically design and develop unique treatments for each
patient based on the patient's need and condition.1
Although there have been advancements in anesthesia for labor and delivery in recent
years, many couples today choose to have a natural childbirth experience. It has been substantiated
by the research that birth outcomes for mother and baby can be greatly enhanced through the
natural childbirth process. Many free-standing and hospital-based family birthing centers are
popping up around the country to meet this growing need. Several nonpharmacological
interventions are available to laboring mothers including hypnosis, biofeedback, touch and
massage, hydrotherapy, acupuncture, and transcutaneous electric nerve stimulation, another
successful pain management
Of late, there has been an increase in the demand for non-invasive non-threatening and
non-pharmacological alternatives for pain-management and anxiety management during labor, and
delivery. Music therapy is becoming increasingly popular as a tool for providing the much needed
relaxation to women at the time of labor and delivery. Apart from music therapy, other relaxation
2 techniques, such as progressive muscle relaxation and deep breathing are also considered very effective in providing relaxation to women at the time of labor and delivery.
Music therapy has been in existence for many years from now and there are evidences which clearly indicate that when used along with conventional treatment, music therapy can help to relieve anxiety, stress and pain. Music therapy is also found to be effective in regulating the heart beat, blood pressure, and breathing rate, which are very crucial at the time of labor and delivery.
A Music Therapy Assisted Childbirth program is conducted by a board-certified music therapist, (with a minimum of a bachelor's degree) and consists of a series of sessions usually offered in the last trimester of pregnancy. Some music therapists also provide labor and delivery support for the couple during the birth and post-natal visits. Couples are taught how to use music to support their physical and emotional needs throughout the stages of labor and delivery.
A recent study of 14 couples who participated in a Music Therapy Assisted Childbirth program found that music therapy was very beneficial during the labor and delivery process. The use of music during labor and delivery was most effective in supporting (rhythmic) breathing
(86%), remaining calm (86%), focus (71%), and pain management (64%).2
Women who practiced the techniques at home and who were familiar with their music felt in control and had more positive birth experiences. Many of the women (64%) felt in control most of the time during labor and delivery. Imagery techniques were effective when paired with the music and (71%) stated that these techniques were the most beneficial. All of the women (100%) felt well supported during labor and delivery. All participants (100%) stated that the music therapy program enhanced family bonding with the baby during the immediate postpartum period. The music therapy helps provide rhythmic breathing, by easing out the stress and help the mothers in
3 relaxing. When the mother focuses her complete attention on the music, her mind gets diverted
from the pain and suffering that she is undergoing. During delivery, music helps the mother to
concentrate, relax, and breathe rhythmically and divert the mind from focusing on the pain being
experienced by her. Not only this, music assisted relaxation sessions and music therapy have also
been proven to reduce anxiety and provide alternative coping strategies for high-risk hospitalized
mothers who have been diagnosed with obstetrical complications. The music therapy act as an
attention-focusing stimulus and to be a distraction stimulus to divert attention from pain .It also
acts as a conditioned stimulus for relaxation. It decreases tension and anxiety. It is used as a
structural aid to breathing and provides a stimulus for pleasure response and stimulates and
pacifies newborn3
6.1. NEED FOR THE STUDY
4 The need of the study is to identity the methods of music therapy to relieve pain, their treatment, and nurse’s responsibility to do it in a proper way and to find out various protective measures provided to staff in a multi specialty hospital. The music therapy is to create the awareness among the staff nurses and also among the pregnant mother and to know about the latest techniques that are used to improve the music therapy.
Anxiety and stress, as indicated by physicians, can negatively impact the progress of labor and increase the risk of obstetrical complications. Relaxation can help to relieve pain, stress, and anxiety to a great extent.
Of late, there has been an increase in the demand for non-invasive non-threatening and non- pharmacological alternatives for pain-management and anxiety management during labor, and delivery. Music therapy is becoming increasingly popular as a tool for providing the much needed relaxation to women at the time of labor and delivery. Apart from music therapy, other relaxation techniques, such as progressive muscle relaxation and deep breathing are also considered very effective in providing relaxation to women at the time of labor and delivery.4
In some modern hospitals which believe in the power of noninvasive pain management techniques, music therapy is administered by trained music therapists. The therapy sessions are commenced soon after the patient is brought in for delivery. Music therapy is administered before, during, and sometimes, even after the birth of the child.5
The music therapy helps provide rhythmic breathing, by easing out the stress and helps the mothers in relaxing. When the mother focuses her complete attention on the music, her mind gets diverted from the pain and suffering that she is undergoing. During delivery, music helps the mother to concentrate, relax, and breathe rhythmically and divert the mind from focusing on the pain being experienced by her. Not only this, music assisted relaxation sessions and music therapy
5 have also been proven to reduce anxiety and provide alternative coping strategies for high-risk hospitalized mothers who have been diagnosed with obstetrical complications.
Apart from these aspects, music therapy has also been proved to be extremely beneficial for post-operative obstetric and gynecological patients. The use of music and relaxation techniques soon after the delivery has been proved to reduce the extent of pain and consequently, the dosage of pain-control medication required by the mothers.6
Music therapy has been used on clinical medicine. Only few scientific studies validate the value on labor women. The findings support that music listening is an acceptable and non-medical coping strategy for laboring women. Especially, apply in reducing the pain and anxiety for women who are at the early phase of labour. The nurse assists the couple in selecting and applying a specially chosen music program to calm, comfort, block pain and focus breathing for each mother.
The nurse may also provide instruction in imagery and relaxation techniques, movement training, singing of lullabies and womb songs, and other creative arts experiences. (A womb song is a special song that is written for the baby while in utero.) Familiar music can help comfort the mother during the birth experience and practice with the music before the birth is essential. This therapy has been found to significantly decrease the mother’s anxiety and pain responses, decrease the need for analgesic medications during birth, and has contributed to overall positive feelings about the birth process.This study describes a new clinical music therapy program for application in the labor and delivery setting, and presents results of a preliminary study to evaluate effectiveness of the treatment.7
6.2. REVIEW OF LITERATURE
6 A Review of literature is a body of text that aims to review the critical points of current knowledge and methodological approaches on a particular topic, the role of the literature review is to formulate and clarify the research problems, to ascertain what is already known in relation to problem of interest, for developing a broad conceptual context, facilitate cumulating scientific knowledge for interpreting the result of the study.
Section-A: Studies related to knowledge of use of music to enhance relaxation and decrease pain responses
Section-B: Studies related to knowledge about treatment protocol for music therapists for working with labor and delivery mothers.
Section-C: Studies related to knowledge of distraction from pain
Section-A: STUDIES RELATED TO KNOWLEDGE OF MUSIC TO ENHANCE
RELAXATION AND DECREASE PAIN RESPONSES
A study was conducted on the use of music to enhance relaxation and decrease pain responses in mothers during childbirth. The music therapists used music to cue rhythmic breathing, assist the mothers in relaxation, prompt positive associations, and help focus attention on the music as a diversion from pain and hospital sounds. A small sample of seven Lamaze- trained mothers was used and subjects served as their own controls. Two individual music therapy sessions were conducted with the subjects prior to the birth experiences. In the first session the music therapist established rapport and determined the musical preferences of the mother. Prior to the second session the music therapist developed an individualized music program for each mom.
During the second session the mothers were familiarized with their music programs and instructed in relaxation and breathing techniques. The music therapists attended the births and monitored
7 music during the experience. During labor each mother experienced periods of music and non- music and were observed under both conditions. Observations of tension and relaxation in various parts of the body were made and recorded. Two other relaxation behaviors, breathing and verbalization were observed and recorded as positive, negative, or neutral. During the delivery phase the music therapists played music that was specially selected by each mother and her coach.
One week after the delivery each mother was given a post-delivery questionnaire and was asked how the music helped her concentrate, relax, and whether it helped with rhythmic breathing.
Results indicated that all of the mothers had fewer pain responses in the music vs. no-music condition, and that music aided concentration, relaxation, cued breathing, and diverted attention from pain. Coaches and hospital staff also responded well to the music, indicating that the music made a positive contribution to the labor and delivery experience.8
A study was conducted on the use of music, it has been suggested that attention focusing cannot only increase pain tolerance, but may totally eliminate pain sensation. It is perhaps preferable to distraction techniques because of the active, purposeful mental involvement of the patient .The potential of music for becoming an effective attention-focusing stimulus is great, for it is difficult to ignore and, appropriately chosen, pleasurable to hear. 9
Another study was conducted on the use of music to relieve pain. , found, not only that music "took their minds off pain," but also that many used the music to focus attention more than, or instead of, Lamaze-practiced visual focal point techniques.10
A study was conducted to describe a highly effective music therapy treatment for such anxiety that resulted in significant decreases in levels of anxiety and an increased sense of control.
Numerous life stressors during pregnancy, such as concerns for the baby, self, medical care, childbirth, and finances, can contribute to elevated levels of anxiety. This anxiety can be further intensified by hospitalization for high-risk complications. It has been suggested that high anxiety
8 or psychological stress in the mother can result in a higher number of fetal abnormalities and maternal obstetrical complications11.
Section-B: STUDIES RELATED TO KNOWLEDGE ABOUT TREATMENT PROTOCOL
FOR MUSIC THERAPISTS FOR WORKING WITH LABOR AND DELIVERY
PATIENTS
A landmark study about treatment protocol was the first published treatment protocol for music therapists for working with labor and delivery patients. Their investigation was a preliminary study of the effectiveness of music for pain relief during labor and delivery. They found that music serves several functions in the natural childbirth process including attention focusing, distraction from pain, stimulating pleasure responses, focusing breathing, and as a conditioned stimulus for relaxation. There were 20 subjects in this study. Thirteen experimental subjects received 6 pre-natal music training sessions with a music therapist. Seven control group subjects did not receive the music treatment. The treatment sessions were focused on selecting appropriate music and learning/practicing music-assisted relaxation techniques. The experimental group patients each received a stereo cassette tape for home practice in order to become familiar with the relaxation techniques. The Music Therapist was notified when each subject went to the hospital and assisted the patients in labor and delivery. The therapist played the music continually and relied on it more than verbal contact when the woman was in labor. During the pushing phase, the tempo, intensity, and energy of the music were increased to give the mothers energy to push.
Special music, which was chosen by the parents, was played at the time of the delivery and the music concluded when the patient left the delivery room. After the birth, the music therapist administered a childbirth experience questionnaire to each subject. Results indicated that the music group had higher success scores on 5 out of 7 indices of the childbirth process. A moderate correlation between home practice with the music and successful outcome was also found. The authors also noted the possibility that perhaps support from a music therapist during labor and
9 delivery contributed to successful outcome. Overall, findings suggested that music therapy may successfully contribute to reducing anxiety during childbirth, as well as augment positive feelings of support throughout the childbirth experience. 12
A study about treatment protocol by the music therapist who assists the couple in selecting and applying a specially chosen music program to calm, comfort, block pain and focus breathing for each mother. The music therapist may also provide instruction in imagery and relaxation techniques, movement training, singing of lullabies and womb songs, and other creative arts experiences. (A womb song is a special song that is written for the baby while in utero.) Familiar music can help comfort the mother during the birth experience and practice with the music before the birth is essential. This therapy has been found to significantly decrease the mother's anxiety and pain responses, decrease the need for analgesic medications during birth, and has contributed to overall positive feelings about the birth process.13
Section-C: STUDIES RELATED TO DISTRACTION FROM PAIN
A study was suggested about distraction which can be effective in moderating pain primarily through the cognitive component of the Gate-Control Theory of Pain. Attending to a pleasant stimulus occupies the capacity of the information processing system, disabling the individual from fully attending to the pain-causing stimulus as cited in Stevens (1990) points out the importance of a distracter for patients undergoing surgery; this distracter provides an escape through imaginative thought which is important in relieving stress, anxiety, and fear associated with pain , suggest pleasant imagery increases a sense of control, thereby decreasing anxiety and feelings of helplessness. Music can be a strategy for refocusing attention during a painful experience. By acting as a competing stimulus to pain or distracter, it can reduce the perceived intensity of pain. Simultaneously, it can decrease the sense of loneliness and feelings that the hospital environment is impersonal14.
10 Another study about this principal involves bodies that are vibrating in slightly different
ways that eventually catch up with each other to vibrate simultaneously. States music therapists
entrain a client’s heart rate (or respiration) by first matching the music to the heartbeat, then
slightly altering the music tempo so that the heart rate follows the beat of the music. The type of
music used can entrain the body to respond in different ways. Sedative music can alleviate anxiety
and stress levels resulting in less use of pain medication, shorter recovery periods, and higher
patient satisfaction, while simulative music can be physically and psychologically motivating,
which is beneficial during rehabilitation.15
6.3. STATEMENT OF THE PROBLEM
11 A study to assess the effectiveness of self instructional module on knowledge regarding the
effectiveness of music therapy in relieving labour pain among staff nurses in a selected hospital at
Bangalore
6.4. OBJECTIVES
1. To assess the existing level of knowledge of staff nurses on music therapy in relieving
labour pain.
2. To assess the post test knowledge of staff nurses on music therapy in relieving labour pain.
3. To assess the effectiveness of Self instructional module on music therapy in relieving
labour pain among staff nurses.
4. To find out the association between selected demographic variables of staff nurses with
their knowledge level of music therapy in relieving labour pain
6.5. RESEARCH HYPOTHESES
. H1: There will be statistically significant difference between the pre and post knowledge
scores of staff nurses regarding music therapy in relieving labour pain.
. H2: There will be significant association between knowledge regarding musical therapy in
relieving labour pain among staff nurses with their selected demographic variables.
6.6. OPERATIONAL DEFINITIONS
1. Assessment: It is the organized systematic & continuous process of collecting information
about pre test & post test. Knowledge from staff nurses regarding music therapy in
relieving pain .
2. Effectiveness: It implies to produce a desire effect for an action.
12 3. Self instructional Module: Refers to the systematically prepared materials which help the
staff nurses for the self learning and provide information regarding music therapy in
relieving labour pain.
4. Knowledge: It refers to correct response of staff nurses to knowledge items on music
therapy in relieving labour pain
5. Staff Nurses: An individual who is qualified as registered nurse and who is giving care to
the client.
6. Labour Pain: Pain is an unpleasant sensory and emotional experience associated with
actual or potential tissue damage at time in which actual delivery takes place
7. Music Therapy: Music therapy is an allied health profession and a field of scientific
research which studies correlations between the process of clinical therapy and
biomusicology, musical acoustics, music theory, psychoacoustics and comparative
musicology.
6.7. ASSUMPTIONS
1. Staff nurses improve knowledge regarding Music therapy in relieving pain .
2. The self instructional module will enhance the knowledge in Music therapy in relieving
pain
6.8. DELIMITATIONS
1. The study was limited to the staff nurses who are posted in the OBG wards.
2. The study was limited to those who able to understand Kannada or English
3. Sample size is limited to 60 staff nurses.
13 6.9. PROJECTED OUTCOME
The investigator will come to know the existing knowledge of staff nurses regarding music therapy and its effect on labour pain.
14 7.0. MATERIALS AND METHODS
7.1 SOURCES OF DATA
The data will be collected from staff nurses of selected hospitals in Bangalore.
7.1.1 RESEARCH DESIGN AND APPROACH
The research design used in this study was Quasi-experimental design.
O1 X O2
O1: Pre test assessment of knowledge of staff nurses
O2: Post test assessment of knowledge of staff nurses
X: Self instruction module
The research approach used in the study is quantitative approach
7.1.2. SETTING
The study will be conducted in a selected hospital at Bangalore
7.1.3. POPULATION
The target population of this study is staff nurses working in a selected hospital
7.2. METHODS OF DATA COLLECTION
Data will be collected by self administered, knowledge and practice questionnaire.
7.2.1. SAMPLING TECHNIQUE
The sampling technique adopted for the study is simple random sampling technique.
7.2.2. VARIABLES UNDER THE STUDY
Independent Variable: Self instructional module on music therapy
15 Dependent Variable: Knowledge of staff nurses regarding music therapy and its effect on labour
pain
7.2.3. SAMPLE SIZE
The proposed sample size of the study is 60 staff nurses
7.2.4. DURATION OF THE STUDY
The proposed study duration is 4 weeks.
7.2.5. INCLUSION CRITERIA
1. Staff nurses who are posted in obstetric and gynecological wards
2. Staff nurses who are willing to participate in the study.
3. Staff nurses those who can understand Kannada or English.
7.2.6. EXCLUSION CRITERIA
1. Staff nurses who are not interested in study can be excluded in the study.
2. Staff nurses who don't know Kannada and English.
7.2.7. INSTRUMENT TO BE USED
A structured self reporting questionnaire will be used to data collection of about 60 staff
nurses.
Procedure for data collection:
The investigator will collect the data from staff nurses using structured questionnaire schedule
to assess the knowledge after obtaining prior permission from the participant.
Pretest will be conducted following which a structured knowledge questionnaire will be
given. Post test will be conducted after 7 days and data will be analyzed using descriptive and
inferential statistics.
16 7.2.8 DURATION OF THE STUDY . The study will be conducted for a period of 4 weeks
7.2.9 LIMITATIONS
1. The study will be limited to ante natal mothers only
2. The study is limited a selected maternity hospital at Bangalore
7.2.10. PLAN FOR DATA ANALYSIS Descriptive Statistics: Assessing the pre test knowledge on staff nurses regarding the effect of music therapy on labour pain will be interpreted by descriptive statistics such as mean.
Inferential statistics: Paired “t” test will be used to see the difference between the pre-test and post test knowledge scores. Chi square test will be used to associate the pre and post test knowledge with selected demographic variables.
7.3. DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION OR TO BE CONDUCTED ON THE PATIENT OR OTHER HUMAN OR ANIMALS?
Yes. The self instructional module will be used as an intervention among the staff nurses.
7.4. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION?
Yes, permission will be obtained from the concerned authority of the institution and from the sample.
17 7.5. ETHICAL COMMITEE
A A study to assess the effectiveness of self instructional module on
knowledge regarding the effectiveness of music therapy in relieving labour
Title of the topic pain among staff nurses in a selected hospital at Bangalore
Name of the candidate Ms. Sunitha Sanivada
Course and the subject MSc Nursing in Obstetrical and Gynecological Nursing
Name of the guide Prof. Kalaivani
Ethical committee Approved
18 8.0 LIST OF REFERENCES
1. American Music Therapy Association (n.d.). Frequently asked question about music
therapy. Retrieved November 22, 2003, fromhttp://www.musictherapy.org/faqs.html
2. Bally, K., Campbell, D., Chesnick, K., & Tranmer, J. (2003, April). Effects of patient-
controlled music therapy during delivery. Critical Care Nurse, 23(2), 50-58.
3. Cohen, B. (2001). Use of aromatherapy and music therapy to reduce anxiety and pain
perception . Access, 15(6),34-41.
4. Evans, D. (2002). The effectiveness of music as an intervention for hospital patients: a
systematic review. Journal of Advanced Nursing, 37(1), 8-18.
5. Gfeller, K. (2003). Therapeutic power of music. Currents, 4(3). Retrieved November 18,
2003, fromhttp://www.uihealthcare.com/news/currents/vol4issue3/o3music.html
6. Good, M., Grass, J.A., Anderson, G.C., Lai, H.L., Roykulcharoen,V., & Adler, P.A.
(2001). Relaxation and music to reduce post surgical pain. Journal of Advanced Nursing,
33(2), 208-215.
7. Kwekkeboom, K. (2003). Music versus distraction for proceduralpain and anxiety in
patients with cancer. Oncology Nursing Forum,30(3), 433-440.
8. Megel, M.E., Houser, C.W., & Gleaves, L.S. (1998). Childrens' responses to
immunizations: lullabies as a distraction. Issues in Comprehensive Pediatric Nursing,
21(3), 129-145
9. Music as Medicine: Music Therapy of University Hospitals ofCleveland (n.d.). What is
music therapy? Retrieved November 18, 2003,from
http://www.musicasmedicine.com/aboutmt.htm
10. Music therapy strikes a cord with cancer patients. (2003).[Electronic Version]. Biotech
Week, 594-595.
11. Roberts, S. (2002). Music therapy for chronic pain. TheDiabetes Forecast, 55(9), 26-28.
19 12. Stevens, K. (1990). Patients' perceptions of music duringsurgery. Journal of Advanced
Nursing, 15(9), 1045-1051.
13. Q & A: Joke Bradt, Assistant Professor, Music. (2002). Retreived November 18, 2003,
from Monclair State University, InsightOnline Web
sitehttp://www.montclair.edu/pages/insight/INSIGHT04-01-02/qa.html
14. Wade, J.B., & Hart, R.P. (2002). Attention and the stages ofpain processing. Pain
Medicine, 3(1), 30-38.
15. Yang, M. (n.d.). Mechanisms by which music therapy operates. Retrieved November 18,
2003, from Macalester College, UndergraduateBehavioral Neuroscience Resource Project
Web site: http://www.macalester.edu/psychology/whathap/UBNRP/Audition/site/how
%20music%20therapy%20work
20 9 Signature of the candidate
10 Remarks of the guide The study is vital in controlling the labour pain and
also it improves the knowledge of staff nurses
Name and designation of
11.1 Guide Prof. Kalaivani
11 11.2 Signature
11.3 Co-Guide (if any)
11.4 Signature
11.5 Head of the department Prof. Kalaivani
11.6 Signature
12.1 Remarks of the Principal The study is feasible and can be done to identify the
knowledge of staff nurses regarding music therapy and
its importance in controlling labour pain 12
12.2 Signature 21 .
22