Medical Center of Central Georgia Neonatal Intensive Care Unit The Effect of Music Therapy as a Nursing Intervention for the Inconsolable 32-40 Week Critically Ill Infant Dr. Douglas Keith, PhD, MT-BC Dr. Kendra Russell, RN, PhD Barbara Weaver, RN
Medical Center of Central Georgia 600+ beds (2 nd in Georgia) Level 1 Trauma Center Serves 28 counties (> 750 k residents) 5000+ employees; 1500 nurses Regional economic impact > $1 Billion Magnet designated 5/17/2007
Georgia College & State University Georgia s Public Liberal Arts University Milledgeville, Georgia 6,000 students
Collaboration Music Therapy GCSU School of Health Sciences Nursing NICU Unit Council
Nursing Research Council Membership Educates Mentors Reviews and approves Consults
Introduction Prematurity: 10-12% of all US births MCCG average daily census: 50 babies (March of Dimes, 2007)
Stress for Infants Routine care in the NICU causes stress for infants Painful Non-painful Effects of stress Physiologic Behavioral (Evans, Vogelpohl, Bourguignon, & Morcott, 1997)
Stress for Caregivers Difficult to console babies: challenging for caregivers Parents Helplessness Emotional pain Despair Nurses Environmental stress Frustration Helplessness (Hughes, 2002)
Interventions for stress: Nursing Neurodevelopmental care Kangaroo care Nonnutritive sucking (NNS) Swaddling Containment (Aucott, Donahue, Atkins & Allen, 2002)
Music Therapy in the NICU Provided by Board-Certified Music Therapist (MT-BC) NICU Music Therapy interventions Recorded music (age-appropriate) Live singing & multimodal stimulation Pacifier-activated lullaby (PAL)
Music Therapy in NICU: Evidence-based effects Improve O 2 saturation Increase weight gain Shorten hospital stay Reinforce NNS Increase tolerance for stimulation (Standley, 2000)
Purpose To explore the effectiveness of music therapy to reduce crying among our patients To promote parental bonding To reduce workload and environmental stress for our nurses.
Research Questions 1. What is the effect of music therapy on the inconsolable behaviors of critically ill infants? 2. What is the effect of music therapy on the physiological measures (heart rate, respiratory rate, mean arterial pressure and oxygen saturation) of critically ill infants during periods of inconsolability? 3. What is the effect of music therapy on nursing care in the NNICU?
Method Sample 24 Infants in Level III NICU 90 Nurses Recruitment Neonatal Nurses approached parents of infants who met inclusion criteria Nurses who cared for infants enrolled in the study were asked to participate
Method Instrumentation Nursing researchers designed form to gather data on infants and from nurses
Inclusion/Exclusion criteria (A) Inclusion/Exclusion Criteria: 32-40 weeks gestation Admitted to the Level III NNICU Not mechanically ventilated NPO No pain medications used No history of drug withdrawal
Inclusion/Exclusion criteria (B) Customary nursing interventions unsuccessful Nonnutritive sucking Swaddling Changing diaper Repositioning Quiet and dark environment Inconsolable crying 5 minutes postintervention Intense, loud rhythmic and sustained cry vocalizations, High motor activity
Research Design: Repeated measures Each infant assigned to one of two four-day protocols ABAB BABA Each infant experienced both conditions Protocols differed in order of presentation
Condition A: Music day Provide nursing interventions If unsuccessful, record nursing interventions and vital signs Provide music intervention Record behavioral state, vital signs, and duration of crying
Condition B: No music day Provide nursing interventions Record behavioral state, vital signs, and duration of crying
Data Collection Process
Research tools Informed consent form Research packets for random assignment to treatment protocol Red or green selection cards Data collection tools Quick reference guides Contact information for investigators
Research Tools CD player & small speakers CD of developmentally appropriate music 18 minutes (guideline: < 30 min) Female voice (GCSU music therapy student) In English (culturally appropriate) Unaccompanied lullabies Narrow pitch and dynamic range Nursing staff questionnaire
Nursing Research Tool Physiological Assessment data Nursing Interventions Infant Response Music Intervention
Nursing questionnaire Five survey questions with rating scale Strongly disagree Strongly agree 1 2 3 4 5 Demographic questions
Nursing Questionnaire Survey questions Answer area Shift info / Parent comments
Sample Demographics: Infants n = 24 infants (complete data for 22) Mean adjusted gestational age: 33.125 weeks (SD = 2.45) 68% Male, 32% Female Most common diagnosis: Respiratory distress syndrome 98% single births Mean APGAR scores at 3 and 5 minutes were 5.82 (SD = 1.74) and 8.50 (SD =.86)
Analysis of Infant Data Paired-sample t-tests ANOVA
Results: Frequency of inconsolability episodes Mean number of episodes SD Condition A: Music 4.29 1.14 Condition B: No Music 7.21 2.83 t (23) = 6.61; p <.001)
Results: Duration of inconsolability episodes Mean duration (minutes) SD Condition A: Music 5.53 1.14 Condition B: No Music 23.14 9.99 t (23) = 8.94; p <.001)
Results: Physiological measures Music Condition No Music Condition Pre Post Pre Post Heart Rate 152.15 144.39* 154.36 154.28 Respiration Rate 56.25 48.98* 59.60 60.45 O 2 Sat 91.16 92.67* 90.56 90.90 * Significant difference between pre- and post-intervention
Results: Infants 1. What is the effect of music therapy on the inconsolable behaviors of critically ill infants? Music days: 4 inconsolable episodes/day, lasting 5.5 minutes Non-music days: 7 inconsolable episodes/day, lasting 23 minutes
Results: Infants 2. What is the effect of music therapy on the physiologic measures of critically ill infants during periods of inconsolability? Positive effects Heart rate Respiratory rate Oxygen saturation
Sample Demographics: Nurses 51% (n= 46) Dayshift Nurses 49% (n = 44) Nightshift Nurses
Analysis of Nurse Data Descriptive measures
Results: Nurses Music therapy decreased the stress I experienced with this inconsolable baby (M = 4.59) MT was an effective intervention for this inconsolable baby (M = 4.59)
Results: Nurses MT with this inconsolable baby helped me make more efficient use of my time (M = 4.58) MT made my workload lighter (M = 4.52) Music therapy impacted the parentinfant bonding process (M = 4.53)
Comments from Nursing Form Comments: Loved music therapy, thought it helped, wanted CD, worried about B days of research Mom felt like we were doing what she would have done if she could have with music therapy Wanted to keep using after four days Parents felt music therapy helped a lot Parents loved music therapy CD Parents thought it helped a lot
Conclusions Music intervention was well tolerated Reduction in duration and frequency of inconsolability in premature infants Improved physiological measures Nurses expressed agreement that MT was an effective intervention, impacted parental bonding and their work environment positively.
Implications for Practice NICU staff can consult with Board- Certified Music Therapists (MT-BC) to provide developmentally appropriate music interventions Music therapy is an effective, research-based intervention in the hospital setting
Limitations Nurse researchers were not blinded to participant status Use of a convenience sample No tests of infant hearing Variability in nursing and infant behaviors (e.g., order of interventions) Use of recorded music
Recommendations for Future Research Using recordings of the mother s voice in her native language Use of live vs. recorded music Music interventions in infants under 32 weeks, looking at other indicators of stress based on gestational age Impact of music therapy on the work environment of nurses in NICU
Acknowledgements Mitch Rodriguez, MD Nursing researchers Judith Danford, RN Nursing Research Grant, MCCG $4,175.00 Alicia Bembenek, PhD
References Aucott, S., Donahue, P., Atkins, E. & Allen, M. (2002). Neurodevelopmental care in the NICU. MRDD Research Reviews, 8, 298-308. Evans, J., Vogelpohl, D., Bourguignon, C. M., Morcott, C. S. (1997). Pain behaviors in LBW infants accompany some "nonpainful" caregiving procedures. Neonatal network, 16 (3), 33-40. Hughes, M.B. (2002). Infant excessive crying: Temperament, development and parenting stress. Unpublished doctoral dissertation, University of Pennsylvania. March of Dimes (2007). Premature fact sheet: The growing problem of prematurity. Retrieved November 10, 2007 from http://marchofdimes.com/files/prem_fact_sheet_final_oct_2007.pdf Standley, J. M. (2000). A meta-analysis of the efficacy of music therapy for premature infants. Journal of Pediatric Nursing, 17 (2), 107-113).