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R E S E A R C H P A P E R

Music intervention study in abdominal surgery patients: Challenges of an intervention study

in clinical practice

Anne Vaajoki MNSc RN

Doctoral Student, Department of Nursing Science, University of Eastern Finland, Kuopio Campus, Kuopio, Finland

Anna-Maija Pietilä PhD RN

Professor, Department of Nursing Science, University of Eastern Finland, Kuopio Campus, Finland Health and Social Centre, Kuopio, Finland

Päivi Kankkunen PhD RN

University Lecturer, Department of Nursing Science, University of Eastern Finland, Kuopio Campus, Kuopio, Finland

Katri Vehviläinen-Julkunen PhD RN

Professor, Department of Nursing Science, University of Eastern Finland, Kuopio Campus, Research Unit Kuopio University Hospital,

Kuopio, Finland

Accepted for publication June 2012

Vaajoki A, Pietilä A-M, Kankkunen P, Vehviläinen-Julkunen K. International Journal of Nursing Practice 2013; 19:

206–213Music intervention study in abdominal surgery patients: Challenges of an intervention study in

clinical practice

Evidence-based nursing requires carefully designed interventions. This paper discusses methodological issues and explorespractical solutions in the use of music intervention in pain management among adults after major abdominal surgery. Thereis a need to study nursing interventions that develop and test the effects of interventions to advanced clinical nursingknowledge and practice. There are challenges in carrying out intervention studies in clinical settings because of severalinteracting components and the length and complexity of the causal chains linking intervention with outcome. Interventionstudy is time-consuming and requires both researchers and participants’ commitment to the study. Interdisciplinary andmultiprofessional collaboration is also paramount. In this study, patients were allocated into the music group, in which

patients listened to music 30 minutes at a time, or the control group, in which patients did not listen to any music duringthe same period.Key words: clinical practice, music intervention, postoperative pain management, quasi-experimental study design.

INTRODUCTIONThere has been a growing interest in and the use of musiclistening during the perioperative period. Music listeninghas an effect on anxiety and pain alleviation,1,2 improvesmood and enhances the feeling of wellness.3 The effects of music listening postoperatively have been studied with

Correspondence: Anne Vaajoki, Department of Nursing Science, Uni-versity of Eastern Finland, Kuopio Campus, PO Box 1627, 70211Kuopio, Finland. Email: [email protected]

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International Journal of Nursing Practice 2013; 19: 206–213

doi:10.1111/ijn.12052© 2013 Wiley Publishing Asia Pty Ltd

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various surgical procedures such as gynaecologic opera-tions,4 caesarean section,5,6 mastectomy operations,7

orthopaedic operations,8,9 cardiac surgery10 and duringpostanaesthesia care.11

Pain is a complex and subjective experience thatincludes physiological, sensory, affective, cognitive,behavioural and sociocultural components.12 It can beaccessed on the basis of the patient’s behaviour and byrating his/her pain intensity and distress or recognizingpain from physiological factors such as blood pressure,heart rate, respiratory rate, peripheral thermal noun andcomplexion.13 The multidimensional aspects of painshould be assessed from more than one dimension.14

Many of the previous music intervention studies inadults’ postoperative pain management have methodo-

logical variations. A literature review (Table 1) revealsthat there are only few music intervention studiesbetween 2006 and 2010 that have used pretest–posttestcontrol group designs.4,8,10 The calculation used to deter-mine sample size is not always declared.6,9,10 Moresparsely used interests are respiratory rate,8 anxiety5,10

and assessing the effects of music listening on both painintensity and pain distress.4 Only one study held a differ-ent position,6 and one study evaluated the duration of theeffect of music listening.6 There are also variations in thetype of music employed: Patients’ favourite music,11

music chosen from a list musical genres4,5,9,10

or musicprovided by researchers.8 In music intervention studiesbetween 2006 and 2010, qualitative data about patients’experiences listening to music have not been evaluatedsystematically. Often statistically significant changeobtained from quasi-experimental designs has beenaccepted as evidence. According to literature, qualitativeapproaches can benefit as a rich source of data that allowsthe experience of the subjects to be reported and can beused with quantitative data by providing informationabout intervention utility.

Complex clinical interventions include several compo-nents and are difficult to describe, standardize, reproduceand administer consistently to all patients. They work bestif tailored to local circumstances and should include adetailed description of the intervention.15 In the previousmusic intervention studies, there is little informationor discussion about difficulties or problems that theresearcher has had by implementing intervention innursing practice. However, this type of information isvaluable to other novice researchers in order to considersolutions in advance. Little is known about music as a

non-pharmacological intervention in patients with majorabdominal surgery. Despite the increased research evi-dence for music listening as an intervention for relievingpain and enhancing well-being during recovery, clinical

nurses make very limited use of music.According to the literature, the reporting of non-pharmacological trials is not generally adequate. The Con-solidated Standards for Reporting Trials (CONSORT)checklist contains a set of recommendations for thereporting of randomized, controlled and quasi-experimental trials 16 The purpose of this paper is to pointout challenges and practical solutions through a quasi-experimental study process concerning music listeningafter major abdominal surgery in adults’ pain managementusing the methods established by the CONSORT.

METHODSStudy design

A quasi-experimental repeated measure, pretest–posttestdesign,4,8,10 was used to evaluate the effect of listening tomusic on pain intensity and pain distress during bed rest,during deep breathing and position shifting, physiologicalparameters such as blood pressure, heart rate and respi-ratory rate, analgesia, adverse effects and length of hospi-tal stay after major abdominal surgery. Patients wereallocated into either the music group or the control group

using an alternate week arrangement until each group hadat least 83 patients. The following hypotheses weretested.

Patients in the experimental group who get standardcare and listen to music after surgery have less pain inten-sity and pain distress; have lower systolic and diastolicblood pressure, heart rate and respiratory rate; have lessanalgesic use, shorter hospital stays and will experienceless adverse effects than those in the control group.

In addition after every music intervention patientsexperiences of music listening were written down. In the

paper, we describe patients’ experiences on music listen-ing by using qualitative data.

Participants and settingIt is important to specify the target population clearlybecause there are certain subgroups that are much moreor much less likely to be interested in participating in amusic intervention study. The use of music listening aftersurgery has grown in recent years. It is also important toassess participants’ characteristics because people who

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Table 1 Music intervention studies in adults postoperative pain management carried out in 2006–2010

Author(s) Music intervention Sample Outcome measures Main results

Allred et al . 20108

USA

Music group: Easy-listening

music on 1, postop, before

and after ambulation.

Control group: Rest in silence

Prepost measures

Total knee joint

n = 56

Power-analysis

VAS pain

Bp, HR, RR,

SpO2

Analgesia

Listening experience

There were no statistical findings

between groups in outcome

measures.

Easter et al . 201011

USA

Music group: country,

easy-listening, gospel or rock

music during PACU stay.

Control group: No music

Day surgery

n = 213

Power-analysis

DOS pain

Analgesia

Bp, HR, RR,

SpO2

Satisfaction

There were no statistical findings

between groups in pain or

physiologic parameters. Patients

in the music group were more

satisfied with their PACU stay

compared with the control

group.

Sen et al . 20106

TurkeyMusic group: Patient’s favourite

music 1 h after surgery


Caesarean sectionn = 70

VAS lying and sittingposition

Bp, HR, RR

VRS (sedation, nausea,

vomiting)

Analgesia

Satisfaction

In the music group, pain in sittingand lying position and analgesic

use were lower after surgery

compared with the control

group.

Ebneshahidi et al .

20085

Iran

Music group: Patient’s favourite

music during PACU stay.

Control group: Headphones, no

music

Caesarean section

n = 80

Power-analysis

VAS pain/anxiety

Bp, HR

Analgesia

In the music group, the pain

intensity and analgesia used were

significantly lower compared

with the control group.

Good and Ahn 20084

Korea

Music group: Ballads, religious,

piano, orchestra music on the

1st and 2nd postoperative

day.

Control group: Bed rest

Prepost measures

Gynaecologic surgery

n = 73

Power-analysis

VAS pain Significantly lower pain intensity

and pain distress in the music

group were reported on both

postoperative days compared


Sendelbach et al .

200610

USA

Music Group: Easy listening,

jazz, classical music on the

1st, 2nd and 3rd

postoperative day.

Control group: Bed rest

Prepost measures

Cardiac surgery

n = 86

NRS pain

STAI

Bp, HR

Analgesia

In the music group, patients were

less anxious and their pain

intensity was lower compared


McCaffrey and Locsin20069

USA

Music group: Favourite musicfrom the list after surgery

1h ¥ 4/day.


Hip and knee surgeryn = 124

NRS painAnalgesia

Confusion

Ambulation after

surgery

Satisfaction

In the music group, patients’ painintensity was lower, they needed

less analgesia, the patients’ acute

confusion reduced, ambulation

improved and satisfaction scores

were higher after surgery.

Bp, Blood pressure; DOS pain, Descriptive ordinal scale; HR, Heart Rate; NRS, Numeric Rating Scale; PACU, Post Anesthesia Care Unit; RR,

Respiratory Rate; SpO2, Saturation of Peripheral Oxygen; STAI, State Trait Anxiety Inventory; VAS, Visual Analogue Scale; VRS, Verbal Rating

Scale.

208 A Vaajoki et al.


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agree to participate have strong preferences for usingmusic and might not agree to randomization.17

Inclusion criteria for this study were as follows: Patientunderwent major upper abdominal incision, had epidural

analgesia after surgery, an estimated hospital stay of atleast 4 days, and an anaesthesia physical status classifica-tion of 1–3. Exclusion criteria were drug abuse, psychi-atric disorders, hearing impairment, dementia, chronicpain problems or patients admitted to other departmentsafter surgery. Inclusion and exclusion criteria were thesame in the music group and the control group.

Twenty-two patients refused to participate, fromwhich one patient refused to participate because he or sheshould have listened to music and one refused because heor she belonged to the control group. Fifteen patients

stopped because they were very tired or the surgeon hadgiven them bad news after the operation. For researchreasons, 19 patients were excluded, for example, theywere not given epidural analgesia despite the anaesthesiaplan, and 46 patients met the exclusion criteria.

A calculation of the required sample size was based onthe power analysis18 with respect to the visual analoguescale (VAS) pain scale.5,11 A mean of 3.5 and a standarddeviation of 2.4 were expected. A clinically significantdifference of 30% and a statistically significant level of a = 0.05 were expected. With a power of 80%, a sample

size for each group of 83 patients (n = 166) was calculatedas appropriate.19

Outcome measuresTreatment fidelity is of integral importance when deliv-ering music intervention and control. The CONSORTchecklist requires both primary and secondary outcomesand how and when data on the outcomes were collected.Seven main outcome measures were employed in thismusic listening intervention: Pain intensity and pain dis-tress4 with VAS,5,8 numeric rating scale (NRS),9,10 blood

pressure and heart rate5,7,11

with OMRON M5-I of OMRON M6 (Dalian, China) and respiratory rate8,11 bycounting the number of times the patient’s chest roseand fell for 1 min. The amount of analgesia5,11 used andadverse effects during the first 72 h after the operation,the duration of epidural pain management and the timeepidural catheter was removed were measured. Each par-ticipant’s length of hospital20,21 stay was measured in daysfrom the day of admission to discharge from the hospital.Secondary outcome measures were patients’ experiencesabout music listening. After each of seven interventions,

if patient described or commented on listening to musicexperience, it was recorded. On the third postoperativeday, participants completed the questionnaire, which wasdeveloped by the researchers. It consisted of both struc-

tured and open-ended questions about the patient’s musicexposure frequency, musical background,6,22 favouritemusic, postoperative pain experiences before thissurgery23 and pain management experiences after abdo-minal surgery.24 The questionnaire was pilot tested andmodified accordingly before the study. Data collectionand outcome measures were done by one researcher.

Music intervention procedureDetails of the intervention for each group of the trialand how and when the interventions were administered

include the number of sessions of the intervention, theduration of each session, the amount of time betweensessions, how the control has disguised and who deli-vered control (usual care) and interventions. Also, wherethe intervention will be executed must be carefullyconsidered.

Cooperation, discussions with nurse staff and theirinformation are paramount when developing and planninga music intervention.18 In this study, there was no researchassistant; rather, one researcher (AV) executed the musicintervention. The reasons for that were not only limited

staff and financial resources but also that researcherwanted methodological experience from the complexclinical music intervention process.25,26

In this study, the basis for the pilot work and existingliterature music listening time was 30 minutes, and theintervention was repeated in the evening of the operationday, in the morning (8–9 am), at noon (13–15 pm) and inthe evening (18–20 pm) on the first and second postop-erative days, seven times in total. On the third postopera-tive day, music was not played, but measures were takenonce to evaluate the long-term effects of music listening.

The control group did not listen to music but they had a30-min break between pre- and posttests and at all thesame phases as the music group. During the 30-min break,the control group patients were asked not to listen tomusic. Intervention was carried out in the patient’s roomtogether with the department’s daily rounds. Each patientin both groups had 15 assessments, seven times beforeand seven times after intervention, and one during thefollow-up visit (Fig. 1).

The subjects consisted of all patients who were sched-uled for a major abdominal surgery that met inclusion



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criteria. According to a yearly calendar from the startingpoint of the study, patients were enrolled in the musicgroup or to the control group via an alternate-weekarrangement so that music was listened to every secondweek until each group had at least 83 patients. This assig-nation process was determined before the pilot study.

Participants were screened from departments’ opera-tion plan lists every week, and the researcher countedpatients who potentially met the inclusion criteria andexamined the final operation and anaesthetic plan. The

researcher interviewed and informed patients prior to theday of surgery, which lasted an average of 1 h. Patientswere told whether they belonged to the music group orthe control group. The participants were given theirfavourite music in the light of discussions with the musictherapist and based on earlier literature.22 There were twosets of headphones (Sennheiser HD 555, Tullamore,Ireland and AKG K28NC, Vienna, Austria) and MP3-players (Apple iPod 8GB, CA, USA). Different selectionsof the most popular and classic music in Finland wererecorded, and songs were written to the file from which

the participants chose their favourite music. Selections of music were added according to participants’ wishesduring the study. The music alternatives were domestic orforeign hit songs, dance, pop, rock, soul, blues, spiritualor classical music. The researcher discussed music prefer-ences with the participants and presented a music list priorto the day of surgery.

Ethical approvalEthical considerations were a very important part of theintervention study. In this study, before data collection,

the study was approved in June 2007 by the ResearchEthics Committee Hospital of the District of NorthernSavo 6/2007. Before and during data collection, the staff received information about the study and its progress bythe researcher. All participants were given a writteninformed consent form. Participation was voluntary, andrefusing to participate did not affect the care receivedduring hospitalization. It was also possible for the patientto stop without providing a reason.

Data analysisThe specification requirements of the statistical methodswere used to produce an estimate of the effect of theintervention. Data were recorded, and a statistical analysiswas carried out using the Statistical Package for SocialSciences (SPSS 16.0 for Windows, SPSS Inc., Chicago, IL,USA) software. Frequencies and percentages were used todescribe the demographics of patients and the adverseeffects of epidural analgesia. The c

2 test was used toexamine the independence of the treatment group assign-ment. The Kolmogorov–Smirnov test was used to

examine the normality of the continuous data. The resultssuggested that non-parametric tests were appropriate.The parametric test analysis of variance was used forrepeated measurements to analyse pain intensity, paindistress, systolic and diastolic blood pressure, heart rateand respiratory rate over time between the two groups.The duration of anaesthesia, surgery, postanaesthesia careunit stay, epidural analgesia and the long-term effect of music on systolic and diastolic blood pressure, heart rateand respiratory rate were analysed using the nonparamet-ric Mann–Whitney U -test for independent groups. The

Operation Day First and Second Postoperative Day Third Postoperative Day

Evening Morning Afternoon Evening Afternoon

6-8 p.m. 8-9 a.m. 1-3 p.m. 6-8 p.m. 12-4 p.m.

Pretest

Posttest

Music

Group

n = 83

Pretest

Posttest

Final testPretest

Posttest

Pretest

Posttest

Pretest

Posttest

Control

Group

n = 85

Pretest

PosttestFinal testPretest

Posttest

Pretest

Posttest

6-8 p.m. 8-9 a.m. 1-3 p.m. 6-8 p.m. 12-4 p.m.

Evening Morning Afternoon Evening Afternoon

Operation Day First and Second Postoperative Day Third Postoperative Day

Figure 1 Study design. Repeated pretest

and posttest measures with a music group and

a control group during 25 months.



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duration of epidural analgesia and the length of hospitalstay were also analysed using the Kaplan–Meier test. Dif-ferences were regarded as statistically significant if thetwo-sided P -value was less than 0.05. The content analysis

was conducted about patients’ music listening experi-ences. The data of content analysis were quantified withincategories: how many patients described music listeningexperiences in a particular way. Same patient was able touse many different descriptions of their experiences.

Because the missing data totalled over 50%, the opera-tion day was dropped from the analysis. The main reasonfor this was that patients were discharged from postanaes-thesia care unit late in the evening because of majorabdominal cancer surgeries. Patients were also extremelytired from the operation, anaesthesia and analgesia. On

the third postoperative day, one patient in the controlgroup suffered from delirium and could not complete thequestionnaire, and the researcher could not measure painor physiological parameters on that day.

RESULTSFirst, the hypothesis that patients in the experimentalgroup who receive standard care and listen to music aftersurgery have less pain intensity and pain distress thanthose in the control group was partially supported. On thesecond postoperative day, after intervention, pain inten-

sity and pain distress were significantly lower in the musicgroup compared with the control group.27

Second, the hypothesis that patients in the experimen-tal group who receive standard care and listen to musicafter surgery have lower systolic and diastolic blood pres-sure, heart rate and respiratory rate than those in thecontrol group was partly supported. On the first andsecond postoperative day, after intervention, respiratoryrate and systolic blood pressure were significantly lowerin the music group compared with the control group. Onthe third postoperative day, when there was no interven-

tion, respiratory rate was significantly lower comparedwith the control group.28

Third, the hypothesis that patients in the experimentalgroup who receive standard care and listen to music aftersurgery have less analgesic use, experienced less adverseeffects and shorter hospital stay than those in the controlgroup was not supported.29

After seven music interventions 55/83 (66%), patientscommented spontaneously on music listening. Twenty-eight patients (51%) said that music was lovely and theyliked it. Twenty (36%) patients fell asleep or experienced

that music listening had sleepy effect. Listening to musicwas good or excellent experience according to 17 (31%)patients. Sixteen (29%) patients experienced relaxed afterlistening to music. Sixteen (29%) patients said that music

distracted from pain and away from hospital environment.Ten (18%) patients commented that time passes quicklyby listening to music. Seven patients (13%) commentedthat the ward environment disturbance their music listen-ing, and two patients (4%) said that pain was too severe tofocus on music.

DISCUSSIONBased on the researcher’s experiences while conductingthe music intervention in a complex clinical environment,

there are certain methodological weaknesses, strengthsand challenges that need to be addressed. First, due to theinexperience of researcher, the participants were not ran-domly assigned to the music and control groups. Despitethis, the groups’ baseline characteristics were compara-ble, and according to literature, if the changes are verysmall or take a very long time to appear, a non-randomised design is a feasible option.30 In this study, datacollection continued for 25 months. Second, theresearcher and participants were not blinded to groupassignments, and the presence of the researcher through-

out the procedure might have influenced the participantsto offer more positive responses. In both groups, thosewho answered the open question said that participatingin the study was a positive experience. However, theresearcher could not influence participants’ physiologicalparameters, length of hospital stay, analgesic use oradverse effects of analgesic. It has to be taken into accountthat perhaps these were not the most adequate parameterswhere can evaluate music listening effects. It is also knownthat, when the treatment is non-pharmacological, blind-ing is more difficult.31 Because the music intervention was

executed every second week, the remote possibility existsthat the participants discussed the study with each other.Moreover, in most cases, the participants were positionedin separate rooms. Third, the music intervention tookplace in the patients’ rooms during the daily routines of normal nursing practice, and patients were occasionallydisrupted during the intervention. These interruptions,for example, doctor’s rounds, nursing actions, tele-phone calls or visits by relatives, occasionally disturbedand irritated patients and might affect their physiologicalparameters.



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The strengths of this study were that the sample sizewas based on a power analysis, and the intervention waspilot tested with 10 patients using similar patients andsettings to those in which the intervention would be

used to test instructions, usability measurements,data collection, study design and unanticipated effects.30

One researcher, who has extensive previous experienceworking on a surgical ward, collected all the data over a25-month period. The principal researcher knows thedata well and has solid knowledge about and experiencewith executing a music intervention study.26 Patients’commitment to participating in the study was paramount.They assessed pain intensity and pain distress using twopain scales (VAS and NRS) in different positions (in rest,deep breathing and shifting position) 12 times before and

after each intervention. On the other hand, the researcherprovided full attention to each patient during the studyand did not hurry the patient. The pain assessment andphysiological parameters were always taken the sameway. The VAS and NRS used in this study are reportedto be sensitive14,32 in assessing the efficacy of non-pharmacological interventions. The same blood pressureand heart rate monitors were used on the ward, andmonitors were calibrated once a year. Also, the question-naires were pretested with the pilot study in gastro-intestinal surgical patients.

These results cannot be generalized because all datawere collected in only one hospital. However, our datasupport the earlier findings that indicate that musiclistening can be a beneficial adjuvant to other non-pharmacological and pharmacological pain relief meth-ods.33 Our qualitative data also support findings thatlistening to music has distraction effect from pain1,2 andenhances the mood.3 This music intervention study withrepeated pretest and posttest setting and outcome meas-urements can be applied to other surgical patient groups.Further studies are needed to evaluate the optimal time

for music listening so that patients can self-administermusic therapy after surgery. Also, a greater emphasisshould be placed on evaluating patients’ experiences andself-reports about music listening experiences in thefuture.

In summary, planning and executing an intervention istime consuming, requiring extensive preparation and agreat deal of forethought. In addition, it requires skill inworking with patients, practitioners, administrators, dataanalysts, representatives of different professions and dis-ciplines and a deep understanding of practice. In essence,

the researcher must be prepared for unexpected changes.Another challenge is also how this music interventionwill be implemented in nursing practice to contribute tothe health and well-being of all patients. Although the

intervention study faced several challenges, it is alsorewarding and an extremely good way to develop thenursing practice.

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