Journal of Pediatric Nursing (2013) 28, 249257

Impact of Music Therapy Interventions (Listening, Composition, Orff-Based) on the Physiological and Psychosocial Behaviors of Hospitalized Children: A Feasibility Study
Cynthia M. Colwell PhD, MT-BC a,, Robin Edwards PhD, MT-BC a , Emily Hernandez MT-BC b , Kristine Brees RN b
a b

The University of Kansas, Lawrence, KS University of Kansas Hospital, Lawrence, KS

Key words:
Orff-based music therapy; Hospitalized children

The purpose of this study was to compare three music therapy strategies (music listening, music composition, and Orff-based active engagement) on physiological (heart rate, blood pressure, oxygen saturation, and pain) and psychosocial (anxiety) behaviors of hospitalized children (N =32, 17 females,15 males, ranging in age from 6 to 17). This study was designed and facilitated cooperatively by pediatric nurses and music therapists. Results indicated no clinically significant changes in heart rate, blood pressure, or oxygen saturation (p N .05). Pain and anxiety both decreased significantly (p =.01) but not differentiated among conditions. Videotape analysis determined level of engagement in copingrelated behaviors. 2013 Elsevier Inc. All rights reserved.

SPENDING TIME IN the hospital as a patient can be highly upsetting for a child. This experience can influence physiological and psychosocial aspects that can impact the physical and mental health of the hospitalized child. Altered vital signs including increased heart rate, elevated blood pressure, and decreased oxygen saturation can indicate physiological responses to this stressful experience. Increased anxiety and enhanced pain perception are self-reported psychosocial and physiological measures respectively that also may be affected. Behavioral distress can be observed in the patient's level of engagement through changes in copingrelated behaviors of eye contact, facial affect, verbal interaction, and participation. The efforts of the hospitalized child to cope with this stressful environment can be observed through changes in these physiological and psychosocial measures.
Corresponding author: Cynthia M. Colwell, PhD, MT-BC. E-mail address: ccolwell@ku.edu (C.M. Colwell). 0882-5963/$ see front matter 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pedn.2012.08.008

In their text, Stress, appraisal, and coping, Lazarus and Folkman (1984) describe a psychological stress theory, in essence a Stress and Coping theory. They talk about stress as not being within a person or within an environment but instead the interplay between the two thus making stress relational or a transactional experience. Therapy is designed to decrease stress and increase coping with the understanding that both are contextual and change as an intervention unfolds thus creating a therapeutic process. Children exhibit coping strategies in response to the hospital environment, medical personnel, and internal/ external events that occur in those surroundings. Coping strategies are behavioral or psychological attempts to interact with stressful events aimed at reducing, avoiding, or tolerating stressful situations (Lazarus & Folkman, 1984). Research on coping strategies has focused on broad dichotomies of coping types including problem-solving versus emotional-focused or active versus avoidant. The strategy used is determined by personality and type of

250 stressful event but it is generally felt that active strategies are preferred (Boyd & Hunsberger, 1998; Folkman & Lazarus, 1980; Holahan & Moos, 1987; Spirito & Stark, 1994). Coping strategies can include avoiding distressful situations and noncompliance to treatment (avoidant) or seeking distracting events, expressing feelings about illness/hospitalization, exhibiting enhanced interest in medical information/ procedures, seeking support and relationships from others, and participating in pleasurable or normalizing activities (active) (Folkman & Lazarus, 1980; Hubert, Jay, Saltoun, & Hayes, 1988). Children who are positively and actively engaged with the environment typically cope with the trauma of hospitalization in a more appropriate way (Bossert, 1994; Gil, Williams, Thompson, & Kinney, 1991; Hubert et al., 1988; Pretzlik & Sylva, 1999; Robb et al., 2008). Music therapy interventions can provide a distracting event that is a pleasurable and normalizing coping strategy. Through these cost effective interventions, patients can explore feelings and obtain information about the illness, hospitalization, and procedures, improve quality of life and can be encouraged to interact with family and friends (Walworth, 2005; Walworth, Rumana, Nguyen, & Jarred, 2008). Music therapy interventions can include passive music listening, cognitively active music making through song writing and composition, and physically active music making through singing, chanting, instrument playing, and body movement (Hendon & Bohon, 2008; Hilliard, 2006; Nilsson, 2008; Stouffer, Shirk, & Polomano, 2007; Walworth, 2005). Hospitalized individuals can be positively and actively engaged through music therapy (Avers, Mathur, & Kamat, 2007; Evans, 2002; Standley & Hanser, 1995; Standley & Whipple, 2003) to address mood (Barrera, Rykov, & Doyle, 2002), anxiety (Aldridge, 1993; Chetta, 1981; Fagan, 1982; Ferrer, 2007; Gettel, 1985; Klassen, Liang, Tjosvold, Klassen, & Hartling, 2008; McDonnell, 1983; Sendelbach, Halm, Doran, Miller, & Gaillard, 2006; Walworth et al., 2008; Whitehead-Pleaux, Baryza, & Sheridan, 2006), pain (Cepeda, Carr, Lau, & Alvarez, 2006; Klassen et al., 2008; Noguchi, 2006; Sahler, Hunter, & Liesveld, 2003; Sendelbach et al., 2006; WhiteheadPleaux, Zebrowski, Baryza, & Sheridan, 2007; WhiteheadPleaux et al., 2006), respiratory distress (Grasso, Button, Allison, & Sawyer, 2000), and behavioral distress (Malone, 1996; Noguchi, 2006; Robb, 2000a). Music listening is one of the most common music therapy coping strategies in the hospital setting. It can be used therapeutically as an independent event or in combination with other therapeutic elements of drawing, relaxation, or imagery (Bae, 2002; Barker, 1991; Clark et al., 2006; Dun, 1995; Mitchell & MacDonald, 2006; Robb, 2000a; Robb, Nichols, Rutan, Bishop, & Parker, 1995; Standley, 1992). Robb et al. used music listening and relaxation to decrease preoperative anxiety while Standley used music listening to decrease nausea in cancer patients during chemotherapy. Bae found that active music listening decreased anxiety and pain

C.M. Colwell et al. more significantly than artwork making and significantly decreased pain perception from pre- to posttest in hospitalized children. Song writing and composition are more cognitively active coping strategies used with children in pediatric hospital settings (Bellamy, 1990; Colwell, Davis, & Schroeder, 2005; Hartley, 1989; Lane, 1993). Song writing that involves the patient in individual sessions is common to the pediatric unit and can take on a variety of forms including fill-in-the-blank, improvisation, from scratch during the session, piggyback songs, etc. (Robb, 1996). Song writing can include both vocal and instrumental selections and has been used clinically to help patients express emotions about relationships (Aasgaard, 2001), to address separation issues (Daveson & Kennelly, 2000), to express concerns about their illnesses (Colwell et al., 2005; Fagan, 1982; Kennelly, 2001), and in preparation for invasive procedures (Micci, 1984). In a study comparing music composition with art composition, Colwell et al. examined the effect of composition on self-concept of hospitalized children. The music condition used the software program Making More Music (Subotnick, 2007) to create an instrumental selection burned to a CD for the patient to keep. Although improvements were noted, one composition modality did not have more impact on self-concept than the other. Physically active music making involves the patient in the therapeutic intervention through singing, playing instruments, or movement (Edwards, 1994, 1995; Robb, 2000b; Robb et al., 2008). Hartley (1989) compared stories told by children who were chronically ill after participation in either an active or a listening session. In the active session they created their own improvisation, then told a story based on that improvisation, while in the listening session they told a story they created after listening to improvised prerecorded music. Results indicated children in the active session told stories with more established characters, less seconds of silence, more cohesiveness, more activity and interactions, increased socialization themes, and higher levels of fantasy content. Robb found that hospitalized children in isolation exhibited a higher frequency of engaging behaviors when participating in music interventions than in other more traditional hospital activities. In a later study, Robb et al. found that children undergoing cancer treatment exhibited more coping-related behaviors during active music engagement when compared to music listening or audio storybooks. Walworth et al. (2008) examined the effects of live music therapy sessions on patients undergoing elective surgical procedures for the brain. Results indicated that live music therapy session could improve quality of life indicators such as anxiety, perception of the situation, relaxation, and stress. Results of all four studies indicate an increased level of engagement that may in turn indicate functional coping skills. One design for active music making as a coping strategy is Orff-based (Colwell, 2005, 2009; Colwell, Achey, Gillmeister, & Woolrich, 2004; Hilliard, 2007; Register &

Impact of Music Therapy Interventions Hilliard, 2007). Orff-Schulwerk (school-work) refers to active involvement in making music that includes speech, singing, movement and instrument playing with a creative element inherent in each orchestration. The process involves using song, chant, or poem as elemental music, teaching instrument parts first on the body before transferring to instruments and layering parts and adapting them to the abilities of participants [American Orff-Schulwerk Association (AOSA), 2011]. Children's literature, i.e., a storybook, can be used as the thematic basis for applications using the Orff process. Singing, chanting, movement, listening, and playing instruments are developed through this process using the book text, body percussion, unpitched and pitched percussion instruments, improvisation, borduns (open fifth of tonic and dominant), and various ostinati (a repeated rhythmic pattern) (Colwell, 2005). Music therapy can function as a coping strategy for hospitalized children. The purpose of this study was to compare three music therapy strategies (listening, composition, and Orff-based) on physiological and psychosocial behaviors of hospitalized children. These physiological and psychosocial outcomes can indicate effectiveness of various coping strategies.

251 visitors arrived, medical procedures taking precedence or difficulties with videotaping. The research design of this study was a pre-test/post-test group design with a matched sample for age and gender.

Treatment Conditions
Patients participated in one session targeting either music listening of CDs loaded onto an iPod, music composition using the computer, or an Orff-based approach to music therapy. Each session had an overall theme, All About Me, in an attempt to have each patient focus on who s/he is as a person not just as a patient. This theme was chosen based on the clinical experience of the researchers, both music therapists and nurses. Children often identify themselves only as a patient and discussions in the hospital often focus heavily on the issues that manifest due to that role. The intent of the music therapy interventions was to focus on them as individuals and allow opportunities for emotional expression, social interaction, choices and decision-making, and verbal processing of creative choices. All three conditions were designed to have a therapist present in the room and interact with the patient so all participants in the study would have personal contact with an individual. All pretest, posttest and treatment sessions were conducted on an individual basis. In the music listening condition, the patient was given the opportunity to choose preferred music from a set of CDs loaded onto an iPod. A comprehensive list divided into categories (for example, Children's, Hip Hop, New Age, Rock, Male Pop, Female Pop) was provided. The patient was given up to 45 minutes to relax and listen to the chosen music. Each patient was invited to listen to as many different song fragments, individual songs or complete albums during that time period as they wanted to but were asked to not engage in additional activities while listening. The music therapist remained in the room and maintained contact with the patient by asking him/her why the music that was chosen represented who s/he is as a person. The therapist encouraged a brief dialogue after each choice was made. The therapist also assisted the patient in finding particular artists, songs or albums as needed. In the music composition condition, the patient was asked to create an instrumental composition that depicted who s/he is and then create a CD label with a title and jacket cover with a short description of why the composed music represented the theme All About Me. The patient created this instrumental music composition using the computer program Making More Music (Subotnick, 2007). During this session, the patient was able to make various musical selections, including instrument choices, tempo, and melody. After the patient finished the composition, the music was burned onto a CD for the patient to keep. Each patient then designed and printed a CD label and a jacket insert for the CD jewel case. The patient was given up to 45 minutes to complete the

Method
Participants
Participants (N =32, 17 females and 15 males, ranging in age from 6 to 17) were children hospitalized on the pediatric unit of a large mid-western teaching hospital. Participants were admitted to the pediatrics unit, recruited from the current patient population and selected by the nursing staff. Diagnoses of patients varied greatly yet primarily included cancer, sickle cell disease, injuries due to accidents, and respiratory viral infections. Patients might be on the unit for the first time or might be individuals who had chronic illnesses that required frequent hospitalizations. Human subjects approval was granted by the IRB of this teaching hospital. Informed consent was obtained in writing from parents or guardians of patients prior to participation in the study. The patients were asked to sign an assent form as they were under the age of 18. The researchers explained the forms to both the patients and their responsible parties. Patients and families were given ample opportunity to ask questions prior to agreeing to participate. Patients were divided into three groups, music listening (n3=9) (M age=9.4, SD =3.97), music composition (n2 =13) (M age=11.9, SD =2.78), and Orff-based music therapy (n1 = 10) (M age = 11.9, SD = 2.96). Participants were matched to balance for age and gender across the three conditions. Groups are not equal as some patients' data were not included in the final analysis if they did not complete the session or testing due to interruption when not feeling well,

252 composition and CD case. Throughout the music composition session, the patient was asked how the music and artwork represents who s/he is a person as s/he made choices during the composition process. In the Orff-based music therapy condition, all of the interventions stemmed from the book Hooray for You! A Celebration of You-ness (Richmond, 2004) which focused on the patient and all about who s/he is as a person. Throughout the session that followed the Orff process, the patient was provided with various opportunities to make choices about specific music activities that would be performed during the rhythmic reading of the book. Each patient was asked several questions pertaining to favorite things, future goals, and other self-descriptions on the theme All About Me with the answers to those questions performed musically as a chanted refrain through the book. Throughout this session, the patient participated in playing unpitched and melodic percussion instruments, speech chanting, and body percussion. The patient was given up to 45 minutes to participate in active music making.

C.M. Colwell et al. to questions/choices, initiating conversation), participation (on-task, verbal off-task, motor off-task, passive off-task) and length of session task (duration). Time- sampling was conducted using a data sheet with 10 second observe and 5second record segments. Researchers watched each session and recorded whether the behavior (i.e., positive facial affect) occurred during that time segment. More than one category of behavior could be counted within an interval. After watching the tape, the percentage of overall intervals containing each observed behavior was calculated.

Results
As previously stated, the purpose of this study was to compare the impact of three music therapy interventions (listening, composition, and Orff-based) on physiological and psychosocial behaviors of hospitalized children. See Table 1 for data by condition. A nurse measured three physiological behaviors, heart rate, blood pressure, and oxygen saturation. Pain and anxiety were gathered through self-report using the FACES scale and the STAI-C.

Materials
As pre- and posttest measures, a pediatric nurse recorded three physiological measures: heart rate, blood pressure, and oxygen saturation. The nurse manger requested these physiological measures as she was interested in determining if any of the music therapy interventions would have an impact on them. Following these three physiological measures, the principal investigator and co-therapists recorded two additional measures: one physiological, the WongBaker FACES Pain Rating Scale (Wong, Hockenberry-Eaton, Wilson, Winkelstein, & Schwartz, 2001) and one psychosocial, the State-Trait Anxiety Inventory for Children (STAIC) (Spielberger, Edwards, Montuori, Lushene, & Platzek, 1973). The WongBaker FACES Pain Rating Scale has six faces ranging from smiling to crying across scores of 0 (no pain) to 10 (worst pain ever experienced). It is reliable for children ages 3 through 18 years with a reliability of .79 (WhiteheadPleaux et al., 2007). The State-Trait Anxiety Inventory for Children (STAIC) is a self-report questionnaire used to determine how anxious a person feels generally (trait) as well as at a given moment (state). For this study, patients completed only the 20-questions related to state anxiety. Patients respond to various statements by choosing appropriate endings from a field of three to the sentence fragment I feel. The STAIC has been used with children from age 6 to 18 years, with a reported reliability of .82 for males and .87 for females (Spielberger et al., 1973). Each session was videotaped for behavioral analysis using a time-sampling approach for behaviors potentially common to all three groups that might indicate level of engagement: eye contact (with therapist or with materials), facial affect (positive, neutral, negative), verbal interactions (responding

Physiological Measures
A 32 mixed-design ANOVA was calculated to examine the effects of the condition (listening, composition, and Orffbased) and time (pretest, posttest) on heart rate, systolic blood pressure, diastolic blood pressures, and oxygen saturation. No significant main effects or interactions were found except for the main effect for condition on oxygen saturation [F(2,29)=3.97, p =.03]. Examination of the data indicated that the Orff-based condition showed the greatest increase in oxygen saturation although a follow-up MANCOVA with the pretest as the covariate yielded no significant results due to condition. See Table 2 for a summary of the results of the measures taken by the nurses. The physiological behavior of pain was gathered through self-report using the WongBaker FACES Pain Rating Scale. A 32 mixed-design ANOVA was calculated to examine the effects of the condition (listening, composition, and Orff-based) and time (pretest, posttest) on pain. The main effect for time was significant [F(1,29)=7.32, p =.01]. No main effect for condition [F(2,29)=.167, p =.85] or interaction was significant [F(2,29)=.213, p =.81]. Although all three conditions showed a decrease in pain, it appears that patients in the listening condition had the greatest decrease.

Psychosocial Measure
The psychosocial behavior anxiety was gathered through self-report using the State-Trait Anxiety Inventory for Children (STAIC). The desired direction was a lower number on the posttest than on the pretest. A 32 mixeddesign ANOVA was calculated to examine the effects of the

Impact of Music Therapy Interventions

Table 1 Pre- to Posttest Comparisons (Vitals, Pain, Anxiety) by Treatment Condition. Listening Variable Physiological Heart Rate Systolic BP Diastolic BP O2 Sat Pain Anxiety Time Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Mean 81.4 85.2 106.2 112.9 59.9 63.0 97.3 97.3 2.8 1.8 28.8 28.7 SD 19.2 18.6 11.4 11.4 7.4 8.1 1.7 2.1 3.0 2.5 3.8 3.2 Composition Mean 92.5 93.9 119.4 118.8 68.2 71.7 98.6 98.7 2.0 1.4 27.8 25.9 SD 16.3 13.6 14.6 12.5 19.8 7.8 1.3 1.1 2.9 2.1 4.5 4.6 Orff-Based Mean 94.3 96.1 113.5 114.7 63.9 62.4 94.4 97.0 2.4 1.8 33.3 29.9

253

SD 14.7 16.8 10.9 15.9 9.7 13.6 7.2 1.5 2.6 2.4 7.4 7.1

Psychosocial

condition (listening, composition, and Orff-based) and time (pretest, posttest) on anxiety. The main effect for time was significant [F(1,29) =7.14, p = .01]. No main effect for condition [F(2,29)=2.61, p =.09] or interaction was significant [F(2,29)=1.84, p =.18]. Patients in both the composition and Orff-based conditions showed a decrease in anxiety with those in Orff-based having the greatest decrease.

Level of Engagement
In addition, researchers completed a time-sampling analysis of level of engagement exhibited through copingrelated behaviors of eye contact, facial affect, verbal interaction, and participation. See Table 3 for data by treatment condition. An independent observer watched 20% of the videotapes for the purpose of conducting inter-rater reliability. Reliability is reported as 80% for eye contact, 82% for facial affect, 71% for verbal interaction, and 95% for on-task participation. Eye contact was divided into four behaviors: eye contact with therapist, with materials, no eye contact, or other which
Table 2 Results of 32 Mixed-Design ANOVAs for Nurse Recorded Physiological Measures. df Heart rate Time Condition Timecondition Time Condition Timecondition Time Condition Timecondition Time Condition Timecondition 1, 29 2, 29 2, 29 1, 29 2, 29 2, 29 1, 29 2, 29 2, 29 1, 29 2, 29 2, 29 F 1.61 1.59 0.156 1.84 1.69 1.46 0.347 2.59 0.312 1.66 3.97 1.50 p .22 .22 .86 .19 .20 .25 .56 .09 .74 .21 .03 .24

Systolic BP

Diastolic BP

Oxygen sat

Significant difference.

was defined as purposeful eye contact with other people/ objects in the room. A one-way MANOVA was calculated examining the effect of condition (listening, composition, Orff-based) on eye contact. A significant effect was found [Lambda(8,46)=.198, p =.000]. Follow-up univariate ANOVAs indicated that eye contact with therapist was significantly different by condition [F(2,26)=15.97, p =.000]. The Orff-based group had the highest percentage of eye contact with the therapist, followed by listening group, and then composition. Other eye contact was also significantly different by condition [F(2,26)=4.22, p =.026]. The listening condition had the highest percentage of other eye contact with composition and Orff-based being lower and similar to each other. Facial affect was divided into four behaviors: positive, neutral, negative, or other. A one-way MANOVA was calculated examining the effect of condition (listening, composition, Orff-based) on facial affect. No significant effect was found [Lambda(8,46) =.735, p =.479]. None of the facial affect behaviors were significantly influenced by condition. Examination of the data indicated that the Orffbased group had the highest percentage of positive facial affect, while the composition group had the highest percentage of negative facial affect. The neutral and other categories were similar across conditions. Verbal interaction was divided into four behaviors: initiating conversation with therapist, responding to questions/making choices, not responding to question/not making choices, or other which was defined as off-task talking with others. A one-way MANOVA was calculated examining the effect of condition (listening, composition, Orff-based) on verbal interaction. No significant effect was found [Lambda(8,46)=.540, p =.058]. None of the verbal interaction behaviors were significantly influenced by condition. Examination of the data indicated that the listening condition had the highest percentage of verbal initiation and no responses, while the Orff-based condition had the highest percentage of responding to questions/choices and other verbal behaviors.

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Table 3 Level of Engagement Comparisons by Treatment Condition. Listening Variable Eye contact Therapist Materials None Other Positive Neutral Negative Other Initiate Response None Other On-task Verbal off Motor off Other Mean 39.78 71.89 7.56 40.11 28.89 84.22 4.11 6.44 20.56 35.00 51.22 6.67 87.11 7.78 7.11 8.33 SD 26.0 24.2 10.7 29.0 17.9 14.8 5.0 11.9 21.7 14.5 30.1 9.5 12.0 10.6 7.9 10.5 Composition Mean 12.25 86.92 1.42 19.92 26.75 80.50 11.58 8.17 13.92 44.17 47.42 3.08 88.25 3.58 1.75 10.08 SD 6.8 17.3 1.3 18.1 13.9 23.1 24.3 10.5 11.5 18.2 22.7 1.7 15.3 3.5 1.8 11.5

C.M. Colwell et al.

Orff-Based Mean 68.63 86.38 4.75 13.00 46.13 75.63 5.38 5.63 9.13 58.13 41.75 8.38 94.13 3.00 1.25 6.50 SD 30.8 8.2 9.2 8.4 18.9 23.7 8.2 8.0 6.4 12.2 21.6 13.2 9.3 6.6 1.5 8.3

Facial affect

Verbal Interaction

Participation

Participation was divided into four behaviors: on-task, verbal off-task, motor off-task, and other or passive off-task behavior. A one-way MANOVA was calculated examining the effect of condition (listening, composition, Orff-based) on participation. No significant effect was found [Lambda(8,46)=.707, p =.387]. None of the participation behaviors were significantly influenced by condition. Examination of the data indicated that the highest percentage of on-task participation was found in the Orff-based condition with the highest percentage of verbal and motor off-task behavior found in the listening condition. Patients in the composition group exhibited the highest percentage of other, or passive off-task behavior. The researchers were also interested in examining session duration of the conditions. A one-way ANOVA was computed to compare duration. A significant difference was found among conditions [F(2,26) = 8.58, p = .001]. Tukey's HSD was used to determine the differences between conditions. This analysis revealed that patients who were in the composition condition had a significantly longer session (m =44.17 minutes, SD=11.6) than those in either the Orffbased (m =25.63, SD =7.16) or listening conditions (m = 29.17, SD=12.2).

Discussion
The impetus behind this study began when a nurse and the primary investigator were discussing ways that the nurses could use music on the unit as a non-pharmacological intervention. This particular nurse was in graduate school and was interested in researching the impact of music listening on the vital signs of children on the pediatric unit. This led to discussion about a potential partnership of care

for a long term effort targeting decreased wear and tear on the nurses through reduced use of call lights, increased hospital satisfaction, and potential distraction during procedural support. This study was designed as a feasibility study to examine three different potential music therapy protocols: music listening as initially suggested by the nurse, music composition as previously examined by the primary investigator (Colwell et al., 2005) and Orff-based music therapy, a form of active music engagement (Colwell, 2005, 2009; Robb et al., 2008). Three physiological behaviors suggested by the nurse, heart rate, blood pressure, and oxygen saturation, were all within normal ranges on both pretest and posttest. Although some slight changes were reported, there was no statistical or clinical significance due to these physiological changes. Heart rate actually increased from before to after the session in all three groups but the change was minimal and was considered normal fluctuation. Heart rate might have increased due to engagement in some type of activity rather than sitting passively, which patients were often doing when researchers entered the room. Blood pressure (systolic/diastolic) measures were also all within normal ranges. Systolic BP increased slightly in the Orff-based and listening conditions and decreased in the composition condition while diastolic BP increased slightly in the composition and listening conditions yet decreased in the Orff-based condition. All changes were minimal and were considered normal fluctuation. Oxygen saturation means were above 94% and considered good. Percentages stayed the same or increased slightly from pre- to posttest with the increase seen in the Orff-based condition. Although statistics found a significant difference for condition, follow-up analysis removed that significance when pretest data were separated as a covariate. The slight increase in the Orff-based condition

Impact of Music Therapy Interventions may have been due to the nature of the activities within this session, deeper breathing through chanting/singing or physical exertion through body percussion/movement and instrument playing. The WongBaker FACES Pain Rating Scale measured pain and the STAIC measured anxiety, both through selfreport. A decrease was the desired change with significance from pre- to posttest found for both measures when the three conditions were combined. Individually, each of the three conditions showed a slight decrease in perceived pain from pre- to posttest with the greatest decrease (1 on a 10 point scale) evident in the listening condition. All three conditions also showed slight decreases in state anxiety from pre- to posttest with the greatest decrease evident in the Orff-based condition. Participation in music therapy, regardless of condition, seemed to show a slight trend toward decreasing pain and anxiety in this population. Perhaps an increase in the number of patients might further impact this result. These decreases support the results of previous studies examining the use of music therapy on pain (Bae, 2002; Whitehead-Pleaux et al., 2007) and anxiety (Aldridge, 1993; Bae, 2002; Chetta, 1981; Walworth et al., 2008; Whitehead-Pleaux et al., 2007). Active music engagement (Robb et al., 2008) has been found to impact coping-related behaviors in hospitalized children receiving cancer treatment. Robb et al. defined coping-related behaviors as positive facial affect, active engagement (participation), and initiation. Researchers in the current study expanded this list and through time sampling examined eye contact, facial affect, verbal interaction, and participation. Overall, patient eye contact with the therapist and materials was high. The Orff-based condition had the highest eye contact with the therapist and may be explained by the more personally engaging nature of this condition as the patient needed to look at the therapist during echo singing/chanting/body movement and when answering questions while writing chant refrains. Eye contact with the therapist was lowest for the composition group, but eye contact in this instance was intentionally directed to shared focused on the computer screen. Other (purposeful) eye contact was highest in the listening condition. This may have been due to the somewhat awkward situation for the patient of where to look when listening. Do you look at the therapist, the iPod or song list (materials), or do you focus on other people or objects in the room? Facial affect was the most positive in the Orff-based condition perhaps due to the positive subject matter and responsiveness of the therapist. Negative facial affect, although not high, was most prevalent in the composition condition and seemed to be attributed to concentrating on the computer screen. Although differentiated among conditions, both indicated an appropriate level of contextual engagement that has the potential to function as a coping strategy (Robb et al., 2008). There was not much differentiation among conditions for any of the categories within verbal interactions. Patients seemed to initiate more verbal interactions in the listening

255 condition and respond more in the Orff-based condition. In the listening condition, patients asked questions of the therapist about how to work the iPod, how to find specific songs found on the song list, as well as about songs that were not on the list. In the Orff-based condition, answering questions was built into the procedure of the session, as patients had to answer personal questions during the creation of the chant refrain. Patients exhibited high levels of engagement in all treatment conditions with slightly higher incidence of on-task behavior in the Orff-based condition. A slightly higher percentage of intervals with verbal and motor off-task behaviors were recorded for the listening condition. Patients would sometimes get off-task in their discussions and branch out to topics not related to the music or the theme of All About Me. This offtask conversation is not considered negative though, as initiation of conversation or reaching out for personal engagement with an individual can be seen as an appropriate coping strategy. Patients would also be somewhat fidgety during this intervention as they were not as physically engaged as they were in the Orff-based or composition sessions. Session duration was also compared and patients in the composition condition had longer sessions as it appeared to be a highly engaging treatment and had a more prescribed sequence of events for completion, creating the composition, designing the jacket/label, and burning the CD. The other two interventions were more directed by the patient and could be of varying lengths while still feeling complete. If these treatments were used for procedural support, these two more fluid interventions might be more usable due to the needed flexibility. These interventions could easily be adjusted to varying lengths of procedures and require less physical participation of the patient which might be critical for certain medical procedures. One of the most significant limitations of this study was time. Because each session is designed for 1:1 intervention with set-up, getting a large sample size took a considerable amount of time. The investigators were also limited to 1 day per week to meet with participants that caused difficulty in accessing parental consent. This once-a-week format limits the availability for procedural support and advanced planning for such treatment opportunities thus this study was completed at bedside. The pediatric nurses were particularly concerned about measuring the three vital signs only as pretest/posttest data rather than as continuous readings throughout the session. In future studies, it might be informative to gather these measures across the session to get a more comprehensive picture of what is happening throughout as well as during specific events within the session. It would also be interesting to examine how heart rate, blood pressure, oxygen saturation, pain and anxiety would be impacted if these three treatment conditions were compared during procedural support as opposed to bedside therapeutic intervention. Medical procedures typically produce anticipatory and procedural anxiety that in turn can impact heart rate, blood pressure, oxygen saturation and pain.

256 Finally, the researchers would like to compare these music therapy treatment interventions with a more traditional child life approach to examine the impact of music versus no music. The researchers would also be interested in comparing various facets of Orff-based music therapy, perhaps comparing chant-based therapist-composed interventions with patient improvisation through pentatonic melodic instrumentation and then comparing these with child life. As children with acute and chronic illnesses may have different hospitalization experiences, it would be interesting to compare these two groups of patients and the impact of such music therapy interventions. Future studies with adjustments to the design based on these limitations are planned. In conclusion, as previously indicated, this feasibility study was designed after a discussion between nurses and music therapists about the impact of music therapy interventions on heart rate, blood pressure, and oxygen saturation. The researchers were further interested in the impact of these same interventions on pain and anxiety. No clinical significance was indicated as a result of treatment on heart rate, blood pressure, or oxygen saturation but there was a decrease in self-reported pain and anxiety. These decreases could improve in-hospital quality of life and subsequent patient and family satisfaction with the hospital experience. Nurses could be made aware of this impact and help facilitate referrals to board certified-music therapists as a means to provide nonpharmacological interventions for pain and anxiety. While nurses do not have certification to facilitate music therapy interventions, they could provide therapist-prepared music listening materials (CDs, iPods, etc.) with a variety of options. These options could help facilitate patient preferred listening opportunities as a means to manage pain either during times when medication is not indicated or available or during noninvasive or invasive procedural support. This collaborative approach between nursing and music therapy can provide alternatives or additions that may significantly impact the physiological and psychosocial behaviors of our patients.

C.M. Colwell et al.

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Acknowledgments
Research was funded in part by the Graduate Research Fund of the University of Kansas.

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