Florida State University Libraries
Electronic Theses, Treatises and Dissertations
The Graduate School
2006
The Effect of Music Listening on Mood
State and Relaxation of Hospice Patients and
Caregivers
Seong-Eun A. Kim
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THE FLORIDA STATE UNIVERSITY
COLLEGE OF MUSIC
THE EFFECT OF MUSIC LISTENING ON MOOD STATE AND RELAXATION OF
HOSPICE PATIENTS AND CAREGIVERS
By
SEONG-EUN A. KIM
A Thesis submitted to the
College of Music
In partial fulfillment of the
Requirements for the degree of
Master of Music
Degree Awarded:
Fall Semester, 2006
The members of the Committee approve the thesis
of Seong-Eun A. Kim defended on June 5, 2006.
______________________________
Jayne M. Standley
Professor Directing Thesis
______________________________
Clifford K. Madsen
Committee Member
______________________________
Dianne Gregory
Committee Member
The Office of Graduate Studies has verified and approved the above named committee members
ii
ACKNOWLEDGEMEMTS
I would like to thank God, who has given me the talent to share my passion for music
with people. To my parents, who loved and supported me with endless prayers and believed in
me. To Goeun, my sister and my best friend, who always there for me. To Dr. Standley, who
taught and shared her passion for music therapy and guided me through out my graduate studies.
To Natalie Wlodarczyk, for her encouragement and continuous support and music therapists,
music therapy interns, and all staffs at Big Bend Hospice for their generosity and helping make
this study possible.
iii
TABLE OF CONTENTS
List of Tables ……………………………………………………………………………… vi
List of Figures …………………………………………………………………….………..vii
Abstract ……………………………………………………………………………………. viii
CHAPTER 1 ………………………………………………………………………………. 1
Introduction ………………………………………………………………... ……... 1
Review of Literature ………………………………………………………………. 1
CHAPTER 2 ………………………………………………………………………………. 11
Purpose and Null Hypothesis ……………………………………………… ……... 12
Subjects ……………………………………………………………………………. 12
Setting ……………………………………………………………………..………. 14
Design …………………………………………………………………….……….. 14
Material ……………………………………………………………………. ………15
Measure ……………………………………………………………………. ………15
Procedure ………………………………………………………………………….. 16
CHAPTER 3 ………………………………………………………………………………..17
Results ……………………………………………………………………... ………17
CHAPTER 4 ………………………………………………………………………..………27
Discussion …………………………………………………………………..……... 27
APPENDICES …………………………………………………………………………….. 29
Appendix A: Human Subjects Committee Approval Form ……………………….. 29
Appendix B: Patient Consent Form (Experimental Group) ……………………….. 31
Appendix C: Patient Consent Form (Control Group) …………………….……….. 33
Appendix D: Legal Guardian Consent Form (Caregiver- Experimental Group)….. 35
Appendix E: Legal Guardian Consent Form (Caregiver- Control Group) .……….. 37
Appendix F: Patient Assent Form (Experimental Group) ………………………… 39
Appendix G: Patient Assent Form (Control Group) ………………………………. 41
Appendix H: Legal Guardian Assent Form (Caregiver- Experimental Group)……. 43
Appendix I: Legal Guardian Assent Form (Caregiver- Control Group) …...………45
Appendix J: Relaxation Scales ……………………………………………………..47
iv
Appendix K: Music Preference Chart ……………………………………... ………49
Appendix L: Big Bend Hospice Music Therapy Assessment Form ………………. 51
Appendix M: Visual Analogue Mood Scales …………………………….……….. 53
Appendix N: Raw Data ……………………………………………………………. 62
REFERENCES ……………………………………………………………………………. 72
BIOGRAPHCAL SKETCH ………………………………………………………………. 77
v
LIST OF TABLES
Table 1 Patient Demographics …………………………………………………………….. 11
Table 2 Caregiver Demographics …………………………………………………………. 12
Table 3 Design …………………………………………………………………………….. 14
Table 4 Results of Repeated measures ANOVA for VAMS of patients……………………17
Table 5 Pretest/Posttest Mean for negative ……………………………………….………..18
and positive mood across sessions of patients
Table 6 Results of Repeated measures ANOVA for VAMS of caregivers…………………19
Table 7 Pretest/Posttest Mean for negative and …………………………………………… 19
positive mood across sessions of caregivers.
Table 8 Interpretation of VAMS T scores ………………………………………………….20
Table 9 Overall Pretest/Posttest Mean for negative ………………………………………..20
and positive mood by group of patients
Table 10 Overall Pretest/Posttest Mean for negative ……………………………………… 21
and positive mood by group of caregivers.
Table 11 Pretest/Posttest Mean for Relaxation Level by group of patients ……………….. 22
Table 12 Results of Repeated Measures ……………………………………………………24
ANOVA for Relaxation Level of Patients
Table 13 Results of Repeated measures ……………………………………………………24
ANOVA for Relaxation Level of Caregivers
Table 14 Pretest/Posttest Mean for relaxation level by group of caregivers ……………… 25
vi
LIST OF FIGURES
Figure 1. Patients’ Relaxation Level Graph across sessions………………………………..23
Figure 2. Caregivers’ Relaxation Level Graph by groups ………………………………….26
vii
ABSTRACT
The purpose of the study was to investigate the effectiveness of music listening on mood
state and relaxation of hospice patients and caregivers. Subjects (N=39) were patients (N=24)
receiving Big Bend Hospice care who were admitted to Big Bend Hospice House, an in-patient
unit, or resided in assisted living facilities in Leon County, Gasden County, Jefferson County,
and their caregivers (N=15). Subjects were randomly assigned to one of three groups: preferred
music, unfamiliar music, and no music. The experimental groups received for 15-30 minutes of
music listening for three days within a seven day period. The control group received preferred
activities excluding music for 15-30 minutes for three days within a seven day period. Pre and
posttests were given each session. The Visual Analogue Mood Scales and Relaxation Scale were
used to measure changes in mood and relaxation. Repeated measures ANOVA statistical
analyses were conducted in this study. Results revealed a significant difference between negative
and positive moods and relaxation levels pre and post in both patient and caregiver groups.
viii
CHAPTER 1
Introduction
People who have been diagnosed with a terminal illness can experience anxiety, fear,
sadness, physical pain and negative responses to environmental elements. These symptoms
interrupt enjoyment and activities of everyday life. Often times, people who are at the end of life,
spend most of their time at home, in a nursing home, or in an in-patient hospice facility (Krout,
2000, Hilliard, 2004). Sometimes they watch TV, talk to family members, sleep, or listen to
music to take their mind off their emotional/physical pain.
Many of the clinical research studies in palliative care show that music enhances quality
of life, decreases anxiety and fear, decreases perception of pain, helps express feelings, helps
with issues regarding family relationships, and provides comfort (Krout, 2000). According to
Weber (1999), music listening is used “to facilitate relaxation and to aid in pain management in a
palliative care setting.” Music therapy case studies in hospice reveal that music listening is the
most used clinical technique in hospice and palliative care. A survey done by Fellow and Jones
(1994) indicated that a music listening activity was the most popular choice for relaxation
techniques. A research study by Davis & Thaut (1989) discovered that “ state anxiety and selfreported levels of relaxation decreased consistently while listening to preferred music.”
Review of Literature
Effects of Music
Imagine there is no music when watching TV, commercials, movies, going to sports
games, stores, attending church or many other activities. It would probably feel empty, awkward,
and somewhat out-of-place. There would probably be no excitement or even emotional response
(Hays, & Minichiello, 2005). Life would be incapacitated.
Often times people say, music is a universal language, or music is song, expression
without words. Encyclopedia Britanica defines music as “ [an] art concerned with combining
vocal or instrumental sounds for beauty of form or emotional expression, usually according to
1
cultural standards of rhythm, melody, and, in most Western music, harmony” (Britanica, 2005).
Bruscia (1998) reported that “individuals can use music to express the human condition as well
as their own unique ideas, feelings, and identities” (p. 100).
Music plays an important part in our lives. It is gracefully intertwined within our lives.
Music has the enormous power to unite people as one. Fans cheer for their team and shout to
encourage their team to win the game (Wodraska, 2006). During tragic times such as the 9/11,
Katrina, or Tsunami disasters, musicians give concerts to help victims, families and friends by
sharing and dedicating their music to people (Stamberg, 2001). It is a tool that reflects emotions,
creates a comforting environment, and binds people together.
Many people start listening to music when in their mother’s womb. As a baby, a mother
sings songs or lullabies to her baby to comfort them. Babies respond to the music by interacting
with the mothers, giggling, smiling or peacefully sleeping. As children, they respond well to
music and other auditory stimuli (Ang, 2005).
When children reach adolescence, the impact of music plays a huge part in their lives.
Music becomes the outlet for them to express their feelings, to match their mood, and to socialize
with friends. A research study by Woody and Burns (2001) found that 63% of non-music major
undergraduates responded that they “choose music to match their mood”, and 37% of the
students responded that they “choose music to change their mood” (p.4). Schwartz and Fouts
(1999) reported that the purposes of listening to music among adolescents were to feel better, to
relieve boredom, and to keep the mood they are in. When older people listen to music from
young adulthood, it brings back many memories and a variety of emotions.
Music effects everyday life in many different ways: socially, as entertainment,
commercially, and medically. Social gatherings like weddings and parties use music to create an
enjoyable and happy atmosphere and to increase mood level in people. People show it by
dancing, laughing and increasing in levels of talking while socializing. In performances such as
going to a concert, or watching a music video, the artist communicates and expresses his/her
emotion through music.
In commercial fields, there has been numerous research studies about the effect of music
in various commercial settings such as the amount of time callers will wait on hold (Knott et al,
2004), the amount of time customers spend in a particular store (Milliman, 1982), and the
effectiveness of advertising (Kellaris, Cox, & Cox, 1993).
2
Knott et al. (2004) studied the effect of music choice and announcement duration on the
wait time on hold. Two groups were compared. Results showed higher satisfaction when subjects
were allowed to choose music during the wait time as compared to the subjects were not allowed
to choose music. The study also found that the long announcement created more accurate wait
time estimation than did the short announcement.
Milliman (1982) examined the effect of background music on behavior of supermarket
shoppers’ behaviors. The study was conducted in a medium-size chain of supermarkets. The
study observed each customer and compared how long it took to pass between these three
sections in the store: no music, slow tempo music and fast tempo music. Results showed that instore traffic flow was slower with slow tempo music than the faster tempo music and the in-store
traffic flow during slower tempo music was slower than during the no music group.
Kellrais, Cox, & Cox (1993) explored the effect of music on advertising. Two hundred
thirty-one students from upper-level business classes at an urban university participated in this
study. Each participant was randomly assigned to listen to the radio ad (voice over background
music) produced by the researcher. This study found that when “music evokes messagecongruent (versus incongruent) thought”, the audience attention increased as did the message
reception (p. 114).
Research that shows the effect of music and its use in various medical treatments is
abundant. Standley’s (2000) meta-analysis demonstrated that the use of music can be beneficial
in several medical and dental treatments, especially for patients who are experiencing pain and
anxiety. According to Standley’s (1986) research study, music was used “as an audioanalgesic in
dental procedures” (p.3). The positive outcome of the effect of music in dental procedures led
many other researchers to use music and experiment in medical surgery with
obstetric/gynecologic patients and pediatric patients. These studies found decreased pain,
anxiety, and levels of analgesic medication (Standley, 1986).
Music is effectively used in gynecology treatment during childbirth. Hanser, Larson, and
O’Connell (1983) used music with seven expectant mothers during labor to assist in increasing
relaxation and decreasing anxiety and pain from environmental sound. They focused attention on
the music, cued rhythmic breathing with music, and promoted positive thinking through music
listening. The results indicated that 100% of the mothers who were in the specially designed
3
music group during labor displayed less pain and anxiety as compared to the mothers who had
received the same relaxation instruction but no background music during labor.
The effectiveness of music is also evident with pediatric patients for pre and post surgery.
Other tests and treatments reduce anxiety, pain, decrease amount of analgesic drugs, and promote
recovery from procedures (Robb, Nichols, Rutan, Bishop, & Parker, 1995). Robb et. al (1995)
investigated the effect of music on preoperative anxiety of pediatric burn patients. Twenty
pediatric burn patients aged 8 to 20 years in a pediatric burn hospital participated in the study.
Participants were divided into either experimental or control groups. Participants in the
experimental group received music assisted relaxation such as music listening, deep breathing,
imagery, and progressive muscle relaxation during the preoperative period. Participants in the
control group received standard preoperative procedures. Results showed a significant decrease
in the anxiety score in the experimental group but so significant change in anxiety.
Strauser’s (1997) study examined the effect of music listening versus silence prior to and
right after chiropractic treatment and measured state anxiety, perceived relaxation, and
physiological responses of the patients. Results showed music listening groups had significantly
less anxiety and tension; however, there were no significant differences in physiological
measurements between music and silence.
Standley (1992) reported that patients who listen to recorded music either before, during,
or after chemotherapy showed decreased anxiety levels and less incidence of nausea and
vomiting. Standley (2000) also reviewed numerous research studies on the effect of listening to
music of different populations receiving medical treatment such as bronchoscopy,
gastrointestinal endoscopy, coposcopy and many others (p. 6).
Matejeck, Mulik-Kolasa, and Stupnicki (1996) investigated the effectiveness of music
listening on physiological responses of pre-surgical patients before and after non-orthopedic
surgery. Physiological responses such as heart rate, glucose count, skin temperature, cardiac
output, and arterial pressure were measured every 20 minutes during the hour prior to surgery.
Results found that physiological responses returned to original levels in the music listening
group while the non-music listening group showed signs of stress.
Bonny (1983) evaluated the effect of programmed taped music on stress reduction of
patients in an intensive coronary care unit. Twenty-six patients participated for a 10 month
period. Patients were asked to choose tapes to listen to (classical, folk, country, jazz, and swing).
4
The result of this study showed decreases in anxiety, depression, and heart rate, and increased
pain tolerance.
Mood State and Relaxation
Patients who have been diagnosed with a terminal illness go through emotional chaos:
anxiety, fear, sadness, and anger. They also experience physical pain as well as psychological
distress, sensitivity and negative responses to environmental elements. All these physical and
psychological distresses interrupt daily life. Patients who are at the end of life receive care
mostly at home and patients who do not have family that could provide care or whose caregiver
needs to rest or work, receive care at a nursing home, assisted living facility or an in-patient
hospice facility (Forman, Kitzes, Anderson, & Sheehan, 2003). Patients who receive care from
nursing homes and other facilities may spend most of their time in their room. Because they are
bed-bound, the choice of activities which they are able to participate may be limited. So they
may watch TV, sleep, or have conversations with family members and staff. Sometimes they
may listen to music to take their mind off of pain, fear, loneliness, and isolation.
When people associate thoughts with the word “music”, most cite something that is
positive, pleasant and relaxing (Davis & Thaut, 1986). Music is also associated with how we feel
or the mood state that we are in. North and Hargrave’s (2002) article states that “music is
important. It is prevalent in everyday life [and] a tool we use to achieve desired psychological
states and a means of defining our identity and many research studies show the effect of music
on positive physiological and psychological changes” (p. 407). Burns (2001) reported that many
psychosocial treatment research studies show positive effects of music therapy in cancer
treatment as a psychosocial intervention in “alleviating emotional distress and improving quality
of life” (p. 54). Burns (2001) also found that many clinicians and researchers in the music
therapy field have implemented a music therapy intervention “to decrease pain and nausea,
improve mood, increase quality of life, and increase family communication” (p. 54).
Numerous anecdotal reports from clinical case studies have demonstrated the
effectiveness of music therapy and the use of its intervention to improve mood states with
different types of populations like “depressed older adults (Hanser & Thompson, 1994) and
forensic patients (Thaut, 1989)” (p. 21). A pilot study by Magee, and Davidson (2002) examined
the effect of music therapy on mood states in neurological patients. Fourteen subjects with
5
neurological disabilities residing in a rehabilitation facility participated in the study. A Profile of
Mood states (Bipolar form) was compared pre and post session. The study reported “significant
differences in positive directions [in certain mood states:] composed-anxious, energetic-tired and
agreeable-hostile after music therapy intervention” (p. 24). In this research study, Magee and
Davidson (2002) cited numerous studies that support the effect of music/ music therapy on mood
states. The use of music therapy to facilitate behavioral and psychological changes in people
with stroke shows statistical significance for improving feelings of depression and anxiety
(Purdie, Hamilton, & Baldwin, 1997). Music also improves mood states in neurological patients
with music therapy intervention showing greater improvement than that experienced by the
control group (Nayak, Wheeler, Shiflerr, & Agnostinelli, 2000).
Merriam-Webster’s medical dictionary defines relaxation as “the act of relaxing or state
of being relaxed” and the reduction of contractile force in a muscle or muscle fiber” (2005). By
observing behavioral responses such as body posture, respiration rate, facial expression, and
other physical movements, clinicians are able to tell whether or not a person is relaxed. Also,
decreases in anxiety, depression and stress level are signs of being relaxed.
Various music therapy studies used music as a tool for relaxation: music listening, music
as background, music assisted relaxation, or music with guided imagery. According to the survey
by Fellows and Jones (1994), listening to music was the most popular and most frequently used
method for relaxation. Miluk-Kolasa & Matejek, (1996) evaluated the effect of music listening
on physiological changes with presurgical patients. Researchers found that patients who were
told about their surgical procedure and allowed to listen to music were calmer than the patients
who did not listen to music. Results of this study were measured by heart rate, arterial pressure,
skin temperature, and glucose count of the patients.
Stratton (1992) conducted a research study to examine the effectiveness of music when
stressors were given. Ninety undergraduate students participated in the study and were told that
they were participating in a psychological experiment. Some participants were asked to sit in the
hallway in silence and others were asked to sit in the hallway with soothing background music.
Behavioral responses were videotaped. Results showed that the participants who were sitting in
the hallway listening to the music were less anxious and less active than the group sitting in
silence.
6
Hirokawa’s (2004) study, the effect of music listening and relaxation instructions,
examined arousal changes and memory tasks in older adults. There were fifteen female older
adults who participated in all three conditions: preferred music, relaxation instruction, and
silence for 10 minutes. Arousal level, energy, tiredness, tension, and calmness were measured
before and after the session. Results indicated the preferred music condition increased the energy
level and decreased tensions.
Caregivers
It is certainly difficult, sad, painful, and exhausting to care for patients who have a
terminal illness. It takes a great deal of emotional and physical energy. Not only does the patient
go through physical and emotional pain and anxiety, but also the caregiver feels emotionally and
physically distressed, tired and sad about loosing loved one (Kinsella, Cooper, Picton, &
Murtagh, 1998).
When it comes to taking care of a patient who is facing the end of life sitting next to the
bedside all day long and constantly monitoring the patient, it is emotionally and physically
stressful and fatiguing (National Hospice Palliative Care Organization, 2005). Helping with daily
dressing changes, feeding, monitoring safety, and stabilizing medications also contributes to
physical burnout (National Hospice Palliative Care Organization, 2005; Kinsella, et. al, 1998).
Caregivers of hospice/palliative patients recognize that the priority is the patient, not themselves.
However, caregivers need to realize that not only the patient needs care but caregivers need care
as well. They also need assistance to cope with and to deal with stress, loss, and grieving over a
loved one. Caregivers need to rest and do things they enjoy for stress relief, emotional comfort
and for their well-being. This could be taking a walk, reading a book, or talking to the loved ones
and family members by reminiscing about the times and memories that they have shared
(National Hospice Organization, 2006; Forman, Kitzes, Anderson, & Sheehan, 2003; Munro,
1984).
Hospice nurses, social workers, or certified nursing assistants providing care for patients
and the family also experience stress and physical burnout. It is not easy to provide constant care
and interaction with patients who are faced with death. It is a very sensitive matter. Some
patients might have difficulties communicating with family, some might be faced with financial
issues, and some might have other kinds of unresolved problems. Therefore, as care providers,
7
they work as a team and as a mediator between patients and families to increase overall quality
of life (Kalish, 1980; Quill, 2001).
Music Therapy plays an important and valuable role in hospice care not only for patients
but also for families and caregivers. Krout and Dileo (2000) state that “music therapy has
evolved as a complementary therapy to many traditional medical services and procedures
provided to persons with life-threatening illnesses” (p.325). Music therapy is using music to
achieve physical, spiritual, and psychological needs of patients or clients and helps caregivers
(family and staff) communicate with patients better and in non-threatening ways. In the music
therapy study, Strauser (1997) reported that,
“There are two major categories that delineate the coping progress:
instrumental and palliative. Instrumental is defined as environmental changes
via direct action. Palliative is decribed in more cognitive terms by regulating
emotions and minimizing perceptions. Music therapy facilitates both instrumental
and palliative coping strategies by providing a controlled environment within the
session to identify and solve problems. It also facilitates both strategies through
relaxation and visualization (Hanser, 1985)” (p.91).
In a study by Allen, and Blascovich (1994), the effect of music on physicians’ stress
level while operating was evaluated. Fifty surgeons participated in the study. The results
indicated that surgeons who listen to music while operating were physiologically less aroused
than the surgeons who performed operations in silence.
Music Therapy to Improve Quality of life
“Every patient has his or her own unique belief system about the illness, and each
member of the family also has his or her own beliefs” (Hall, Stone, & Fiset, 1998 p.46). It may
be due to cultural difference, or different physiological responses to treatment and these are
important factors when caring for patients with terminally illnesses.
The hospice movement started in Britain in the 1960s by Dame Cicely Saunders (Young,
1981, Krout, 2003, Forman, Kitzes, Anderson, & Sheehan 2003). Hospice is a service for
patients with life-threatening illnesses using an interdisciplinary team approach to providing
comfort, pain management, spiritual, and emotional support (National Hospice and Palliative
Care organization, 2005; Hilliard, 2003; Munro, 1984). The focus of hospice care is to deliver
holistic care for patients and their families, not to cure the illness (Hall, Stone, & Fiset 1998;
Hilliard, 2003). Krout (1999) asserts that music therapy is effective for terminally ill patients for
physical problems and for psychological, spiritual and psychosocial problems. The ultimate goal
8
of hospice/palliative care is to decrease pain and provide comfort for patients and families to
increase their quality of life until the end (Krout, 1999; Hilliard, 2003).
Many of the clinical research studies on palliative care and hospice show that music
enhances quality of life, decreases anxiety and fear, decreases perception of pain, helps express
feelings, helps with issues regarding family relationships and provides comfort (Krout, 2000). In
her theoretical study, O’Callaghan (1993) stated that various music therapy interventions could
be used for brain impaired palliative care patients as a communication tool such as song writing,
engaging patients in instrument playing, life review through music, and counseling. Kubler-Ross
(1974), worked with terminally ill patients and cited music as an effective tool for
communication between patients and family.
Music therapy case studies in hospice reveal that music listening is the most used clinical
technique in hospice and palliative care (Krout, 2000). Boldt (1996) investigated the effect of
music on motivation, psychological well-being, physical comfort, and exercise endurance of
bone marrow transplant patients. Six subjects participated in this study that compared the effects
of music (live or recorded) vs. non-music groups. Results showed that the music increased
relaxation, comfort, and endurance. A research study by Davis & Thaut (1989) examined the
effect of preferred relaxing music on anxiety, relaxation and physiological responses. Eighteen
subjects participated. Heart rate, muscle tension and finger skin temperature were collected for
physiological responses. Results reported that “state anxiety and self-reported levels of relaxation
decreased consistently while listening to preferred music” (p. 170). In his book, Aldridge (1999)
stated that music listening facilitated relaxation and assisted with pain management in a
palliative care setting.
Numerous clinical studies have discovered that preferred music listening is the most
effective. Hogan (1999a), an Australian music therapist, reported that patient-selected music
listening (pre-recorded or live) was the most frequently used in her music therapy sessions with
terminally ill patients. In a study by Curtis (1986), terminally ill patients were asked to listen to
their preferred music for 15 minutes. The results showed decreases in anxiety, discomfort, and
pain. Gerdner and Swanson (1993) investigated the effect of individualized music on agitated,
confused, elderly persons. Researchers used individualized taped music. Five subjects who
resided in a long term care facility, participated in this study. Results showed that all the
participants had decreased agitation due to the intervention.
9
Stratton & Zalanowski (1984) examined the effect of music on relaxation and degree of
enjoyment. Thirty-six college freshmen participated in the study. They were asked to listen to
music for 15 minutes, then answered a questionnaire on relaxation and music preference. The
study found that students who liked the music the most were more relaxed than students who
liked the music less. The result also found that 70% of the participants who listened to music
reported that music enhanced relaxation.
Although there are many qualitative, anecdotal, and case studies in hospice and palliative
care music therapy citing benefits in patients’ mood, relaxation, and quality of life, there are far
fewer studies done in hospice music therapy on caregivers. Caregivers include families and
hospice staff such as nurses, certified nursing assistants, family support counselors, and social
workers. Also there is a lack of research on hospice patients who reside in hospice in-patient
units, assisted living facilities, and nursing homes (Hilliard, 2004). Facing end-of-life is an
extremely difficult and sensitive time for both patients and caregivers. Further research is needed
for assessing overall quality of life of patients who receive care in in-patient units, assisted living
facilities, or nursing homes and effects on their caregivers.
10
CHAPTER 2
METHOD
Purpose and Null Hypothesis
The purpose of this study was to investigate the effects of music listening on mood states
and relaxation levels of hospice patients and their caregivers. Null hypotheses for this study are:
1. There will be no significant differences among music groups and the non music groups on
mood state and relaxation levels. 2. There will be no significant difference between the preferred
music group and the unfamiliar music group on mood states and relaxation levels. 3. There will
be no significant differences on mood states across three days of participation.
Subjects
Subjects for this study (N=39) were patients (N=24) receiving Big Bend Hospice Care
who were admitted to Big Bend Hospice House, an in-patient unit or resided in assisted living
facilities in Leon County, Gasden County, Jefferson County, and their caregivers (N=15). All
subjects were adults between 18 and 94 years old who consented to participate in the study. The
criteria for patients were; patients who were in respite care, who had achieved symptom
management (whose medication had been stabilized for two days), and patients who did not have
severe dementia. Subjects were selected by referrals from Big Bend Hospice Staff, including
registered nurses, music therapists, and family support counselors. Patients were randomly subdivided into preferred music, unfamiliar music and no music groups. Caregivers were defined as
family members and professionals giving direct care to patients such as social workers, nurses,
certified nursing assistants and bereavement counselors. Caregivers were also randomized into
three groups: preferred music, unfamiliar music, and no music.
11
Table 1. Patient Demographics
Experiment / Control
Age
Gender
Diagnosis
Experiment 1-1
67
Male
Stomach Cancer
Experiment 1-2
89
Female
Debility Unspecified
Experiment 1-3
80
Male
Lung Cancer
Experiment 1-4
74
Male
Debility Unspecified
Experiment 1-5
81
Female
Chronic Obstruct Pulmonary Disease
Experiment 1-6
80
Female
Debility Unspecified
Experiment 1-7
78
Female
Lung Disease
Experiment 1-8
82
Male
Debility Unspecified
Mean Age
78.9
Experiment 2-1
84
Female
Debility Unspecified
Experiment 2-2
89
Female
Debility Unspecified
Experiment 2-3
87
Female
Debility Unspecified
Experiment 2-4
64
Female
Breast Cancer
Experiment 2-5
85
Female
Senile Dementia Uncomplication
Experiment 2-6
93
Female
Debility Unspecified
Experiment 2-7
88
Female
Vascular Dementia Unspecified
Experiment 2-8
85
Female
Debility Unspecified
Mean Age
81.6
Control 1-1
84
Female
Debility unspecified
Control 1-2
69
Female
Debility Unspecified
Control 1-3
89
Female
Senile Dementia Uncomplication
Control 1-4
94
Female
Bronchiectasis
Control 1-5
94
Female
Debility Unspecified
Control 1-6
89
Female
Debility Unspecified
Control 1-7
86
Male
Debility Unspecified
Control 1-8
87
Male
Cardio Vascular Accident
Mean Age
86.5
12
Table 2. Caregiver Demographics
Experiment / Control
Age Group
Gender
Role
Experiment 1-1
55-94
Female
Family
Experiment 1-2
55-94
Female
Chaplain
Experiment 1-3
18-54
Female
Nurse
Experiment 1-4
18-54
Female
Nurse
Experiment 1-5
18-54
Female
CNA
Experiment 2-1
55-94
Female
Social Worker
Experiment 2-2
18-54
Female
Nurse
Experiment 2-3
18-54
Female
Bereavement Counselor
Experiment 2-4
18-54
Female
Bereavement Counselor
Experiment 2-5
18-54
Female
Bereavement Counselor
Control 1-1
55-94
Female
Social Worker
Control 1-2
18-54
Female
PCG
Control 1-3
55-94
Male
Family
Control 1-4
55-94
Female
Family
Control 1-5
18-54
Female
CNA
Setting
Big Bend Hospice (BBH) is a place where palliative care is provided for people
diagnosed with terminal illnesses. Comfort and emotional support are provided to patients and
their families. BBH also offers care at the Hospice House, a facility that provides care for
patients who need short term, 24-hour medical management. It is a 12 bed facility used for
patients who need care for pain management, symptom control, and caregivers who can no
longer care for patients at home due to the patient’s condition.
Design
The design consisted of three days of music listening for each of three groups of patients:
preferred music, unfamiliar music and no music and three days of listening for each of three
groups of caregivers. The independent variables were types of music vs. no music. The
dependant variables were mood states and relaxation tested pre and post session. Mood states
13
(eight states) were measured by the Visual Analog Mood Scales. Relaxation was measured by
behavior observation using the Relaxation scale, which was adapted from the affect scale portion
of the Big Bend Hospice Music Therapy Assessment form. Caregivers in each group were also
pre and posted test using the same measures.
Table 3. Design
Group
Preferred Music
Unfamiliar Music
No Music
Patient
8
8
8
Caregiver
5
5
5
13
13
13
Total
N=39
Participants
6 groups (N=39): 3 patient groups (N=8 each) and 3 caregiver groups
(N=5 each).
Material
The materials used in this experiment were CD Players (Sony, K231007 and Emerson,
PD 5203), patient’s preferred music selection CD made by the researcher, or a compilation CD
of solo piano music by Jill Palmer defined as the unfamiliar music. Music was played on the
speaker of the CD Player.
Measures
The Relaxation Scale was adapted from the affect scale of Big Bend Hospice Music
Therapy Assessment Form and used for pre and post-test (copy in Appendix L). The Visual
Analog Mood Scales (VAMS) were used for measuring patient’s mood state pre-test and posttest (copy in Appendix M). The Visual Analog Mood Scales (VAMS) has been used to assess
mood states in neurologically impaired patients. It has also been used for other clinical and
research purposes. VAMS has been used to assess patients who are cognitively and linguistically
impaired, to screen for mood disorders in primary care settings, to do repeated assessment of
mood states in clinical trials researchs and to assess mood states in clinical practice to monitor
14
the efficacy of an intervention (Stern, 1997). It is also used by many different clinicians: clinical
psychologists, neurologists, nurses, occupational therapists, social workers, primary care
physicians, and physical therapists (Stern, 1997).
VAMS has been used in psychiatric and behavioral medicines settings for about 30 years
(Stern, 1997). Many clinicians who have used VAMS with psychiatric and pain patients reported
that the VAMS has good psychometric properties (Stern 1997). The VAMS measurement is
reliable and valid, and easy to use for patients who are cognitively or linguistically impaired
(Stern, 1997).
The VAMS is administered by using standard instruction included in its manual.
Participants were instructed to verbally, use gestures, or to make a pen mark or point on the
100mm vertical line to show how they were feeling at that moment. The score is based on the
mark’s location along the line, with a possible score of 0 to 100. According to the manual, “0
represents the extreme lack of endorsement of that mood state and 100 represents the extreme
endorsement of that mood state” (Stern, 1997).
Procedures
After agreeing to volunteer for this study, participants in this experiment were then given
the verbal instructions and consent forms. Each of the patients and his/her caregiver groups were
randomly assigned to preferred music, unfamiliar music and no music groups. Patients and
caregivers listened to music separately.
For the experimental groups, the music preference chart, adapted from the BBH Music
Therapy Assessment Form, was given as pre-test to determine the participant’s preferred music.
A Relaxation Scale assessment was completed by the researcher, and a Visual Analog Mood
Scales (VAMS) test was then given as a pre-test before listening to music. Participants were then
asked to listen to music for a period ranging from 15minutes (minimum) to a half hour
(maximum) for 3 days within a period of 7 days. Then, the researcher turned on the music, left
the room and came back after 15 minutes to 30 minutes to give the post-tests. A Relaxation Scale
assessment was completed by the researcher, and a Visual Analog Mood Scales test was
completed by the subject after music listening. The researcher assisted some participants in
turning pages while taking the post-test.
15
For the control group, pre-tests were conducted similarly before subjects participated in
any activity they chose (T.V., radio, ambient and reading) except music for 15minutes
(minimum) to half hour (maximum) for 3 days within a period of 7 days. The researcher left the
room and came back after 15 minutes to 30 minutes to give the post-tests. A Relaxation Scale
was completed by the researcher, and a Visual Analog Mood Scales test was completed by the
subjectafter the activity. The researcher assisted some participants in turning pages while taking
the post-test. The subsequent 2 days of testing were similarly conducted.
16
CHAPTER 3
RESULTS
The Visual Analog Mood Scale was used to measure mood states in patient groups pre
and posttest for 3 days. A repeated measures ANOVA was used in data analysis of VAMS pre
and posttest by group and by time (the 3 sessions). There was a statistically significant difference
in overall negative and positive moods, F = 67.489; p < .00. There were no significant
differences between pre and posttests, F = 4.229; p > .05. There was no significant difference
across time, F = 1.233; p > .05.
Table 4. Results of Repeated measures ANOVA for VAMS of patients.
Within subjects source
df
MS
F
Significance
Pre/Posttest
1
151.187
4.229
0.052
Pre/post x group
2
7.99
0.223
0.802
Error(pre/post)
21
35.751
Negative&positive Moods
1
18219.28
67.489
0
Negative/positive x group
2
196.24
0.727
0.495
Error(negative/positive)
21
269.959
sessions
2
49.019
1.233
0.302
sessions x group
4
11.228
0.282
0.888
Error(sessions)
42
39.766
Pre/post x negative/positive
1
9.15
0.398
0.535
Pre/post x negative/positive x group
2
15.297
0.666
0.524
Error(pre/post x negative/positive)
21
22.965
Pre/post x sessions
2
16.716
0.718
0.494
Pre/post x sessions x group
4
30.321
1.302
0.285
Error(pre/post x sessions)
42
23.296
Negative/positive x sessions
2
126.525
1.579
0.218
Negative/positive x sessions x group
4
21.255
0.265
0.899
Error(negative/positive x sessions)
42
80.135
Pre/post x negative/positive x sessions
2
16.463
0.498
0.611
Pre/post x negative/positive x sessions x group
4
37.243
1.126
0.357
Error(pre/post x negative/positive x time)
42
33.074
17
Table 5. Pretest/Posttest Mean for negative and positive mood across sessions of patients.
Pretest
Group
1 Preferred
Pretest 2 Unfamiliar
1st
3 Control
negative
Total
1 Preferred
Pretest
2 Unfamiliar
2nd
3 Control
neg.
Total
1 Preferred
Pretest
2 Unfamiliar
3rd
3 Control
neg.
Total
1 Preferred
Pretest 2 Unfamiliar
1st
3 Control
positive
Total
1 Preferred
Pretest
2 Unfamiliar
2nd
3 Control
pos.
Total
1 Preferred
Pretest 2 Unfamiliar
3rd
3 Control
pos.
Total
M
SD
n
63.31
54.19
56.58
58.03
61.85
52.33
54.50
56.23
62.63
52.31
53.69
56.21
44.56
38.88
38.88
40.77
40.06
43.06
41.56
41.56
44.56
37.38
42.50
41.48
13.66
7.36
6.95
10.17
13.36
7.87
6.63
10.19
13.82
9.35
8.07
11.24
8.31
8.52
5.40
7.71
8.99
11.01
4.44
8.31
9.81
8.48
8.15
8.99
8
8
8
24
8
8
8
24
8
8
8
24
8
8
8
24
8
8
8
24
8
8
8
24
Posttest
Posttest
1st
negative
Posttest
2nd
neg.
Posttest
3rd
neg.
Posttest
1st
positive
Posttest
2nd
pos.
Posttest
3rd
pos.
Group
Mean
SD
n
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
64.04
54.71
57.69
58.81
58.73
50.94
52.75
54.14
58.98
51.27
52.46
54.24
40.19
37.94
38.75
38.96
43.25
35.31
39.69
39.42
41.69
36.75
41.63
40.02
13.78
7.46
6.09
10.09
12.58
6.00
6.79
9.20
12.45
6.07
8.78
9.69
7.79
9.41
7.34
7.92
8.42
6.86
5.01
7.38
9.96
7.90
3.95
7.72
8
8
8
24
8
8
8
24
8
8
8
24
8
8
8
24
8
8
8
24
8
8
8
24
Table 5 shows the results of the VAMS ANOVA and includes pretest and posttest means,
n, and standard deviations for negative and positive moods by groups across sessions of patients.
Results indicated that the means for negative moods in both pre and posttest were higher for the
preferred music group than the other groups indicating more negative attitudes, though scores
were within normal limits <59. Mean for positive moods in both pre and posttest were within
normal limits >41 (see Table 8).
The Visual Analog Mood Scale was also used to measure mood states among caregiver
groups. A repeated measures ANOVA was used in data analysis of VAMS pre/posttest by group
and by sessions. There was a statistically significant difference between pre and posttest by
negative and positive moods, F = 5.639; p < .05. Negative moods scores were significantly
higher and generally decreased across time while positive moods fluctuated from session to
session. There were no significant differences between pre and posttests by groups, F = .071; p >
18
.05. There were no significant differences across sessions, F = .290; p > .05. Table 6 provides
results of the repeated measures ANOVA of the VAMS results for the caregiver group.
Table 6. Results of Repeated measures ANOVA for VAMS of caregivers.
Within subjects source
df
MS
F
Significance
Pre/posttest
1
6.226
0.071
0.795
Pre/post x group
2
55.741
0.631
0.549
Error(pre/post)
Negative/positive moods
Negative/positive x group
12
1
2
88.287
284.114
211.856
0.845
0.63
0.376
0.549
Error(negative/positive)
Sessions
Sessions x group
12
2
4
336.208
9.138
20.214
0.29
0.641
0.751
0.638
Error(sessions)
Pre/post x negative/positive
Pre/post x negative/positive x group
24
1
2
31.516
950.011
17.856
5.639
0.106
0.035
0.9
Error(pre/post x negative/positive)
Pre/post x sessions
Pre/post x sessions x group
12
2
4
168.459
8.139
10.46
0.937
1.204
0.406
0.335
Error(pre/post x sessions)
Negative/positive x sessions
Negative/positive x sessions x group
24
2
4
8.684
98.829
56.694
1.211
0.694
0.316
0.603
Error(negative/positive x sessions)
Pre/post x negative/positive x sessions
Pre/post x negative/positive x sessions x group
24
2
4
81.636
21.707
17.829
1.413
1.16
0.263
0.353
Error(pre/post x negative/positive x sessions)
24
15.365
Table 7. Pretest/Posttest Mean for negative and positive mood across sessions of caregivers.
Pretest
prt1n
prt2n
prt3n
Group
M
SD
n
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
53.07
50.50
55.33
52.97
52.93
52.33
51.00
52.09
49.90
52.13
47.87
49.97
7.29
3.77
5.54
5.68
9.41
10.96
8.79
9.08
8.01
5.06
3.67
5.72
5
5
5
15
5
5
5
15
5
5
5
15
Posttest
PtT1n
PtT2n
PtT3n
19
Group
M
SD
n
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
45.17
45.47
50.67
47.10
48.50
47.43
49.10
48.34
46.67
46.10
47.97
46.91
3.73
2.51
6.73
5.06
8.13
7.30
8.81
7.53
7.88
2.94
6.08
5.61
5
5
5
15
5
5
5
15
5
5
5
15
Table 7. Continued.
prt1p
prt2p
prt3p
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
42.80
47.30
39.10
43.07
47.00
44.30
39.20
43.50
52.00
45.70
43.70
47.13
15.29
6.68
12.09
11.55
10.18
13.30
8.86
10.67
8.90
10.99
11.32
10.35
5
5
5
15
5
5
5
15
5
5
5
15
PtT1p
PtT2p
PtT3p
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
1 Preferred
2 Unfamiliar
3 Control
Total
52.80
47.50
44.90
48.40
53.50
49.70
45.60
49.60
54.70
46.10
51.00
50.60
11.25
9.53
15.73
12.02
9.06
7.91
14.69
10.68
10.03
3.29
13.52
9.87
5
5
5
15
5
5
5
15
5
5
5
15
Table 7 shows the results of pretest and posttest means, n, and standard deviation for
negative and positive moods across sessions of caregivers. Results indicated that the means for
negative moods in both pre and posttest were within normal limits < 59. Means for positive
moods in both pre and posttest were within normal limits >41 (see Table 8).
Preferred music group means were consistently higher than those of other groups in all measures
for both positive and negative moods.
Table 8. Interpretation of VAMS T scores
VAMS scale
Negative moods
Afraid
Confused
Sad
Angry
Tired
Tense
Within normal limits
<59
Borderline
60-69
Abnormal
>70
Positive moods
Energetic
Happy
>41
31-40
<30
Table 9. Overall Pretest/Posttest Mean for negative and positive mood by group of patients.
GROUP
1 Preferred
Mean
Pre Negative
Pre Positive
Post Negative
Post Positive
62.60
43.06
60.58
41.71
20
Table 9. Continued.
SD
2 Unfamiliar
3 Control
Total
12.84
4.99
11.97
5.37
N
8
8
8
8
Mean
52.94
39.77
52.31
36.67
SD
5.70
7.00
5.36
5.58
N
8
8
8
8
Mean
54.92
40.98
54.30
40.02
SD
N
5.95
8
3.79
8
5.99
8
3.40
8
Mean
56.82
41.27
55.73
39.47
SD
9.43
5.37
8.73
5.13
N
24
24
24
24
Table 10. Overall Pretest/Posttest Mean for negative and positive mood by group of caregivers.
GROUP
Pre Negative
Pre Positive
Post Negative
Post Positive
Mean
SD
n
Mean
SD
n
51.97
7.87
5
51.66
5.00
5
47.27
10.29
5
45.77
7.39
5
46.78
5.79
5
46.33
3.87
5
53.67
9.81
5
47.77
3.54
5
3 Control
Mean
SD
n
51.40
5.05
5
40.67
8.76
5
49.24
6.76
5
47.17
14.23
5
Total
Mean
SD
n
51.67
5.67
15
44.57
8.74
15
47.45
5.35
15
49.53
9.91
15
1 Preferred
2 Unfamiliar
Table 9 shows the results for all sessions combined with pretest and posttest means, n,
and standard deviation for negative and positive moods by group of patients. Results indicated
that groups showed no significant differences on either negative or positive moods between pre
and posttests. The preferred music group means show noticeable decreases in negative and
positive moods. The unfamiliar music group means show slight decreases in both positive and
negative moods. The control group means show no changes for positive or negative moods.
Table 10 shows the results for all sessions combined with pretest and posttest means, n,
and standard deviation for negative and positive moods by groups of caregivers. Results
indicated that all three groups showed no significant differences on either negative or positive
21
moods between pre and posttests. However, posttest means indicated that negative moods
decreased in all three groups compared to the pretest means. In contrast, posttest means for
positive moods increased in all three groups from the pretest means.
The Relaxation Affect Scale was used to measure relaxation levels in patient groups as
observed by the therapist. A repeated measures ANOVA was used to analyze data between pre/
posttests for groups across sessions. There was a statistically significant difference between pre
and posttest results, F =47.09; p < .05. There was a significant difference between pre and
posttest by group, F = 6.98; p < .05. There was a significant difference across sessions, F = 4.19;
p < .05. There were no significant differences by time by group, F = .24; p > .05, by pre and
posttest by time, F = 2.19; p > .05, or by pre and posttest by time by group, F = .627; p > .05.
Table 11 provides results of the repeated measures ANOVA for the Relaxation Scale results of
the patient groups.
Table 11. Pretest/Posttest Mean for Relaxation Level by group of patients.
GROUP
1 Preferred
2 Unfamiliar
3 Control
Mean
SD
N
Mean
SD
N
Mean
SD
N
Pre Relaxation
Post relaxation
2.36
0.60
8
2.58
0.89
8
2.67
0.36
8
3.42
0.61
8
3.21
0.83
8
2.86
0.50
8
Table 11 shows both music groups significant by increased relaxation while the control
group remained stable.
22
Estimated Marginal Means of MEASURE_1
group
3.1
1
2
3
Estimated Marginal Means
3
2.9
2.8
2.7
2.6
2.5
1
2
3
time
Figure 1 Patients’ Relaxation Level Graph across sessions.
Figure 1 shows music groups increased relaxation in the 2nd session and all groups
increased relaxation from pre to posttest in the 3rd sessions.
23
Table 12. Results of Repeated Measures ANOVA for Relaxation Level of Patients
Within subjects Source
df
MS
F
Significance
Pre/post
1
14.06
47.09
0.00
Pre/post x group
2
2.08
6.98
0.01
Error (pre/post)
21
0.30
sessions
2
2.58
4.19
0.02
Sessions x group
4
0.15
0.24
0.92
Error (sessions)
42
0.62
Pre/post x time
2
0.58
2.19
0.12
Pre/post x sessions x group
4
0.17
0.63
0.65
Error (pre/post x sessions)
42
0.27
The Relaxation Affect Scale was also used to measure relaxation level in caregiver
groups as observed by the researcher. A repeated measures ANOVA was used in analysis of
these data. There was a statistically significant difference between pre and posttest, F =58.80; p <
.05. There was a significant difference in time, F = 3.67; p < .05. There were no significant
differences by time by group, F = 2.03; p > .05, by pre and posttest by time, F = .90; p > .05, by
pre and posttest by group, F = 3.60; p > .05, or by pre and posttest by time by group, F = 1.29; p
> .05. Table 13 provides results of the repeated measures ANOVA for Relaxation Scale results
of the caregiver group.
Table 13. Results of Repeated measures ANOVA for Relaxation Level of Caregivers.
Within subjects Source
Pre/post
Pre/post x group
Error (pre/post)
sessions
Sessions x group
Error (sessions)
Pre/post x sessions
df
MS
F
Significance
1
2
12
2
4
24
2
4.90
0.30
0.08
0.81
0.44
0.22
0.23
58.80
3.60
0.00
0.06
3.70
2.03
0.04
0.12
0.90
0.42
24
Table 13. Continued.
Pre/post x sessions x group
Error (pre/post x sessions)
4
24
0.33
0.26
1.30
0.30
Table 14. Pretest/Posttest Mean for relaxation level by group of caregivers.
GROUP
1 Preferred
2 Unfamiliar
3 Control
Mean
SD
N
Mean
SD
N
Mean
SD
N
Pre Relaxation
3.40
.15
5
3.13
.45
5
3.22
.35
5
Post relaxation
4.07
.15
5
3.60
.37
5
3.69
.43
5
Table 14 shows that both music groups of caregivers increased significantly in relaxation
from pre to posttest. Figure 2 shows that while music immediately affected relaxation, the
control group gradually increased across time without music. This indicates that quiet time for
caregivers functioned to promote more minimal levels of relaxation
25
Estimated Marginal Means of MEASURE_1
group
1
2
Estimated Marginal Means
3.8
3
3.6
3.4
3.2
1
2
3
time
Figure 2 Caregivers’ Relaxation Level Graph by groups
26
CHAPTER 4
DISCUSSION
Most of the results of this study were not statistically significant though some effects of
music on mood states and relaxation in hospice patients and caregivers were noted. Music groups
of patients and caregivers showed decreased negative moods, increased positive moods and
significant by increased relaxation. The preferred music group for both patients and caregivers
showed the most relaxation. The results of this study showed that there was statistical
significance in score differentiation of negative vs. positive mood in all groups as expected by
the scoring system of the test. It also showed that there was a statistical significance in relaxation
level from pre to posttest and across sessions.
Unique to this study was the prominent level of communication across the sessions
among subjects and the researcher. It was noticeable that most of the patients were verbalizing
more after the posttest as compared to the pretest. After each session, some patients made
comments about whether they liked the music. Because most of the patients were residing in an
assisted living facility, they expressed how lonely they were, how they did not like the facility
but they needed to stay there, and many asked the researcher to come and see them again the
next day. Staff who participated in this study made positive comments also. Most of them
listened to the music while they were working and stated that they ‘very much enjoyed listening
to the music while they were working because music blocks all the noises that surrounds the.’
They also stated that ‘ work was more efficient and allowed them to concentrate better and feel
much more relaxed.’
There were some complicating factors encountered through out the study. Recruiting
caregivers, especially family members of the patients was hard because they were going through
difficult times caring for their loved ones, many were tired and overwhelmed. Another big factor
was completing all three sessions within a seven day period since the average stay for patients in
the hospice in-patient unit was 5 days. The music therapist had no control of the environment,
such as loud TV noise, music playing in the hallway, or staff constantly checking patients. These
issues may have interfered with music listening for both the patient and caregiver groups.
27
Additionally, some subjects participated on consecutive days while others participated every
other day. All of these issues may have influenced the results of the study.
Convincing caregivers to have Music Therapy or quiet time is a good idea. Sitting next to
the bedside for long periods of time can be tiring. As caregivers, it is crucial to maintain their
own health while they are caring for their loved one. The results of this study showed that music
listening promoted relaxation of caregivers. Also the personal statements from the caregiver
participants revealed that it was effective and positive experience improving their overall quality
of life.
The measure of relaxation was more effective than mood state assessment. Because
hospice patients and caregivers go through very emotional times in their life, there could be
drastic changes in mood due to medications or how they felt at that moment.
Further studies need to examine the effect of music therapy on interaction between family
members and patients who reside in facilities receiving hospice care. While visiting, family
members sometimes experience isolation or loneliness music could increase the overall quality
of their life.
Because the relaxation levels were measured by the researcher using behavioral
observation, this study needed extra monitoring by clinicians to document increasing reliability.
Also, providing relaxation questionnaires, or measuring physiological responses such as
respiration rate or blood pressure could enhance reliability. Larger numbers of subjects’
participating may have change results. These changes could all incorporated into future research.
28
APPENDIX A
Human Subject Committee Approval Form
29
30
APENDIX B
Patient Consent Form
(Experimental Group)
31
32
APENDIX C
Patient Consent Form
(Control Group)
33
34
APENDIX D
Legal Guardian Consent Form
(Caregiver-Experimental Group)
35
36
APENDIX E
Legal Guardian Consent Form
(Caregiver-Control Group)
37
38
APENDIX F
Patient Assent Form
(Experimental Group)
39
40
APPENDIX G
Patient Assent Form
(Control Group)
41
42
APPENDIX H
Legal Guardian Assent Form
(Experimental Group)
43
44
APPENDIX I
LEGAL GUARDIAN ASSENT FORM
(CONTROL GROUP)
45
46
APPENDIX J
RELAXATION SCALES
47
RELAXATION SCALES
(ADAPTED FROM BIG BEND HOSPICE MUSIC THERAPY ASSESSSMENT)
Pre
Post
Pre
1
Post
Pre
2
Post
3
Pre
Post
4
Pre
Post
5
Tense muscle
Moaning
Quiet
Smiling
Laughing
High shoulders
Tense brow
Relaxed brow
High brow
Clapping
Screaming
Low eye gaze
Eye gaze
Eye contact
Toe tapping
Closed eyes
Frown
Level lips
Shoulders back
Relaxed arms
Wrinkled brow
Watery eyes
Arms at rest
Commenting
conversation
48
APPENDIX K
MUSIC PREFERRENCE CHART
49
Music Preference Chart
(Adapted from affect scale of Big Bend Hospice Music Therapy Assessment
Form)
□ Hymns/Gospel
□ Contemporary
Christian Music
□ Spirituals
□ Folk
□ Bluegrass
□ Blues
□ Jazz
□ Classical
□ Oldies
□ Country(old/new)
□ Big Band
□ Soft Rock
50
APPENDIX L
BIG BEND HOSPICE MUSIC THERAPY ASSESSMENT FORM
51
52
APPENDIX M
VISUAL ANALOGUE MOOD SCALES
53
54
55
56
57
58
59
60
61
APPENDIX N
RAW DATA
62
Visual Analogue Mood Scale Raw Score- Patient pretest
Experimental
Group #1
1-1
2
3
2-1
2
3
3-1
2
3
4-1
2
3
5-1
2
3
6-1
2
3
7-1
2
3
8-1
2
3
Experimental
Group #2
1-1
2
3
2-1
2
3
3-1
2
3
4-1
2
3
5-1
2
3
6-1
Afraid
Sad
Angry
Energetic
2
2
3
94
81
92
3
0
12
9
8
0
9
5
11
45
26
11
0
9
99
13
90
91
Confuse
d
2
4
5
96
69
92
84
95
45
2
9
6
50
0
36
10
1
13
8
11
48
45
34
61
2
5
2
28
84
89
91
91
8
8
41
0
9
97
44
44
43
20
73
40
44
92
43
73
2
4
2
87
51
87
78
88
71
11
28
0
3
6
20
43
1
5
5
30
3
94
24
19
41
19
1
37
11
2
13
22
22
6
8
3
10
1
10
21
64
0
6
97
41
25
48
9
47
10
8
40
3
0
4
37
21
30
7
35
44
62
48
48
36
11
8
73
25
80
27
20
29
11
3
6
67
40
22
3
37
8
10
2
2
72
4
6
63
Happy
Tense
2
3
2
31
56
73
82
92
66
52
3
92
0
47
45
29
51
38
79
63
95
50
25
16
Tire
d
54
68
90
99
49
93
4
46
10
95
2
19
89
91
89
45
21
20
5
39
46
90
76
90
53
93
74
96
47
39
99
20
30
95
3
90
45
5
55
44
48
40
3
90
93
92
58
38
4
4
3
96
92
93
78
83
66
92
4
86
10
2
21
70
79
72
10
26
0
92
28
23
21
0
19
88
65
58
45
93
3
8
94
0
10
30
8
3
58
37
9
70
93
94
92
13
98
55
83
100
3
33
2
95
21
21
86
47
50
65
45
43
42
87
92
2
34
30
3
3
49
17
9
6
87
5
3
10
63
19
11
97
0
42
5
67
Visual Analogue Mood Scale Raw Score- Patient pretest (Continued)
2
3
7-1
2
3
8-1
2
3
10
6
2
8
8
5
0
4
12
9
9
10
4
10
8
5
12
5
6
10
7
2
0
3
13
3
3
7
8
9
0
17
27
18
2
7
15
4
89
50
65
43
98
82
81
96
16
12
25
26
46
40
67
87
63
67
35
57
6
11
18
10
5
26
8
3
21
11
12
8
30
6
8
30
8
6
11
2
16
11
8
5
6
41
48
1
0
3
33
34
96
21
35
28
37
7
14
18
6
22
22
42
31
86
9
9
10
97
91
7
2
10
6
95
96
13
12
6
28
84
17
24
6
15
29
32
15
34
54
6
11
25
61
9
20
25
89
43
14
0
6
7
47
8
18
13
11
18
32
15
19
60
31
7
8
39
0
5
7
10
89
2
19
15
16
19
48
55
45
47
39
68
13
29
66
1
2
53
8
83
30
33
45
50
42
97
29
44
32
18
28
18
40
25
18
20
82
19
37
73
87
41
55
29
57
7
58
43
13
97
27
79
72
58
30
48
67
9
90
74
93
46
91
15
53
51
87
93
78
46
70
52
85
52
95
32
18
18
71
19
18
26
11
36
20
54
52
91
43
34
19
30
35
94
82
80
Control
Group
1-1
2
3
2-1
2
3
3-1
2
3
4-1
2
3
5-1
2
3
6-1
2
3
7-1
2
3
8-1
2
3
Visual Analogue Mood Scale Raw Score- Patient posttest
Experimental
Group #1
1-1
2
3
2-1
Afraid
Confused
Sad
2
2
4
8
4
2
3
93
3
2
1
96
Angr
y
1
2
4
16
64
Energeti
c
3
6
3
3
Tired
54
76
75
95
Happ
y
92
59
83
50
Tense
2
4
3
86
Visual Analogue Mood Scale Raw Score- Patient posttest (Continued)
2
3
3-1
2
3
4-1
2
3
5-1
2
3
6-1
2
3
7-1
2
3
8-1
2
3
Experimental
Group #2
1-1
2
3
2-1
2
3
3-1
2
3
4-1
2
3
5-1
2
3
6-1
2
3
7-1
2
3
8-1
2
3
8
71
11
2
4
4
0
1
1
0
2
13
16
10
11
12
5
96
48
22
47
91
92
80
57
7
1
11
41
0
0
7
1
0
6
17
6
22
40
20
71
29
47
80
74
54
78
8
95
0
0
40
31
15
43
30
37
85
40
86
67
71
92
88
94
16
16
18
3
0
0
19
30
0
40
32
5
55
26
23
63
16
73
95
77
25
9
98
0
96
50
20
44
35
67
60
4
72
37
22
47
41
64
30
11
84
84
89
95
0
70
29
41
50
10
21
3
53
60
84
5
33
55
9
22
92
83
98
5
86
71
34
43
50
68
91
100
38
47
8
52
56
35
80
72
48
94
95
93
1
15
40
42
70
17
24
46
100
40
91
30
19
7
20
11
10
9
46
18
7
28
3
7
7
0
17
10
11
3
4
5
2
5
2
15
3
5
100
34
29
46
46
45
13
17
40
4
8
8
36
10
6
2
13
19
2
7
0
83
29
22
28
8
26
12
44
6
10
26
10
3
32
3
16
8
10
3
5
10
1
0
2
18
17
4
5
6
82
6
2
5
15
20
2
4
14
25
10
14
13
3
7
10
2
0
5
75
9
7
14
8
4
43
45
8
12
34
0
13
7
40
27
10
24
2
4
18
3
70
60
83
43
57
89
60
91
97
92
52
53
27
98
27
2
7
73
73
68
92
71
32
58
10
10
51
18
43
19
46
54
96
46
48
88
24
0
0
32
98
10
10
4
2
15
25
96
56
48
17
13
15
100
58
15
46
51
28
6
20
34
15
1
2
30
10
60
93
53
60
96
2
20
65
Visual Analogue Mood Scale Raw Score- Patient posttest (Continued)
Control
Group
1-1
2
3
2-1
2
3
3-1
2
3
4-1
2
3
5-1
2
3
6-1
2
3
7-1
2
3
8-1
2
3
16
7
26
19
15
5
28
16
5
36
19
9
30
25
7
13
3
6
4
41
0
3
0
6
37
31
91
22
32
28
39
18
19
21
3
23
53
30
18
59
6
5
13
19
55
6
5
13
84
91
92
24
10
11
18
4
16
2
16
5
79
25
5
30
8
4
13
30
64
7
31
35
11
39
19
4
9
6
20
8
20
35
12
10
11
30
9
56
15
14
7
38
0
13
12
13
66
79
4
17
0
5
13
43
48
52
26
32
54
82
35
20
3
14
33
13
31
38
26
0
42
32
90
30
28
34
12
30
21
32
52
11
10
77
40
8
70
46
54
46
93
57
8
45
50
15
96
43
71
34
57
36
52
40
15
80
73
71
40
83
17
45
68
70
51
63
47
65
50
82
51
78
25
20
19
60
16
60
45
8
31
28
46
55
85
51
12
31
20
61
90
85
82
Visual Analogue Mood Scale Raw Score- Caregivers pretest
Experimental
Group #1
1-1
2
3
2-1
2
3
3-1
2
3
4-1
2
3
5-1
2
3
Experimental
Group #2
1-1
2
3
2-1
2
3
3-1
2
3
4-1
2
3
5-1
2
3
Control Group
1-1
2
3
2-1
2
3
3-1
2
3
4-1
2
Afraid
Confused Sad
Angry
Energetic Tired
Happy
Tense
50
6
28
8
0
26
7
2
3
0
0
0
8
4
7
10
22
4
0
71
15
28
4
20
16
0
0
7
2
3
62
83
65
50
11
0
1
5
1
19
0
11
1
2
4
17
5
41
0
70
0
4
4
3
0
11
0
2
5
6
15
32
42
72
26
90
28
64
43
0
46
78
100
98
100
78
84
79
83
81
41
72
75
56
78
45
13
3
2
8
5
25
30
71
52
80
62
68
85
1
65
66
100
98
98
38
67
61
100
51
84
67
54
40
83
67
27
0
3
1
3
10
3
16
75
20
5
4
2
0
0
6
28
6
13
18
11
12
31
15
23
5
5
4
31
5
10
16
25
20
1
6
36
15
82
15
5
5
2
13
4
65
28
19
25
1
9
17
19
81
31
5
4
4
1
4
84
31
25
22
49
0
4
66
41
81
4
98
95
58
61
46
36
22
24
48
79
60
37
76
17
28
4
42
53
61
9
61
22
30
67
42
30
91
21
71
61
97
78
80
95
64
61
21
38
8
16
48
52
100
19
68
4
12
65
70
79
56
32
38
6
3
2
26
25
23
13
14
9
0
0
7
3
1
24
22
25
15
14
12
28
0
6
1
2
21
26
30
53
98
15
0
0
59
3
59
18
25
27
22
4
14
0
27
11
4
0
62
80
54
25
37
85
0
34
11
2
1
52
44
30
67
60
11
100
25
18
22
3
68
70
64
47
49
85
0
30
98
0
30
42
28
28
71
61
15
8
56
67
Visual Analogue Mood Scale Raw Score- Caregivers pretest (Continued)
3
5-1
2
3
0
71
8
8
0
36
10
4
0
10
10
7
1
8
7
8
23
74
7
45
0
47
82
81
50
72
40
77
19
40
11
18
Visual Analogue Mood Scale Raw Score- Caregivers posttest
Experimental
Group #1
1-1
2
3
2-1
2
3
3-1
2
3
4-1
2
3
5-1
2
3
Experimental
Group #2
1-1
2
3
2-1
2
3
3-1
2
3
4-1
2
3
5-1
2
3
Control Group
1-1
2
3
Afraid
Confused Sad
Angry
Energetic Tired
Happy
Tense
8
5
19
0
43
2
1
1
3
0
0
0
0
4
3
34
14
6
0
53
4
2
3
3
0
0
0
2
5
0
16
60
71
9
0
0
0
0
0
0
0
0
3
4
1
6
12
49
0
39
0
1
3
2
0
0
0
2
2
1
23
38
52
100
67
100
65
75
70
52
89
76
98
91
99
36
68
79
42
43
22
50
47
30
21
10
11
1
5
30
30
30
13
100
90
100
88
87
83
76
87
87
100
97
100
23
46
22
45
36
6
29
5
9
7
9
3
1
5
47
2
0
2
7
25
18
3
2
2
3
3
10
6
0
3
1
0
1
18
20
13
1
2
4
17
16
65
21
10
24
0
1
2
5
77
13
38
3
7
15
14
29
15
7
6
0
0
0
9
28
12
4
3
7
2
20
51
0
8
14
100
19
57
20
46
46
11
85
50
44
83
57
67
53
45
5
18
25
8
30
26
20
6
15
27
55
36
39
18
18
90
77
60
83
48
55
29
89
55
85
89
76
55
55
41
6
1
3
55
60
15
8
4
21
32
62
67
13
4
21
6
1
0
6
1
1
4
2
0
6
2
1
96
95
87
4
1
0
100
100
99
1
0
0
68
Visual Analogue Mood Scale Raw Score- Caregivers posttest (Continued)
2-1
2
3
3-1
2
3
4-1
2
3
5-1
2
3
28
23
30
12
10
12
0
21
1
18
4
5
33
34
30
20
15
19
0
25
1
15
3
19
32
34
29
41
70
9
0
0
0
15
5
6
28
22
28
16
20
17
0
0
1
42
7
10
69
58
56
79
40
37
59
39
28
35
20
49
78
40
29
37
46
61
15
33
15
33
71
21
32
51
47
67
25
40
60
3
20
0
48
25
75
47
31
52
40
52
34
39
0
9
18
10
60
PATIENTS’ RELAXATION RAW SCORE
Patient
Group Pretest Posttest
#1
Group pretest posttest
#2
Group pretest
#3
posttest
1-1
3
4
1-1
2
4
1-1
3
2
2
3
3
4
4
5
2
3
1
2
2
3
2
3
2
3
3
3
2-1
2
3
2-1
2
2
2-1
3
3
2
3
3
2
4
3
2
3
3
4
5
4
2
3
3
3
3
3
3-1
3
3
3-1
2
2
3-1
3
4
2
3
3
2
5
5
2
3
2
2
3
3
2
3
2
3
3
4
4-1
3
3
4-1
3
3
4-1
3
3
2
3
2
3
4
2
2
3
3
3
4
3
2
3
2
3
3
4
5-1
3
4
5-1
4
4
5-1
3
3
2
3
3
2
3
3
2
3
4
3
5
4
2
3
3
3
3
3
6-1
1
3
6-1
1
1
6-1
3
2
2
3
1
2
3
4
2
3
1
2
2
2
2
3
3
3
3
3
7-1
1
2
7-1
2
3
7-1
2
2
2
3
2
3
4
3
2
3
2
3
3
3
2
3
2
3
2
4
8-1
1
3
8-1
3
4
8-1
1
1
2
3
2
3
2
3
2
3
4
4
4
4
2
3
3
2
3
2
2.666667
2.875
2.375 3.416667
2.583333 3.208333
70
CAREGIVER RELAXATION RAW SCORE
Caregiver Group
Group
#1
Pretest Posttest
Group Pretest Posttest
#2
Control Pretest Posttest
Group
1-1
2
3
3
4
4
3
4
5
1-1
2
3
4
4
3
4
4
4
1-1
2
3
3
3
4
3
5
4
2-1
2
3
3
4
3
4
4
4
2-1
2
3
2
3
3
3
4
3
2-1
2
3
4
3
4
3
4
4
3-1
2
3
3
3
4
4
4
4
3-1
2
3
3
3
3
3
4
3
3-1
2
3
2
3
3
3
3
3
4-1
2
3
3
4
3
4
4
4
4-1
2
3
3
4
3
4
4
4
4-1
2
3
4
3
3
3
3
4
5-1
2
3
4
3
3
4
4
5
5-1
2
3
3
3
3
3
4
3
5-1
2
3
3
2
3
3
3
3
3.13333
3.6
3.133333
3.4
3.4 4.0667
71
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76
BIOGRAPHICAL SKETCH
Name:
Seong-Eun Amy Kim
Date and Place of Birth:
March 22, 1979
Seoul, South Korea
Education:
Bachelor of Music Performance
New England Conservatory of Music
Boston, MA
1998-2002
Clinical Experience:
Tallahassee Memorial Hospital –practicum
Tallahassee Memorial Hospital – Music therapy Student volunteer at NICU
Big Bend Hospice –music therapy intern
77