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International Journal of Nursing Practice 2013; 19: 206213

RESEARCH PAPER

Music intervention study in abdominal surgery

patients: Challenges of an intervention study
in clinical practice
Anne Vaajoki MNSc RN
Doctoral Student, Department of Nursing Science, University of Eastern Finland, Kuopio Campus, Kuopio, Finland

Anna-Maija Pietil PhD RN

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

Pivi Kankkunen PhD RN

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

Katri Vehvilinen-Julkunen PhD RN

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

Accepted for publication June 2012

Vaajoki A, Pietil A-M, Kankkunen P, Vehvilinen-Julkunen K. International Journal of Nursing Practice 2013; 19:
206213
Music intervention study in abdominal surgery patients: Challenges of an intervention study in
clinical practice
Evidence-based nursing requires carefully designed interventions. This paper discusses methodological issues and explores
practical solutions in the use of music intervention in pain management among adults after major abdominal surgery. There
is a need to study nursing interventions that develop and test the effects of interventions to advanced clinical nursing
knowledge and practice. There are challenges in carrying out intervention studies in clinical settings because of several
interacting components and the length and complexity of the causal chains linking intervention with outcome. Intervention
study is time-consuming and requires both researchers and participants commitment to the study. Interdisciplinary and
multiprofessional collaboration is also paramount. In this study, patients were allocated into the music group, in which
patients listened to music 30 minutes at a time, or the control group, in which patients did not listen to any music during
the same period.
Key words: clinical practice, music intervention, postoperative pain management, quasi-experimental study design.

INTRODUCTION
Correspondence: Anne Vaajoki, Department of Nursing Science, University of Eastern Finland, Kuopio Campus, PO Box 1627, 70211
Kuopio, Finland. Email: anne.vaajoki@uef.fi
2013 Wiley Publishing Asia Pty Ltd

There has been a growing interest in and the use of music

listening during the perioperative period. Music listening
has an effect on anxiety and pain alleviation,1,2 improves
mood and enhances the feeling of wellness.3 The effects of
music listening postoperatively have been studied with
doi:10.1111/ijn.12052

Music intervention study

various surgical procedures such as gynaecologic operations,4 caesarean section,5,6 mastectomy operations,7
orthopaedic operations,8,9 cardiac surgery10 and during
postanaesthesia care.11
Pain is a complex and subjective experience that
includes physiological, sensory, affective, cognitive,
behavioural and sociocultural components.12 It can be
accessed on the basis of the patients behaviour and by
rating his/her pain intensity and distress or recognizing
pain from physiological factors such as blood pressure,
heart rate, respiratory rate, peripheral thermal noun and
complexion.13 The multidimensional aspects of pain
should be assessed from more than one dimension.14
Many of the previous music intervention studies in
adults postoperative pain management have methodological variations. A literature review (Table 1) reveals
that there are only few music intervention studies
between 2006 and 2010 that have used pretestposttest
control group designs.4,8,10 The calculation used to determine sample size is not always declared.6,9,10 More
sparsely used interests are respiratory rate,8 anxiety5,10
and assessing the effects of music listening on both pain
intensity and pain distress.4 Only one study held a different position,6 and one study evaluated the duration of the
effect of music listening.6 There are also variations in the
type of music employed: Patients favourite music,11
music chosen from a list musical genres4,5,9,10 or music
provided by researchers.8 In music intervention studies
between 2006 and 2010, qualitative data about patients
experiences listening to music have not been evaluated
systematically. Often statistically significant change
obtained from quasi-experimental designs has been
accepted as evidence. According to literature, qualitative
approaches can benefit as a rich source of data that allows
the experience of the subjects to be reported and can be
used with quantitative data by providing information
about intervention utility.
Complex clinical interventions include several components and are difficult to describe, standardize, reproduce
and administer consistently to all patients. They work best
if tailored to local circumstances and should include a
detailed description of the intervention.15 In the previous
music intervention studies, there is little information
or discussion about difficulties or problems that the
researcher has had by implementing intervention in
nursing practice. However, this type of information is
valuable to other novice researchers in order to consider
solutions in advance. Little is known about music as a

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non-pharmacological intervention in patients with major

abdominal surgery. Despite the increased research evidence for music listening as an intervention for relieving
pain and enhancing well-being during recovery, clinical
nurses make very limited use of music.
According to the literature, the reporting of nonpharmacological trials is not generally adequate. The Consolidated Standards for Reporting Trials (CONSORT)
checklist contains a set of recommendations for the
reporting of randomized, controlled and quasiexperimental trials 16 The purpose of this paper is to point
out challenges and practical solutions through a quasiexperimental study process concerning music listening
after major abdominal surgery in adults pain management
using the methods established by the CONSORT.

METHODS
Study design
A quasi-experimental repeated measure, pretestposttest
design,4,8,10 was used to evaluate the effect of listening to
music on pain intensity and pain distress during bed rest,
during deep breathing and position shifting, physiological
parameters such as blood pressure, heart rate and respiratory rate, analgesia, adverse effects and length of hospital stay after major abdominal surgery. Patients were
allocated into either the music group or the control group
using an alternate week arrangement until each group had
at least 83 patients. The following hypotheses were
tested.
Patients in the experimental group who get standard
care and listen to music after surgery have less pain intensity and pain distress; have lower systolic and diastolic
blood pressure, heart rate and respiratory rate; have less
analgesic use, shorter hospital stays and will experience
less adverse effects than those in the control group.
In addition after every music intervention patients
experiences of music listening were written down. In the
paper, we describe patients experiences on music listening by using qualitative data.

Participants and setting

It is important to specify the target population clearly
because there are certain subgroups that are much more
or much less likely to be interested in participating in a
music intervention study. The use of music listening after
surgery has grown in recent years. It is also important to
assess participants characteristics because people who
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A Vaajoki et al.

Table 1 Music intervention studies in adults postoperative pain management carried out in 20062010
Author(s)

Music intervention

Sample

Outcome measures

Main results

Allred et al. 20108

USA

Music group: Easy-listening

music on 1, postop, before
and after ambulation.
Control group: Rest in silence
Prepost measures
Music group: country,
easy-listening, gospel or rock
music during PACU stay.
Control group: No music

Total knee joint

n = 56
Power-analysis

VAS pain
Bp, HR, RR,
SpO2
Analgesia
Listening experience
DOS pain
Analgesia
Bp, HR, RR,
SpO2
Satisfaction

There were no statistical findings

between groups in outcome
measures.

Sen et al. 20106

Turkey

Music group: Patients favourite

music 1 h after surgery
Control group: No music

Caesarean section
n = 70

Ebneshahidi et al.
20085
Iran

Music group: Patients favourite

music during PACU stay.
Control group: Headphones, no
music
Music group: Ballads, religious,
piano, orchestra music on the
1st and 2nd postoperative
day.
Control group: Bed rest
Prepost measures
Music Group: Easy listening,
jazz, classical music on the
1st, 2nd and 3rd
postoperative day.
Control group: Bed rest
Prepost measures
Music group: Favourite music
from the list after surgery
1h 4/day.
Control group: No music

Caesarean section
n = 80
Power-analysis

Easter et al. 201011

USA

Good and Ahn 20084

Korea

Sendelbach et al.
200610
USA

McCaffrey and Locsin

20069
USA

Day surgery
n = 213
Power-analysis

VAS lying and sitting

position
Bp, HR, RR
VRS (sedation, nausea,
vomiting)
Analgesia
Satisfaction
VAS pain/anxiety
Bp, HR
Analgesia

There were no statistical findings

between groups in pain or
physiologic parameters. Patients
in the music group were more
satisfied with their PACU stay
compared with the control
group.
In the music group, pain in sitting
and lying position and analgesic
use were lower after surgery
compared with the control
group.

Gynaecologic surgery
n = 73
Power-analysis

VAS pain

In the music group, the pain

intensity and analgesia used were
significantly lower compared
with the control group.
Significantly lower pain intensity
and pain distress in the music
group were reported on both
postoperative days compared
with the control group.

Cardiac surgery
n = 86

NRS pain
STAI
Bp, HR
Analgesia

In the music group, patients were

less anxious and their pain
intensity was lower compared
with the control group.

Hip and knee surgery

n = 124

NRS pain
Analgesia
Confusion
Ambulation after
surgery
Satisfaction

In the music group, patients pain

intensity was lower, they needed
less analgesia, the patients acute
confusion reduced, ambulation
improved and satisfaction scores
were higher after surgery.

Bp, Blood pressure; DOS pain, Descriptive ordinal scale; HR, Heart Rate; NRS, Numeric Rating Scale; PACU, Post Anesthesia Care Unit; RR,
Respiratory Rate; SpO2, Saturation of Peripheral Oxygen; STAI, State Trait Anxiety Inventory; VAS, Visual Analogue Scale; VRS, Verbal Rating
Scale.

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Music intervention study

agree to participate have strong preferences for using

music and might not agree to randomization.17
Inclusion criteria for this study were as follows: Patient
underwent major upper abdominal incision, had epidural
analgesia after surgery, an estimated hospital stay of at
least 4 days, and an anaesthesia physical status classification of 13. Exclusion criteria were drug abuse, psychiatric disorders, hearing impairment, dementia, chronic
pain problems or patients admitted to other departments
after surgery. Inclusion and exclusion criteria were the
same in the music group and the control group.
Twenty-two patients refused to participate, from
which one patient refused to participate because he or she
should have listened to music and one refused because he
or she belonged to the control group. Fifteen patients
stopped because they were very tired or the surgeon had
given them bad news after the operation. For research
reasons, 19 patients were excluded, for example, they
were not given epidural analgesia despite the anaesthesia
plan, and 46 patients met the exclusion criteria.
A calculation of the required sample size was based on
the power analysis18 with respect to the visual analogue
scale (VAS) pain scale.5,11 A mean of 3.5 and a standard
deviation of 2.4 were expected. A clinically significant
difference of 30% and a statistically significant level of
a = 0.05 were expected. With a power of 80%, a sample
size for each group of 83 patients (n = 166) was calculated
as appropriate.19

Outcome measures
Treatment fidelity is of integral importance when delivering music intervention and control. The CONSORT
checklist requires both primary and secondary outcomes
and how and when data on the outcomes were collected.
Seven main outcome measures were employed in this
music listening intervention: Pain intensity and pain distress4 with VAS,5,8 numeric rating scale (NRS),9,10 blood
pressure and heart rate5,7,11 with OMRON M5-I of
OMRON M6 (Dalian, China) and respiratory rate8,11 by
counting the number of times the patients chest rose
and fell for 1 min. The amount of analgesia5,11 used and
adverse effects during the first 72 h after the operation,
the duration of epidural pain management and the time
epidural catheter was removed were measured. Each participants length of hospital20,21 stay was measured in days
from the day of admission to discharge from the hospital.
Secondary outcome measures were patients experiences
about music listening. After each of seven interventions,

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if patient described or commented on listening to music

experience, it was recorded. On the third postoperative
day, participants completed the questionnaire, which was
developed by the researchers. It consisted of both structured and open-ended questions about the patients music
exposure frequency, musical background,6,22 favourite
music, postoperative pain experiences before this
surgery23 and pain management experiences after abdominal surgery.24 The questionnaire was pilot tested and
modified accordingly before the study. Data collection
and outcome measures were done by one researcher.

Music intervention procedure

Details of the intervention for each group of the trial
and how and when the interventions were administered
include the number of sessions of the intervention, the
duration of each session, the amount of time between
sessions, how the control has disguised and who delivered control (usual care) and interventions. Also, where
the intervention will be executed must be carefully
considered.
Cooperation, discussions with nurse staff and their
information are paramount when developing and planning
a music intervention.18 In this study, there was no research
assistant; rather, one researcher (AV) executed the music
intervention. The reasons for that were not only limited
staff and financial resources but also that researcher
wanted methodological experience from the complex
clinical music intervention process.25,26
In this study, the basis for the pilot work and existing
literature music listening time was 30 minutes, and the
intervention was repeated in the evening of the operation
day, in the morning (89 am), at noon (1315 pm) and in
the evening (1820 pm) on the first and second postoperative days, seven times in total. On the third postoperative day, music was not played, but measures were taken
once to evaluate the long-term effects of music listening.
The control group did not listen to music but they had a
30-min break between pre- and posttests and at all the
same phases as the music group. During the 30-min break,
the control group patients were asked not to listen to
music. Intervention was carried out in the patients room
together with the departments daily rounds. Each patient
in both groups had 15 assessments, seven times before
and seven times after intervention, and one during the
follow-up visit (Fig. 1).
The subjects consisted of all patients who were scheduled for a major abdominal surgery that met inclusion
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A Vaajoki et al.

Operation Day
Evening
6-8 p.m.

First and Second Postoperative Day

Morning
Afternoon
Evening
8-9 a.m.
1-3 p.m.
6-8 p.m.

Third Postoperative Day

Afternoon
12-4 p.m.

Music
Group
n = 83

Pretest
Posttest

Pretest
Posttest

Pretest
Posttest

Pretest
Posttest

Final test

Control
Group
n = 85

Pretest
Posttest

Pretest
Posttest

Pretest
Posttest

Pretest
Posttest

Final test

6-8 p.m.
Evening
Operation Day

8-9 a.m.
1-3 p.m.
6-8 p.m.
Morning
Afternoon
Evening
First and Second Postoperative Day

12-4 p.m.
Afternoon
Third Postoperative Day

Figure 1 Study design. Repeated pretest

and posttest measures with a music group and
a control group during 25 months.

criteria. According to a yearly calendar from the starting

point of the study, patients were enrolled in the music
group or to the control group via an alternate-week
arrangement so that music was listened to every second
week until each group had at least 83 patients. This assignation process was determined before the pilot study.
Participants were screened from departments operation plan lists every week, and the researcher counted
patients who potentially met the inclusion criteria and
examined the final operation and anaesthetic plan. The
researcher interviewed and informed patients prior to the
day of surgery, which lasted an average of 1 h. Patients
were told whether they belonged to the music group or
the control group. The participants were given their
favourite music in the light of discussions with the music
therapist and based on earlier literature.22 There were two
sets of headphones (Sennheiser HD 555, Tullamore,
Ireland and AKG K28NC, Vienna, Austria) and MP3players (Apple iPod 8GB, CA, USA). Different selections
of the most popular and classic music in Finland were
recorded, and songs were written to the file from which
the participants chose their favourite music. Selections of
music were added according to participants wishes
during the study. The music alternatives were domestic or
foreign hit songs, dance, pop, rock, soul, blues, spiritual
or classical music. The researcher discussed music preferences with the participants and presented a music list prior
to the day of surgery.

Ethical approval
Ethical considerations were a very important part of the
intervention study. In this study, before data collection,
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the study was approved in June 2007 by the Research

Ethics Committee Hospital of the District of Northern
Savo 6/2007. Before and during data collection, the staff
received information about the study and its progress by
the researcher. All participants were given a written
informed consent form. Participation was voluntary, and
refusing to participate did not affect the care received
during hospitalization. It was also possible for the patient
to stop without providing a reason.

Data analysis
The specification requirements of the statistical methods
were used to produce an estimate of the effect of the
intervention. Data were recorded, and a statistical analysis
was carried out using the Statistical Package for Social
Sciences (SPSS 16.0 for Windows, SPSS Inc., Chicago, IL,
USA) software. Frequencies and percentages were used to
describe the demographics of patients and the adverse
effects of epidural analgesia. The c2 test was used to
examine the independence of the treatment group assignment. The KolmogorovSmirnov test was used to
examine the normality of the continuous data. The results
suggested that non-parametric tests were appropriate.
The parametric test analysis of variance was used for
repeated measurements to analyse pain intensity, pain
distress, systolic and diastolic blood pressure, heart rate
and respiratory rate over time between the two groups.
The duration of anaesthesia, surgery, postanaesthesia care
unit stay, epidural analgesia and the long-term effect of
music on systolic and diastolic blood pressure, heart rate
and respiratory rate were analysed using the nonparametric MannWhitney U-test for independent groups. The

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211

duration of epidural analgesia and the length of hospital

stay were also analysed using the KaplanMeier test. Differences were regarded as statistically significant if the
two-sided P-value was less than 0.05. The content analysis
was conducted about patients music listening experiences. The data of content analysis were quantified within
categories: how many patients described music listening
experiences in a particular way. Same patient was able to
use many different descriptions of their experiences.
Because the missing data totalled over 50%, the operation day was dropped from the analysis. The main reason
for this was that patients were discharged from postanaesthesia care unit late in the evening because of major
abdominal cancer surgeries. Patients were also extremely
tired from the operation, anaesthesia and analgesia. On
the third postoperative day, one patient in the control
group suffered from delirium and could not complete the
questionnaire, and the researcher could not measure pain
or physiological parameters on that day.

RESULTS
First, the hypothesis that patients in the experimental
group who receive standard care and listen to music after
surgery have less pain intensity and pain distress than
those in the control group was partially supported. On the
second postoperative day, after intervention, pain intensity and pain distress were significantly lower in the music
group compared with the control group.27
Second, the hypothesis that patients in the experimental group who receive standard care and listen to music
after surgery have lower systolic and diastolic blood pressure, heart rate and respiratory rate than those in the
control group was partly supported. On the first and
second postoperative day, after intervention, respiratory
rate and systolic blood pressure were significantly lower
in the music group compared with the control group. On
the third postoperative day, when there was no intervention, respiratory rate was significantly lower compared
with the control group.28
Third, the hypothesis that patients in the experimental
group who receive standard care and listen to music after
surgery have less analgesic use, experienced less adverse
effects and shorter hospital stay than those in the control
group was not supported.29
After seven music interventions 55/83 (66%), patients
commented spontaneously on music listening. Twentyeight patients (51%) said that music was lovely and they
liked it. Twenty (36%) patients fell asleep or experienced

that music listening had sleepy effect. Listening to music

was good or excellent experience according to 17 (31%)
patients. Sixteen (29%) patients experienced relaxed after
listening to music. Sixteen (29%) patients said that music
distracted from pain and away from hospital environment.
Ten (18%) patients commented that time passes quickly
by listening to music. Seven patients (13%) commented
that the ward environment disturbance their music listening, and two patients (4%) said that pain was too severe to
focus on music.

DISCUSSION
Based on the researchers experiences while conducting
the music intervention in a complex clinical environment,
there are certain methodological weaknesses, strengths
and challenges that need to be addressed. First, due to the
inexperience of researcher, the participants were not randomly assigned to the music and control groups. Despite
this, the groups baseline characteristics were comparable, and according to literature, if the changes are very
small or take a very long time to appear, a nonrandomised design is a feasible option.30 In this study, data
collection continued for 25 months. Second, the
researcher and participants were not blinded to group
assignments, and the presence of the researcher throughout the procedure might have influenced the participants
to offer more positive responses. In both groups, those
who answered the open question said that participating
in the study was a positive experience. However, the
researcher could not influence participants physiological
parameters, length of hospital stay, analgesic use or
adverse effects of analgesic. It has to be taken into account
that perhaps these were not the most adequate parameters
where can evaluate music listening effects. It is also known
that, when the treatment is non-pharmacological, blinding is more difficult.31 Because the music intervention was
executed every second week, the remote possibility exists
that the participants discussed the study with each other.
Moreover, in most cases, the participants were positioned
in separate rooms. Third, the music intervention took
place in the patients rooms during the daily routines of
normal nursing practice, and patients were occasionally
disrupted during the intervention. These interruptions,
for example, doctors rounds, nursing actions, telephone calls or visits by relatives, occasionally disturbed
and irritated patients and might affect their physiological
parameters.
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The strengths of this study were that the sample size

was based on a power analysis, and the intervention was
pilot tested with 10 patients using similar patients and
settings to those in which the intervention would be
used to test instructions, usability measurements,
data collection, study design and unanticipated effects.30
One researcher, who has extensive previous experience
working on a surgical ward, collected all the data over a
25-month period. The principal researcher knows the
data well and has solid knowledge about and experience
with executing a music intervention study.26 Patients
commitment to participating in the study was paramount.
They assessed pain intensity and pain distress using two
pain scales (VAS and NRS) in different positions (in rest,
deep breathing and shifting position) 12 times before and
after each intervention. On the other hand, the researcher
provided full attention to each patient during the study
and did not hurry the patient. The pain assessment and
physiological parameters were always taken the same
way. The VAS and NRS used in this study are reported
to be sensitive14,32 in assessing the efficacy of nonpharmacological interventions. The same blood pressure
and heart rate monitors were used on the ward, and
monitors were calibrated once a year. Also, the questionnaires were pretested with the pilot study in gastrointestinal surgical patients.
These results cannot be generalized because all data
were collected in only one hospital. However, our data
support the earlier findings that indicate that music
listening can be a beneficial adjuvant to other nonpharmacological and pharmacological pain relief methods.33 Our qualitative data also support findings that
listening to music has distraction effect from pain1,2 and
enhances the mood.3 This music intervention study with
repeated pretest and posttest setting and outcome measurements can be applied to other surgical patient groups.
Further studies are needed to evaluate the optimal time
for music listening so that patients can self-administer
music therapy after surgery. Also, a greater emphasis
should be placed on evaluating patients experiences and
self-reports about music listening experiences in the
future.
In summary, planning and executing an intervention is
time consuming, requiring extensive preparation and a
great deal of forethought. In addition, it requires skill in
working with patients, practitioners, administrators, data
analysts, representatives of different professions and disciplines and a deep understanding of practice. In essence,
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A Vaajoki et al.

the researcher must be prepared for unexpected changes.

Another challenge is also how this music intervention
will be implemented in nursing practice to contribute to
the health and well-being of all patients. Although the
intervention study faced several challenges, it is also
rewarding and an extremely good way to develop the
nursing practice.

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