Title Page

THE EFFECTS OF MUSIC AND NATURE SOUNDS ON CANCER PAIN AND

ANXIETY IN HOSPICE CANCER PATIENTS

by

LING-CHUN CHIANG

Submitted in partial fulfillment of the requirements

For the degree of Doctor of Philosophy

Dissertation Advisor: Marion Good, PhD, RN, FAAN

Frances Payne Bolton School of Nursing

CASE WESTERN RESERVE UNIVERSITY

January, 2012

ii

Committee Signature Page

CASE WESTERN RESERVE UNIVERSITY

SCHOOL OF GRADUATE STUDIES

We hereby approve the thesis/dissertation of

Ling-Chun Chiang

Candidate for the Doctor of Philosophy degree*:

Marion Good, PhD, RN, FAAN

Barbara J. Daly, PhD, RN, FAAN

Christopher J. Burant, PhD

Deforia Lane, PhD, MT-BC

August 29, 2011

*We also certify that written approval has been obtained for any proprietary material

contained therein.

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Copyright © 2012 by Ling-Chun Chiang

All rights reserved

iv

Dedication

This dissertation is dedicated to those patients and their families who participated in my

study by showing me their bravery and generosity to life.

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Table of Contents Title Page ............................................................................................................................. i Committee Signature Page .................................................................................................. ii Dedication .......................................................................................................................... iv Table of Contents ................................................................................................................ v List of Tables ...................................................................................................................... ix List of Figures ..................................................................................................................... x Acknowledgement ............................................................................................................. xi Abstract ............................................................................................................................ xiii Chapter One Introduction ................................................................................................... 1

Problem ........................................................................................................................... 3 Significance..................................................................................................................... 5 Intervention ..................................................................................................................... 6 Conceptual Framework ................................................................................................... 7 Summary of Literature .................................................................................................. 10 Assumptions .................................................................................................................. 11 Hypotheses .................................................................................................................... 11 Research Questions ....................................................................................................... 11 Conclusion .................................................................................................................... 12

Chapter Two Review of Literature .................................................................................... 13 Cancer Pain ................................................................................................................... 13

Pathophysiology and mechanisms of cancer pain. ................................................... 13 Cancer pain in hospice patients. ................................................................................ 21 Cultural issues. .......................................................................................................... 26

Anxiety .......................................................................................................................... 29 Pathophysiology and mechanisms of anxiety. .......................................................... 31 Anxiety in hospice cancer patients. .......................................................................... 32 Cultural issues. .......................................................................................................... 36

Cancer Pain and Anxiety ............................................................................................... 39 Music for Pain and Anxiety .......................................................................................... 40

Mechanisms of music for pain and anxiety. ............................................................. 41 Effects of music on pain. .......................................................................................... 42 Effects of music on pain in cancer and hospice patients........................................... 44

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Effects of music on anxiety. ...................................................................................... 45 Selection of music. .................................................................................................... 47

Nature Sounds ............................................................................................................... 49 Combination of Music and Nature Sounds ................................................................... 51 Threats to Internal Validity ........................................................................................... 53 Summary of Literature Review ..................................................................................... 57

Chapter Three Method ...................................................................................................... 58 Design ........................................................................................................................... 58 Sampling ....................................................................................................................... 61

Sample size estimation. ............................................................................................. 61 Inclusion and exclusion criteria. ............................................................................... 61

Setting ........................................................................................................................... 62 Experimental Interventions ........................................................................................... 64

Music......................................................................................................................... 64 Nature sounds............................................................................................................ 65 Combination of music and nature sounds. ................................................................ 66 Equipment. ................................................................................................................ 66

Measures ....................................................................................................................... 67 Cancer pain. .............................................................................................................. 67 Anxiety. ..................................................................................................................... 69 Demographic measures. ............................................................................................ 71 Types of music and nature sounds generally liked. .................................................. 71 Experience with complementary and alternative therapies. ..................................... 71 Length of time and reasons for independent listening. ............................................. 72

Potentially Confounding Variables ............................................................................... 73 Analgesic and anxiolytics intake. ............................................................................. 73 Environmental disturbances. ..................................................................................... 74 Religious chanting box. ............................................................................................ 74

Procedure ...................................................................................................................... 75 Protection of Human Subjects ...................................................................................... 80 Data Management ......................................................................................................... 81 Data Cleaning................................................................................................................ 82 Assumptions of Statistical Tests ................................................................................... 82 Data Analysis ................................................................................................................ 84

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Hypotheses testing. ................................................................................................... 84 Research questions. ................................................................................................... 86

Summary ....................................................................................................................... 86 Chapter Four Results......................................................................................................... 88

Sample........................................................................................................................... 88 Demographic characteristics. .................................................................................... 89 Experience with complementary and alternative therapies. ..................................... 90 Primary sites of cancer. ............................................................................................. 92 Cancer pain and anxiety in hospice patients. ............................................................ 93

Medication Usage ......................................................................................................... 95 Analgesics and Anxiolytics Used by Participants ......................................................... 95 Pain and Anxiety Pretests and Posttests ........................................................................ 96 Correlations ................................................................................................................... 97 Hypothesis Testing ........................................................................................................ 99 Participants’ Suggestions ............................................................................................ 105 Summary ..................................................................................................................... 109

Chapter Five Discussion ................................................................................................. 110 Summary of the Study ................................................................................................ 110 Comparison with the Literature ................................................................................... 111

The effect of music on pain...................................................................................... 111 The effect of nature sounds on pain. ....................................................................... 114 The effect of nature sounds on anxiety. .................................................................. 115 The effect of the combination on pain and anxiety. ................................................ 115 Preferences for music, nature sounds, and combination. ........................................ 116 Length of independent listening.............................................................................. 117 Relationship between pain and anxiety. .................................................................. 118

Rationale for the Outcomes of Music, Nature Sounds, and Combination .................. 118 Limitations .................................................................................................................. 121 Implications for Theory .............................................................................................. 123 Implications for Research ........................................................................................... 124 Implications for Practice ............................................................................................. 126 Conclusion .................................................................................................................. 127

Appendix A ..................................................................................................................... 129 Appendix B ..................................................................................................................... 130

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Appendix C ..................................................................................................................... 148 Appendix D ..................................................................................................................... 166 Appendix E ..................................................................................................................... 167 Bibliography ................................................................................................................... 168

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List of Tables Table 1 Example of Sequence for Assigning Treatment Conditions to Room 59

Table 2 Data Points Table 78

Table 3 Orthogonal Contrasts Table 85

Table 4 Demographic Characteristics of the Participants 91

Table 5 Experience with Complementary and Alternative Therapy 92

Table 6 The Primary Sites of Cancer 93

Table 7 Participants Analgesics and/or Anxiolytics “in Effect” During Each Test 96

Table 8 Pain and Anxiety Pretests and Posttests at Each Test 97

Table 9 Correlations between Pain and Anxiety Pretests and Posttests 98

Table 10 Effect Sizes of Pain and Anxiety by Groups 100

Table 11 Types of Music, Nature Sounds Liked at Onset of the Study 103

Table 12 Intervention Liked by the Participants 105

Table 13 Types of Music and Nature Sounds Selected by Participants by Day 106

Table 14 Minutes of Independent Intervention Use Between Testing Times 107

Table 15 Adjusted R Square between Pain and Anxiety Pretests and Posttests

by Day 108

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List of Figures Figure 1 The Conceptual Framework of this experimental Study 2

Figure 2 Conceptual-empirical Structure 8

Figure 3 Equipment Used in This Study 67

Figure 4 The Study Procedure 79

Figure 5 Pain Posttests by Groups 100

Figure 6 Anxiety Posttests by Groups 102

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Acknowledgement

Such a work cannot be done by a person alone. Many thanks to God and those

people who have stood behind me to complete this rewarding life journey.

However, first and foremost, I would like to thank the members of my dissertation

committee: my committee Chair and former advisor, Dr. Marion Good, for her

inexhaustible patience and invaluable guidance and assistance to be my mentor

scholarly, professionally, and personally; Dr. Barbara Daly, my current advisor and

committee member, my sincere gratitude for sharing her expertise and wisdom in

palliative care and ethics which provided an encouraging and steady path of clarity

to many complex issues; Dr. Christopher Burant for his optimism and reassurance

when I faced numerous challenges; and Dr. Deforia Lane for her unstinting

generosity in sharing her expertise and dedication to music therapy.

This study was also made possible by the support of several thoughtful

individuals in Taiwan. I sincerely appreciate Dr. Chi-Chun Chin, an associate

professor of the College of Nursing at Kaohsiung Medical University, for her

substantial assistance in the IRB process. In addition, the head nurses and staff

nurses at Kaohsiung Medical University Hospital and St. Joseph Hospital,

especially Yu-Wen Huang and Hsiao-Wen Su, for trusting in me to refer their

patients. Finally, Jung-Chun Chang and Chen-Ping Tseng for sharing their

thoughts from different perspectives and making me feel welcomed during the

data collection process.

I would like to express my love and gratitude to my family. To my parents,

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Kuan-Shun Chiang and Hsing-Tzu Liang, for giving me their steadfast support and

teaching me the value of education; my sister, Dr. Ling-Yu Lenny Chiang-Hanisko

and brother-in-law, Jerry Hanisko, for being available for me no matter how busy

they were; my brother, Ling-Chieh Chiang, for taking care of our parents and

helping with the family farm in my absence; and my husband, Matthew McManus,

for bringing his greatest love and patience to me and making my life complete.

My appreciation also goes to my dearest friends, Dr. Jung-Ying Tan, for being

my close friend and sensitive guiding companion who helped me share the passion

for life and strive for perfection during the challenging demands of research and

writing, and to Dr. Emily Liu, Dr. Wariya Muensa, and Dr. Tsai-Yi Au, who kept

me energized and rejuvenated through their unconditional friendship.

This educational journey could not have been possible without the support of

my colleagues at the School of Nursing, HungKuang University (HKU). I would

like to express my gratitude for the financial support provided by HKU and the

Ministry of Education, Taiwan in granting the University Faculty Scholarship

Award. I would also like to thank to Dr. Katherine Jones and Dr. Noreen Brady for

the scholarship support and the enriching opportunities to work at Sara Cole Hirsh

Institute. Finally, I would like to acknowledge the generous funding I received

from Oncology Nursing Society Foundation / Purdue Pharma Trish Greene Pain

Assessment and Management Research Grant and the Sigma Theta Tau

International Alpha Mu Chapter Research Award.

xiii

The Effects of Music and Nature Sounds on Cancer Pain and Anxiety in Hospice Cancer Patients

Abstract

by

LING-CHUN CHIANG

Cancer has been the leading cause of death in Taiwan. Cancer patients who receive

hospice care frequently suffer from pain and anxiety during the dying process. Analgesics

are needed but their side effects can increase suffering and decrease quality of life. The

purpose was to test the effectiveness of sedative music, nature sounds, and the

combination of music and nature sounds for cancer pain and anxiety in hospice cancer

patients in Taiwan. The conceptual framework was based on the Good and Moore middle

range theory of acute pain. A four-group randomized controlled trial using cluster and

adaptive randomization was used with 117 cancer patients in hospice units of two large

hospitals in Taiwan. Participants in the intervention groups listened to music, nature

sounds, or a combination of both for 20 minutes once a day for three days, using MP3

players and earphones or speakers. Participants in the control group lay or sat quietly for

20 minutes, but received a CD of their choice when the data collection process was

completed. The choices of sedative music included classical, piano, harp, religious, easy

listening, Chinese, and Taiwanese music. Nature sounds and the combination of sedative

music and nature sounds were selected from commercially available CDs in Taiwan.

Cancer pain and anxiety were measured before and after each treatment with 100-mm

visual analogue scales. Data were analyzed by multiple regression repeated measures

ANCOVA, using contrasts. The results showed that while controlling for Day 1 pretests,

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the three intervention groups had significantly less pain and anxiety than the control

group, p < .001. Music and combination had medium to large effect sizes on pain and

anxiety. Nature sounds had small to large effect sizes for pain and small to medium for

anxiety. Participants selected Taiwanese folk music and forest sounds most frequently

and used the interventions independently for an average of four hours. Recommendations

are to test the interventions for four or more days and to extend the study to home hospice

settings. Staff nurses can use music, nature sounds, and combination for pain and anxiety

in hospice patients along with analgesics.

1

Chapter One

Introduction

Cancer pain and anxiety have not been managed well among hospice cancer patients

(Bonica, 1990; Chiu, Hu, & Chen, 2000; Lawrie, Lloyd-Williams, & Taylor, 2004;

McCarthy, Phillips, Zhong, Drews, & Lynn, 2000). When patients are in the advanced

cancer stage and during the dying process, cancer pain and anxiety may become more

complicated and difficult to manage with current medication. Undertreated cancer pain

and anxiety often have a reciprocal effect, and both may exacerbate other physical

symptoms and psychosocial distress (Lancee, et al., 1994). Unresolved or undermanaged

cancer pain and anxiety in hospice patients may result in decreased quality of life (S. S.

Hwang, Chang, & Kasimis, 2002; Kutner, Bryant, Beaty, & Fairclough, 2006).

Furthermore, seeing the loved one dying in agony may cause family caregivers to suffer

from emotional distress that may result in a prolonged grieving process and even physical

or psychosocial disorders (McPherson & Addington-Hall, 2004). These consequences

may either directly or indirectly increase healthcare system cost.

Music can touch a person on physical, psychosocial, emotional, and spiritual levels

(Munro & Mount, 1978). Incorporating music into nursing care may attenuate suffering

from physical symptoms, psychosocial and emotional distress, and spiritual or religious

concerns in hospice cancer patients (V. T. Chang, et al., 1998; Chibnall, et al., 2002; Hills,

et al., 2005; Lo, et al., 2002). Studies on the use of music in clinical settings have

demonstrated that it is an effective nonpharmacological adjuvant for reducing suffering

from postoperative pain (Good et al., 1999; Locsin, 1981; Voss et al., 2004), cancer pain

(Beck, 1991; Gallagher & Steele, 2001; Krout, 2001, 2003; Zimmerman, Pozehl, Duncan,

2

& Schmitz, 1989), and anxiety in hospice cancer patients (Gallagher & Steele, 2001;

Krout, 2003). In Taiwan, a few research studies of the effect of music have been

conducted for managing postoperative pain (S. L. Hwang, Chang, Lee, Ko, & Chu, 1996;

D. F. Lee, 1995; Yao, 1998), cancer pain (S. H. Huang, 2000; S. T. Huang, 2006; Hung,

2003; Y. J. Lee, 2000a; P. I. Peng, 2005) and anxiety in cancer patients (Hung, 2003;

Peng, 2005). However, none of these studies were conducted with Taiwanese hospice

cancer patients near the end of life and none were focused on using music for both pain

and anxiety relief.

In addition to music, nature sounds may have some beneficial effect on pain and

anxiety. This may be especially true in Taiwan, where nature sounds are closely

connected to people’s daily lives, but are not usually heard in the hospital setting. Gentle

nature sounds may offer a sense of peace to dying patients (Schrodeder-Sheker, 1994).

No studies of nature sounds were found in Taiwan. Therefore, the purpose of this study

was to test the effectiveness of sedative music, nature sounds, and the combination of

sedative music and nature sounds in relieving cancer pain and anxiety among hospice

cancer patients in Taiwan (Figure 1). It was hypothesized that these three interventions

would decrease cancer pain and anxiety among hospice cancer patients. The results of

this study may not only contribute to the body of nursing knowledge, but also may

improve the quality of life at the end of life among hospice cancer patients.

Figure 1. The Conceptual Framework of this Experimental Study

Music Nature Sounds Combination

Cancer Pain

Anxiety

_

_

3

Problem

Cancer has been the leading cause of death in Taiwan for the past two decades. An

estimated 80% of the world population receives inadequate treatment for cancer pain

relief (A. L. Taylor, Gostin, & Pagonis, 2008). About 75% to 81% of hospice patients

suffer from pain during the dying process (Bonica, 1990; Chiu, et al., 2000; H.-C. Hsu,

Hu, Chuang, Chiu, & Chen, 2002). During the last three days of life, more than 40% of

cancer patients were reported to be in serious pain (McCarthy, et al., 2000). Unfortunately,

cancer pain among hospice patients is not managed well and is frequently associated with

anxiety (Kerrihard, Breitbart, Dent, & Strout, 1999; Massie & Holland, 1987). Before

1990, hospice care was not available for cancer patients who were in the terminal stage.

Today, National Health Insurance in Taiwan covers hospice care for cancer patients who

have less than six months to live. Yet, managing symptoms that hospice cancer patients

encounter remains a major challenge for healthcare professionals (M. B. Chen, et al.,

2004; M. L. Chen & Tseng, 2006). Cancer pain and anxiety have been reported to be the

most common symptoms that hospice patients experience (Newell, Swanson-Fisher,

Girgis, & Ackland, 1999; J.-S. Tsai, Wu, Chiu, Hu, & Chen, 2006).

Anxiety, a common symptom experienced by cancer patients, can be associated with

fear of pain, the dying process, and death (Newell, et al., 1999; Portenoy, Payne, &

Jacobsen, 1999). Multiple research studies indicated that 66% to 77% of terminally ill

cancer patients reported moderate to severe anxiety between admission to hospice care

and the day before death ((M. L. Chen & Tseng, 2006; Ewing, et al., 2004; Georges,

Onwuteaka-Philipsen, van der Heide, van der Wal, & van der Maas, 2005; J.-S. Tsai, et

al., 2006). Anxiety is less easily identified clinically because it is frequently

4

overshadowed by other symptoms, overlooked by healthcare professionals, and

underreported by hospice cancer patients.

Unresolved or undermanaged cancer pain and anxiety in hospice patients may result

in unwanted symptoms, decreased quality of life, and increased distress during the dying

process (Lancee, et al., 1994). In palliative care settings, when patients have more

symptoms, their family caregivers have a higher level of burden and emotional distress

(Andrews, 2001). For example, in interviews conducted after a patient has died, the

family members reported that their loved one had moderate to severe pain more than 50%

of the time during the final three days of life. They said that watching their loved one

dying in agony made them feel emotionally traumatized (The SUPPORT Principal

Investigators., 1995). Caregivers may have a higher risk of a prolonged grieving process

and negative physical and psychosocial sequalae (Hudson, 2003). These may require

health-related treatments or consultations, which may increase costs in the healthcare

system. Moreover, being unable to manage patients’ symptoms and seeing their suffering

may increase stress in healthcare professionals and increase the possibility of early

attrition from the healthcare system (N. Payne, 2001).

In order to manage cancer pain and anxiety, prescribed opioids are primarily used in

healthcare settings. However, hospice patients may suffer from undesired side effects

from medication and refuse to take it in the amount needed to reduce their pain. Studies

have shown that cancer patients have multiple barriers to pain management in terms of

their attitudes and knowledge. They worry about addiction and tolerance from taking

opioid medication, are afraid of the unmanageable side effects, and fear they are not

being a “good” patient (Hodes, 1989; Jacox, et al., 1994; Sun, et al., 2007; Ward, et al.,

5

1993). In Taiwan, cancer patients reported similar misconceptions and were reluctant to

take the amount of medication they needed (C. C. Lin, 1998, 2000; C. C. Lin & Ward,

1995). Opioid analgesics in Taiwan can be quite costly and may be less accessible than

nonpharmacological adjuvants (Bureau of National Health Insurance, 2008), even though

they are recommended (Miaskowski, et al., 2009). Music can be added to enhance the

effect of analgesics and anxiolytics medication in hospice patients. Music usually has no

side effects. Unfortunately, few studies of using music for managing cancer pain or

anxiety have been done in Taiwan and most healthcare professionals do not recognize

music as an available and effective nonpharmacological adjuvant. Hence, the lack of

music in hospice settings may decrease the opportunity for cancer patients to receive

better quality of care.

Significance

The significance of the findings from the proposed study is fourfold. First, the

findings will be important to improve hospice cancer patients’ physical comfort and

decrease emotional distress in the end-of-life process. Second, the results will expand

nursing knowledge of the effectiveness of nonpharmacological adjuvants by adding a

Taiwanese cultural perspective. Third, since nursing is a profession that provides patients

with holistic care, the use of music, nature sounds, and the combination of music and

nature sounds may add to the cancer patients’ pleasure during the terminal stage of their

illness. Fourth, the results of this study will provide knowledge and evidence to extend

the middle range theory of a balance between analgesia and side effects from acute

postoperative pain to cancer pain in a hospice population.

6

Intervention

Music, nature sounds, and the combination of music and nature sounds are the

interventions that were tested in this study. In order for music to have a therapeutic effect,

matching the music to the health-related purpose is very important (Guzzetta, 1989).

Multiple researchers have used relaxing or sedative music with cancer or hospice patients

and have reported its effectiveness in decreasing cancer pain (Beck, 1991; Gallagher,

Lagman, Walsh, Davis, & Legrand, 2006; Gallagher & Steele, 2001; S. H. Huang, 2000;

S. T. Huang, 2006; Krout, 2001; Y. J. Lee, 2000a; Reinhardt, 1999; Zimmerman, et al.,

1989) and anxiety (Bailey, 1983; Gallagher, et al., 2006; Gallagher & Steele, 2001;

Horne-Thompson & Grocke, 2008; Hung, 2003; S.-Y. Li, 2007; P. I. Peng, 2005).

Therefore, sedative music was used in this study. Sedative music is characterized as

having a rate of 60-80 beats per minute (bpm), a sustained melodic quality, a general

absence of strong rhythms or percussion, controlled volume and pitch, and no lyrics

(Gaston, 1951; Good, 1995). Sedative music may facilitate relaxation of the body

because when muscles relax, there is increased blood flow, the relaxation response is

related to better oxygenation of the tissues, and a sense of calm and reduced pain

perception occurs (Gaston, 1951; Standley, 1986). Sedative music may also stimulate the

release of hormones, such as endorphins, to alleviate pain (Goldstein, 1985). Furthermore,

music may reduce pain and anxiety through distraction; that is, by focusing the mind

away from the pain and anxiety toward a more pleasurable stimulus (McCaffrey & Good,

2000; Standley, 1986).

Nature sounds, on the other hand, are not well studied. Schrodeder-Sheker (1994)

suggested that gentle sounds from Mother Nature, such as wind, ocean waves, sounds of

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streams, rain, and birds can offer a peaceful sense and have healing power for dissolving

fears, lessening the burden, sorrows, pain, and emotional wounds in the dying process

and may help the dying patients to relax. Since Taiwan is an island, the majority of

people have their life experience closely associated with the mountains and the ocean.

From the researcher’s personal experience, some Taiwanese patients expressed that they

missed the sounds from the Nature while hospitalized. Sounds of wind, ocean, or the

songs of birds may allow these hospitalized hospice patients to feel a connection with and

embraced by what they are accustomed to hearing in their daily lives, and thus, create a

sense of being at home. Whether or not nature sounds decrease the cancer pain and

anxiety is a gap in knowledge that will be addressed in this study.

Conceptual Framework

The conceptual framework is based on Good and Moore’s (1996) middle-range

theory of acute pain: a balance between analgesia and side effects. The theory prescribes

patient participation, multimodal therapies, and attentive care from nursing actions for

pain relief and to reduce side effects of opioid analgesics. One proposition of the theory is

that multimodal therapies consisting of both pharmacological and nonpharmacological

methods will reduce pain. Nonpharmacological interventions, such as music, imagery,

massage, or cold, were proposed to contribute to decreases in acute pain (Good, 2009).

In the theory of a balance between analgesia and side effects developed by Good and

Moore (1996), music is proposed as a nonpharmacological adjuvant to reduce pain. This

study is expected to extend the theory by supporting that music not only reduces cancer

pain near the end of life, but also alleviates anxiety during that time. Furthermore, the

effect of nature sounds and the combination of music and nature sounds will be studied

8

for their effects as an extension of the concepts of nonpharmacological adjuvants. The

conceptual-empirical structure for this study is shown in Figure 2.

Figure 2. Conceptual-empirical structure

Music and nature sounds and their combination are three kinds of

nonpharmacological adjuvants. Music is theoretically defined as an intentional auditory

stimulus with organized elements of melody, rhythm, harmony, timbre, form, and style,

and is different from noise in the environment (Kemper & Danhauer, 2005). Sedative

music was used with a sustained melody of 60 to 80 bpm with volume and pitch

controlled, and no lyrics. Nature sounds are the sounds of the natural outdoor

environment, sounds that are not made or caused by people (Wright, 2001). Nature

－

100 mm Pain VAS

100 mm Anxiety

VAS

Concepts of the theory

Research concepts

Empirical indications

Nonpharmacological Adjuvants

Pain Emotion

Cancer Pain

Anxiety Music Nature Sounds

Music & Nature Sounds

Sedative music 60-80 beats/min No lyrics Sustained melody Controlled volume & pitch

Patients are correctly using the intervention as instructed

Sedative in nature pleasant & soothing sounds commonly heard in Taiwan Controlled volume & pitch

9

sounds, including wind, ocean waves, streams, birds, frogs, and insects, with volume and

pitch controlled, were also expected to produce relaxation or distraction. The combination

of sedative music and nature sounds is a combination of both individual modalities.

Cancer pain is a kind of pain that is associated with the potentially life-threatening

condition of cancer. It is also called malignant pain and can be categorized as acute or

chronic (International Association for the Study of Pain., 1994). When pain is associated

with the dying process, it is sometimes called “total pain,” which involves a variety of

physical noxious stimuli and affective or emotional discomforts. The pain is related to

interpersonal conflicts, and to fear and nonacceptance of one’s own dying (Saunders,

1976). In hospice patients, pain may no longer be a simple physical discomfort, but may

be accompanied by increasing levels of emotional distress associated with pain and dying,

such as anxiety. Cancer pain was measured before and after listening to 20 minutes of the

intervention and measured on a single 100-mm horizontal visual analogue scale (VAS).

Anxiety is a kind of emotion. Spielberger (1972) proposed differences between trait

and state anxiety. Trait anxiety, or anxiety proneness, often remains stable when

encountering stressors, while state anxiety is situational anxiety, and reacts to stressful

situations differently (Spielberger, 1983). For hospice cancer patients, having pain with

multiple symptoms and knowing they are close to death can be perceived as stressful or

threatening, which results in increased state anxiety. Therefore, state anxiety is used in

this study and defined as “the emotional reaction or pattern of response that occurs in an

individual who perceives a particular situation as personally dangerous or threatening”

(Spielberger, 1972, p. 489). Anxiety will be measured before and after 20 minutes of the

intervention on a single 100-mm horizontal VAS.

10

Summary of Literature

To date, there are only six studies in Taiwan that have tested the effectiveness of

music for pain and anxiety in cancer patients. Five of them were master’s theses with

only brief descriptions of the music intervention used to relieve pain or psychological

distress in cancer patients (S. H. Huang, 2000; Hung, 2003; Y. J. Lee, 2000a; S.-Y. Li,

2007; P. I. Peng, 2005). All of these studies had a small sample size (ranging from 20 to

60 participants), used quasi-experimental design or single group pre-post test design, and

were guided by nursing faculty who might not have had previous experience in using

music as a nursing intervention. Three of these studies did not use sedative music (S. H.

Huang, 2000; Y. J. Lee, 2000a; P. I. Peng, 2005). The sixth study was a dissertation that

tested the effectiveness of sedative music for cancer pain relief (S. T. Huang, 2006). This

study had a larger sample size of cancer patients (N = 126), but only some were in

hospice. It was guided by experienced faculty and a music therapist, and was conducted

in the southern part of Taiwan. Therefore, studies to test the effect of music on multiple

time points for reducing pain and anxiety in hospice cancer patients are needed.

Currently, only five studies have explored nature sounds to help adult patients to

undergo medical and surgical procedures (Dickhaus, et al., 2003; Diette, Lechtzin,

Haponik, Devrotes, & Rubin, 2003; Tsuchiya, et al., 2003), sleep (Williamson, 1992), and

anxiety (Golletz, 1997). Two previous studies conducted in the United States reported the

effectiveness of a videotape containing the sounds of streams and birds along with scenes

of nature on decreasing pain and anxiety during medical and surgical procedures (Diette,

et al., 2003; Tsuchiya, et al., 2003). Another study reported that ocean sounds increased

the quality of sleep in patients who had coronary artery bypass graft surgery (Williamson,

11

1992). However, no similar studies were found in Taiwan.

Assumptions

1. Around-the-clock analgesics are prescribed, but may be insufficient to relieve

pain in hospice cancer patients.

2. Anxiolytic medications are prescribed to patients with signs and symptoms of

anxiety.

3. Patients are able to express their perceptions of pain and anxiety.

Hypotheses

1. Hospice cancer patients who listen to sedative music, nature sounds, or sedative

music combined with nature sounds will have less cancer pain than those who

do not when controlling for baseline.

2. Hospice cancer patients who listen to sedative music, nature sounds, or sedative

music combined with nature sounds will have less anxiety than those who do

not when controlling for baseline.

Research Questions

1. What types of music and nature sounds are generally liked by Taiwanese

hospice cancer patients?

2. How much did Taiwanese hospice cancer patients like their assigned

intervention (music, nature sounds, and the combination of sedative music with

nature sounds)?

3. How many minutes were music, nature sounds, and the combination of sedative

music with nature sounds independently used between testing times?

4. What is the relationship between anxiety and cancer pain in hospice cancer

12

patients?

Conclusion

Cancer pain and anxiety have been the most common symptoms experienced by the

hospice cancer patients. Current pharmacological regimens are primarily used for

managing these symptoms, but may cause unwanted side effects. Based on the Good and

Moore acute pain theory (Good & Moore, 1996), this study tested the effect of sedative

music, nature sounds, and the combination of sedative music and nature sounds for

reducing cancer pain and anxiety on hospice cancer patients in Taiwan. A randomized

controlled trial with cluster and adaptive randomization was used to test the effects of

these interventions in hospice cancer patients, and to extend the acute pain theory.

13

Chapter Two

Review of Literature

The literature review begins with a description of the pathophysiology and

mechanisms of cancer pain, anxiety, and then cancer pain and anxiety in hospice patients;

it also includes culture issues. Second, the literature describing music and nature sounds

is reviewed. Third, the research on effects of music and nature sounds on cancer pain and

anxiety in hospice patients is presented. Finally, the threats to internal validity and

methods to control for these threats are addressed.

Cancer Pain

Cancer pain is defined as a subjective feeling of an unpleasant sensory and

emotional experience associated with the growth and/or the treatment of cancer. The

sensory and affective components of pain may affect one another and exacerbate pain

(Paice & Fine, 2006). Pain associated with cancer may result from tumor infiltration of

structures such as nerves, bone, or soft tissues. Cancer pain can also be a result of

treatments that injure or sensitize tissues, such as chemotherapy, radiotherapy, and

surgery. Cancer pain can be classified based on duration pathophysiology. The duration of

three kinds of cancer pain are: acute pain (duration < 3 months), chronic pain (duration >

3 months), and breakthrough pain (or incidental pain) which occurs on movement.

Pathophysiologically, cancer pain is classified as visceral pain, somatic pain, and

neuropathic pain (de Leon-Casasola & Lema, 2003; R. Payne, 1987).

Pathophysiology and mechanisms of cancer pain. Visceral pain is common in

cancer patients and results from infiltration, compression, distension, or stretching of

thoracic, abdominal, or pelvic viscera (de Leon-Casasola & Lema, 2003; R. Payne, 1987).

14

Visceral pain has some important properties. First, visceral pain cannot be evoked from

all viscera because some viscera lack afferent innervations. Most solid viscera, such as

liver, kidney, and lung parenchyma, are not sensitive to pain. For example, cutting the

intestine does not cause pain, whereas stretching the bladder is painful (Cervero & Laird,

1999). Second, visceral pain is diffuse and poorly localized and can be referred to other

locations. Because the pain is often referred to distant, superficial, and somatic structures,

it becomes difficult to determine the exact source of the pain. This is known as a

viscerosomatic reflex. For example, patients with hepatic tumors may complain of

shoulder pain when the diaphragm receives pressure from an enlarged organ and the

pressure exceeds the pain threshold (Cervero & Laird, 1999; de Leon-Casasola & Lema,

2003). Third, visceral pain is accompanied by motor and autonomic reflexes, so nausea,

vomiting and lower-back muscle tension usually accompany pancreatic, colon, and renal

cell cancer (Cervero & Laird, 1999; Cervero & Morrison, 1986). Patients describe

visceral pain as gnawing, cramping, pressure-like, or deep squeezing (National

Comprehensive Cancer Network, 2008).

Somatic pain is usually caused by the activation of pain receptors in either the

cutaneous or deep tissues, such as musculoskeletal or connective tissues. Common causes

of somatic cancer pain include postsurgical incisional pain, bone metastasis, and pain

accompanying myofascial or musculoskeletal inflammation or spasm (R. Payne &

Gonzales, 2004). Depending on the involved tissues, somatic pain can be either localized

or not localized. This type of pain is frequently described as stabbing, throbbing, burning,

pricking, dull, or aching (National Comprehensive Cancer Network, 2008).

Neuropathic pain is more complex than visceral or somatic pain. Neuropathic pain

15

results from injury to the peripheral or central nervous system as a consequence of tumor

compression or infiltration of peripheral nerves, nerve roots, the spinal cord, or the brain.

Additionally, trauma or chemical injury to peripheral nerves from surgery, radiation, or

chemotherapy may also result in this neuropathic pain (de Leon-Casasola & Lema, 2003;

T. S. Jensen & Gottrup, 2003; R. Payne, 1987). For example, metastatic or

radiation-induced brachial or lumbosacral plexopathies, epidural, spinal cord, and/or

cauda-equina compression, postherpetic neuralgia, and chemotherapy-induced (vinca

alkaloids or platinol compounds) neuropathies are commonly associated with neuropathic

pain (R. Payne & Gonzales, 2004). Neuropathic pain has the qualities of burning, sharp,

tingling, ringing, shooting, or electric shock sensations (T. S. Jensen & Gottrup, 2003;

National Comprehensive Cancer Network, 2008).

Central pain is a type of neuropathic pain that is caused by a lesion or dysfunction in

the central nervous system (Boivie, 2006). It usually involves second- or third-order

neurons and produces hyperalgesia (de Leon-Casasola & Lema, 2003), which is

abnormal sensitivity to both pain and temperature and is manifested by an increased

response to noxious or even non-noxious stimuli (T. S. Jensen & Gottrup, 2003). Even

gentle pressure or a light brush on the skin, or cold and heat stimuli can evoke

excruciating pain. Central pain is associated with neoplastic lesions along the

spinothalamic tract, thalamic or cerebral cortex projections, postherpetic neuralgia, and

phantom limb syndrome (de Leon-Casasola & Lema, 2003).

Sympathetic pain, another type of neuropathic pain, occurs in cancer patients. It

occurs after pathologic fractures, thrombosis due to hypercoaguable states, and

lymphedema of the extremities (de Leon-Casasola & Lema, 2003). Sympathetic pain is

16

associated with dysregulation of the autonomic nervous system and is typified by

constant burning and allodynic pain (Pasero, Paice, & McCaffery, 1999). Moreover,

sympathetic pain may involve sudomotor and vasomotor changes, edema, and coldness

of the affected area (de Leon-Casasola & Lema, 2003).

Despite different causes and classifications of cancer pain, the body’s responses to

noxious stimuli are a series of electrical and chemical events that result in four processes,

known as transduction, transmission, modulation, and perception (Wilkie, 1995). The

first pain process is transduction, in which one form of energy is converted to another.

Transduction is also known as receptor activation (Pasero, et al., 1999). It is a process in

which external or internal noxious stimuli, induced by mechanical, thermal or chemical

sources are converted to electrophysiological activity in primary afferent nociceptors

(PANs) (Beaulieu & Rice, 2003; Besson & Chaouch, 1987). These pain receptors are

located on the terminals of the primary afferent sensory neurons that are responsible for

transmitting sensory information from peripheral tissues to the spinal cord.

Primary sensory neurons can be divided into two major fibers, myelinated A fibers

and smaller-diameter, unmyelinated C fibers. Two types of larger-diameter myelinated A

fibers, A-α and A-β fibers, are low-threshold afferents that receive non-noxious stimuli of

light pressure, soft touch, and vibration from skin, muscle and joints (Djouhri, Bleazard,

& Lawson, 1998). Transmission of noxious information, however, is to the smaller

myelinated A-δ and unmyelinated C fibers, which are specialized sensory neurons that

transmit nociceptive signals (Besson & Chaouch, 1987).

In cancer patients, transduction may begin with nerve fiber damage. For example,

rapid growth of tumor masses may exert pressure on nerve fibers or encircle and constrict

17

peripheral nerves, a nerve plexus, a nerve root, or the spinal cord, and result in nerve

tissue injury (Coyle & Foley, 1987). Antitumor therapies, such as surgery, radiation and

chemotherapy, may also cause nerve damage (Coyle & Foley, 1987). Tumor infiltration

of somatic or visceral tissues also may press on nerves and produce noxious signals

(Coyle & Foley, 1987).

Damage to both normal and cancerous cells produces chemicals that cause nerve

fibers to become activated (Wall, 1988). Phospholipids and other substances are released

to the intracellular space and initiate the arachidonic acid cascade, in which leukotrienes

and prostaglandins are synthesized (Fields, 1987). These endogenous molecules not only

sensitize the primary afferent fibers, but also stimulate substance P to be released from

the distal terminal of PAN (Wilkie, 1995). Substance P dilates nearby blood vessels,

produces edema, and causes release of histamine from mast cells (Bonica, 1990).

Additionally, cell damage results in an inflammatory response. Chemicals are

released or leak out of the cell. For example, bradykinin, histamine, and potassium are

inflammatory exudates, while serotonin is released from platelets and norepinephrine is

released from nerve injury (Bonica, 1990; Fields, 1987). Other inflammation-associated

factors released from damaged tissue include protons (Bevan & Geppetti, 1994; Caterina,

et al., 2000), endothelins (Nelson & Carducci, 2000), and nerve growth factor (McMahon,

1996). If there are sufficient concentrations of these chemicals present in the milieu of the

PAN, they initiate the transduction process.

The second pain process is transmission, in which the transducted and generated

information in the PAN is transmitted to and through the central nervous system (CNS) to

the brain, where pain is perceived (Beaulieu & Rice, 2003). Nociceptive signal

18

transmission is accomplished in three steps, (1) projection to the CNS, (2) processing

within the dorsal horn of the spinal cord, and (3) transmission to the brain. The PAN will

fire an action potential. These nociceptive signals will traverse along the sensory nerve

fiber and through the dorsal root into the dorsal horn of the spinal cord, where it will then

be sent to the brain (Fields, 1987).

Once the dorsal horn of the spinal cord receives the nociceptive signal,

neurotransmitters from the afferent nerve fibers are either released into the synaptic cleft

or bound to receptors in the dorsal horn (Bonica, 1990). These neurotransmitters include

excitatory amino acids (fast transmitters), fluoride-resistant acid phosphatase, and

peptides (slow transmitters). Neural cells (interneurons) excited by the afferent nerve

fibers’ input then release other neurotransmitters, such as gamma-aminobutyric acid

(GABA) and glycine, to influence the transmission process within the dorsal horn

(Bonica, 1990).

The transmission process involves laminae I, II and V of the dorsal horn of the

spinal cord. There are projection cells in lamina I, some projection cells and interneurons

in lamina II, and wide dynamic range (WDR) neurons in lamina III (Fields, 1987). The

projection cells in lamina I send axons to the supraspinal sites, such as the thalamus,

brainstem and cerebellum, and receive excitatory and inhibitory messages from these

sites (Jones, 1992; Wilkie, 1995). The interneurons in lamina II are responsible for

communication with other lamina II cells located within one or two spinal segments, and

with dendrites from cells located in laminae I, III, IV and V (Fields, 1987). The WDR

neurons in lamina V receive direct input from both nociceptive and non-nociceptive

fibers, and then contact cells located in laminae I, II, III and IV via dendritic projections.

19

The WDR neurons then project information to the brainstem and the thalamus (Besson &

Chaouch, 1987; Fields, 1987). Furthermore, since the WDR neurons have large receptive

fields and receive noxious input from both somatic fibers and visceral organs, the WDR

neurons are believed to be associated with referred pain (Cervero, 1985).

Finally, projection cells in the dorsal horn propagate nociceptive stimuli to the

thalamus and brain through several pathways, including the spinothalamic tract (STT),

the spinoreticular tract (SRT), the spinomesencephalic tract (SMT), the spinocervial tract,

the second-order dorsal column tract (SDCT) and the spinohypothalamic tract (Burstein,

Cliffer, & Giesler, 1987; Willis, 1989). After the thalamus receives nociceptive input

from the spinal cord, it projects the signals from the ventrobasal and posterior thalamic

nuclei to the primary somatosensory cortex for sensory discrimination of pain location,

intensity, quality and pattern. In addition, the central lateral and thalamic submedialnuclei

project to the prefrontal for affective responses to pain such as fear, anxiety and suffering,

and to the motor cortex for behavioral responses to pain (Bonica, 1990; Burstein, et al.,

1987; Fields, 1987).

The third pain process is modulation. This includes both enhancement and inhibition

of nociceptive transmission and occurs mostly in the dorsal horn of the spinal cord

(Beaulieu & Rice, 2003; Fields & Heinricher, 1985). Modulation consists of interactions

among peripheral inputs, interneurons, and descending inhibitory systems. The major

neurotransmitters responsible for excitatory transmissions are glutamate, aspartate,

substance P, purines, cytokines, and capasaicin (Dickenson, 1996). The major

neurotransmitters for inhibitory are norepinephrine, 5-HT, GABA, glycine, acetylcholine,

opioids, galanin, somatostatin, neuropeptide Y, neurotensin, adenosine, and cannabinoids

20

(Beaulieu & Rice, 2003).

Descending inhibition of pain is a critical function of modulation. Fields and

Basbaum (1989) proposed that the descending opioid-related pain inhibitory system

involves several centers to generate analgesia. The system includes the midbrain

periaqueductal grey (PAG), the rostral ventral medulla (RVM), and the superficial layers

of the dorsal horn in the spinal cord. When certain conditions occur, such as pain, the

midbrain PAG receives nociceptive inputs from the frontal cortex and hypothalamus, and

projects to neurons in the RVM. The rostral ventral medulla neurons sequentially project

to and control transmission of noxious impulses in the superficial dorsal horn. With

stimulation, both PAG and RVM produce analgesia from the release of endogenous

opioids peptides. The peptides are distributed in the pain inhibitory system. As a result,

pain is modulated (Fields & Basbaum, 1989).

Multiple receptor systems are involved in the pain inhibiting process, including

norepinephrine, serotonin, GABA, glycine, adenosine and cannabinoids (Beaulieu &

Rice, 2003). The major site for producing analgesia is at the opioid receptors in the spinal

cord. Four types of endogenous opioid peptides, endorphin, enkephalin, dynorphin, and

nociceptin, work with their receptors, μ, δ, κ and opioid receptor-like (ORL-1),

respectively. These receptors are located in laminae I and II of the dorsal horn of the

spinal cord (Beaulieu & Rice, 2003; Wick, et al., 1994).

Pain perception is the fourth process of pain. Nociceptive input is recognized in the

brain as an unpleasant sensory experience with affective, defensive, and perceptive

components (Beaulieu & Rice, 2003). The somatosensory cortex in the parietal lobe of

the brain receives noxious input from the somatosensory thalamus and is the center for

21

sensory perception, including pain location, duration, quality, pattern, and intensity

(Bushnell & Apkarian, 2006). The affective component of pain is processed through the

limbic system. In the limbic system, the anterior cingulate cortex receives nociceptive

input from the insular cortex and the thalamus and transmits it to the prefrontal cortex

where the affective dimension of pain is processed (Bushnell & Apkarian, 2006; Kanda,

et al., 2003). Sensory and affective components of pain perception are highly modulated

by cognitive factors. These cognitive factors include attention and previous experience of

pain. Both can alter pain perception. In addition, pain perception can be a very

individualized process in other cultural groups (Wilkie, 1995). For example, Chinese

people may not respond verbally or behaviorally when a noxious stimulus presents

because of their religious beliefs or their stoic cultural background.

Cancer pain in hospice patients. A review of multiple studies suggests that patients

with advanced cancer have more pain than those in earlier stages of the disease

(Thielking, 2003). Cancer patients admitted or referred to hospice care are in an advanced

stage of illness and need symptom control; pain is the most prevalent symptom (Potter,

Hami, Bryan, & Quigley, 2003; Stromgren, et al., 2004; Swanwick, Haworth, & Lennard,

2001; Tang, 2003). Researchers have found that 64% to 93% of hospice cancer patients

experienced moderate to severe pain upon arriving at the hospice setting (Kutner, Kassner,

& Nowels, 2001; W. L. Peng, Wu, Sun, Chen, & Huang, 2006; Potter, et al., 2003;

Stromgren, et al., 2004; Swanwick, et al., 2001). One study indicates that 89% of hospice

cancer patients (N = 245) experienced an average of seven breakthrough pain episodes

daily in addition to ongoing pain (Zeppetella, O'Doherty, & Collins, 2000). As the

hospice cancer patients become close to death, the prevalence of pain increases (W. L.

22

Peng, et al., 2006).

Cancer pain in hospice patients is not only a reflection of underlying

biophysiological factors, but is also influenced by psychological and social factors. When

cancer patients are admitted to a hospice program for palliative care, progression of the

disease leads to a number of diverse pain syndromes. Usually, the location of neoplastic

growth plays a key role in the pain experience of cancer patients (Caraceni & Weinstein,

2001). For example, patients with head and neck cancer and those with gynecological and

prostate cancer suffered significantly more moderate to severe pain than patients with

other primary sites (Vainio & Auvinen, 1996). About 43% of patients (N = 1,112)

suffered from mixed types of cancer pain, such as somatic and neuropathic pain, or

somatic and visceral pain (Caraceni & Portenoy, 1999). Since hospice cancer patients are

in the advanced stage of disease, they may have bone metastases, neuropathic pain, or

mixed pain pathophysiology, which can result in greater severity of pain and declining

performance status (Ger, Ho, Sun, Wang, & Cleeland, 1999; Stromgren, et al., 2004).

Cancer pain is associated with accumulation of comorbidities and debility in hospice

patients, especially in the elderly. Older people have a higher prevalence of cancer

(National Cancer Institute, 2008). Although studies found that different age groups have

similar pain intensity and incidence, age is an important biological factor in the

experience of pain for patients with advanced cancer (C.-C. Lin, Lee, Chiang, Tan, &

Huang, 2006; Mercadante, Ferrera, Villari, & Casuccio, 2006; Vigano, Bruera, &

Suarez-Almazor, 1998). Among cancer patients who are older than 60 years, the

prevalence of painful comorbidities increases at least two times when three or more

comorbid illnesses are involved (Crook, Rideout, & Browne, 1984; C. W. Given, Given,

23

Azzouz, Kozachik, & Stommel, 2001). Comorbid symptoms not only complicate pain

intensity, but also interfere with effective cancer pain treatment, and patients are less

likely to achieve effective pain control (Meuser, et al., 2001). For example, alterations in

body composition, metabolic rate, hepatic mass, and blood flow due to aging and

comorbidities in older cancer patients may increase risk for adverse events from

therapeutic agents. For example, there is an increased risk of peptic ulcer when

nonsteroidal anti-inflammatory drugs (NSAIDs) are used for pain management. In

addition, opioids have adverse effects. The amount of opioid anagelsia may require lower

dosage and careful adjustment to prevent toxicities and side effects of opioids

(Mercadante, et al., 2006; Vigano, et al., 1998).

Cancer pain-related debility also contributes to greater perceived disability,

compromised function, and low activity among hospice cancer patients (B. Given, Give,

Azzouz, & Stommel, 2001). The debility that results from cancer pain limits patients’

ability to receive pain treatment. For example, hospice patients in the end stage of illness

frequently have difficulty swallowing or physically reaching their medications (Coluzzi

& Farirbairn, 1999; Janjan, Delclos, Crane, Ballo, & Cleeland, 2003). These difficulties

may result in changing the route of medication administration and limiting the dosage of

opioids when the cancer patients really need more relief. Furthermore, impaired

communication capacity, agitation, delirium, and the high dose of opioids that is needed

( > 120 mg oral morphine equivalent/day) may prevent accurate pain assessment in

hospice cancer patients (Morita, Tei, & Inoue, 2003).

Research studies on the interplay of psychological factors in hospice cancer patients

are relatively limited. Hospice cancer patients have higher prevalence and incidence of

24

pain when death is imminent. A number of studies have documented the association

between cancer pain and emotional distress. High levels of pain intensity are associated

with significantly higher levels of mood disturbance, frustration, anger, and exhaustion

(Poulos, Gertz, Pankratz, & Post-White, 2001). Patients with cancer pain reported higher

levels of uncertainty than those without, and higher levels of cancer pain severity and

interference are associated with lower levels of hope (T.-H. Hsu, Lu, Tsou, & Lin, 2003).

Cancer patients with pain reported higher scores of depression, anxiety, and hostility than

those without (Zimmerman, Story, Gaston-Johansson, & Rowies, 1996). Female patients

in advanced stage cancer are particularly vulnerable to feelings of helplessness and

hopelessness in association with higher levels of pain (Sela, Bruera, Conner-Spady,

Cumming, & Walker, 2002; Spiegel, Sands, & Koopman, 1994).

Patients’ concerns and misconceptions about pain are major barriers to effective pain

management (Ward, Hughes, Donovan, & Serlin, 2001; Weiss, Emanuell, Fairclough, &

Emanuel, 2001). Common concerns reported by hospice cancer patients include fears of

addiction, concerns about side effects, the idea that “good” patients do not complain

about pain, and negative experiences with cancer pain management (Schumacher, et al.,

2002; Weiss, et al., 2001). These concerns may prevent hospice patients from receiving

adequate pain management and may result in unnecessary suffering during the dying

process. Researchers reported that patients with higher barrier scores were more likely to

have inadequate pain management than patients with lower barrier scores (Ward, et al.,

2001). Inadequate pain management, in turn, has been associated with poorer quality of

life, concern for suffering, patients’ desire for hastened death, and suicide (Arnold, Artin,

Person, & Griffith, 2004; Filiberti, et al., 2001; Mystakidou, Parpa, Katsouda, Galanos, &

25

Vlahos, 2005).

Although pain is a private event, it influences and can be influenced by the social

environment. As hospice cancer patients become increasingly ill at the end of life, their

dependence on family, friends, and healthcare providers to provide care and relief from

symptoms and distress increases. In order to effectively advocate and care for these

patients, caregivers must understand their patient’s experience. However, studies show

that family caregivers of cancer patients overestimate the patient’s symptoms, particularly

pain intensity (Clipp & George, 1992; Ferrell, Chohen, Rhiner, & Rozek, 1991; Yeager,

Miaskowski, Dibble, & Wallhagen, 1995). Moreover, when patients’ pain ratings were

higher than their caregivers’ rating, they had significantly higher levels of anger and

fatigue, poorer psychological and interpersonal well-being, and lower quality of life than

patients in congruent dyads (Miaskowski, Zimmer, Barrett, Debble, & Wallhagen, 1997).

Healthcare professionals in hospice settings are often not able to adequately manage

cancer pain because they have insufficient knowledge and attitudes, and because

interdisciplinary collaboration is less than it should be. In addition, these barriers vary

between medical specialties. When hospice cancer patients were cared for by primary

care physicians, their average pain level was significantly higher than that of patients who

received care from oncologic physicians. The researchers suggest that this finding may be

related to the physicians’ knowledge of pain management and their utilization of

resources for hospice cancer patients (Nowels & Lee, 1999). Researchers of two studies

found that hospice nurses had higher scores on their overall knowledge of pain

management than nurses who work in the hospital oncology unit and nononcology units.

However, even the hospice nurses struggled with understanding the pharmacology of

26

medications, especially the use of opioids to manage cancer pain (Hollen, Hollen, &

Stolte, 2000; Rushton, Eggett, & Sutherland, 2003). Other researchers reported that lack

of nurse-physician collaboration may result in more difficulties in pain management in

hospice cancer patients (Ishikawa, Kawagoe, Kashiwagi, & Yano, 2007). These authors

found that when nurses and physicians did not collaborate well, there were also fewer

specific efforts such as routine team meetings and regular educational seminars for

discussing pain control. As a result, hospice cancer patients were less likely to receive

scheduled orders in prescribing opioid analgesics and other alternative/complementary

medicine for pain management.

Cultural issues. Taiwanese people embrace and are nurtured in the traditional

Chinese culture and beliefs. Chinese culture is heavily influenced by Confucian

philosophy that encourages people to be stoic, starting in early childhood, and to view

public expression of pain as a sign of weakness (C. C. Lin, 2001; T. Y. Lin, 1983; Wills &

Wootton, 1999). In Chinese culture, a cancer diagnosis is viewed as taboo, so that

Chinese cancer patients often feel stigmatized and ashamed of the illness (T. K. Chung,

French, & Chan, 1999; C. C. Lin, et al., 2000). Within the Confucian belief system, pain

is defined as a hurt or an unpleasant feeling, yet an essential element of daily life, a “trial”

or a “sacrifice” (Creel, 2000). Therefore, when a person suffers with pain, he or she

would rather endure the pain and not report it to a clinician until the pain becomes

unbearable. Such beliefs and perceptions are likely to compromise Chinese cancer

patients’ willingness to express their pain to healthcare providers for adequate pain

management.

Fatalism, which is profoundly present in Chinese culture, also negatively affects

27

pain expression and desire for treatment (M. C. Chang, Chang, Chiou, Tsou, & Lin, 2002;

Wang, et al., 1997). A majority of Chinese people believe in Taoism and Buddhism (The

National Science Council, 2004) and are also brought up with Confucianism. In such

beliefs, pain is an essential element of life, and to live with pain is to see and understand

the world as it really is (L. M. Chen, Miaskowski, Dodd, & Pantilat, 2008). Patients who

reported more fatalistic beliefs had more fears that pain represents a sign of cancer

progressing, more pain-related functional interference, less analgesic usage, and higher

psychological distress (M. C. Chang, et al., 2002; C. C. Lin, et al., 2000; Wang, et al.,

1997).

Additionally, within the beliefs of Taoism, pain occurs if Chi (energy) or blood

circulation is blocked. The blockage of Chi or blood circulation can be caused by not

only physical illness such as tumors, but also by psychological unbalance such as feeling

unsafe, or displaying excessive vigilance, suspiciousness, and delusion. To relieve pain,

the blockage of Chi or blood must be removed and the person needs to maintain harmony

with the universe (Y. C . Chen, 2001).

In Buddhist belief, pain and suffering are powers that are unwanted, but nevertheless

exist. Pain is a part of this life and manifests in a combination of physical, emotional,

mental, and spiritual forms (Tu, 1987). However, it is also believed that pain occurs due

to a barrier in the last life. Only if the person faces the pain calmly, without becoming

emotionally distressed, can he/she attain greater states of being in this life (Smith-Stoner,

2003). Traditional Chinese herbal medicine, acupuncture, acupressure, and Tai Chi are

believed to be helpful for Chi balance and blood circulation. Religious chanting or

breathing techniques can calm a person’s emotional distress so that pain becomes

28

endurable. Hence, complementary and alternative medicine therapies are important for

Taiwanese cancer patients. They have a higher preference and better acceptance for

nonpharmacological methods of pain management than those without a Chinese cultural

background (Balducci, 2005).

Additionally, because of the Chinese cultural beliefs, pain management was not

prioritized and valued in Taiwan until 1960 to 1970. Pain management has been included

in the curriculum among medical schools in Taiwan since then. However, many medical

doctors still have limited knowledge about pain medications, misconception of opioid

analgesics, and have disseminated their misconceptions to their patients (C.-H. Hong,

2007). For example, Chen and colleagues (2006) found that some physicians still

prescribed Meperidine to cancer patients, even though it is not recommended by the

World Health Organization (WHO) or American Pain Society (APS) because of its

short-acting duration, painful injection site, and the risk of neurotoxicity (Miaskowski, et

al., 2009; World Health Organization, 1996). They also reported 11.7% of cancer patients

received only PRN drugs for pain. Recently, the first cancer pain management guideline

was published by the Taiwan Cooperative Oncology Group (Taiwan Cooperative

Oncology Group, 2007). However, it is not known how the guidelines are carried out in

clinical practice.

Nurses receive limited and fragmented knowledge about pain management from

pharmacology and medical-surgical courses in basic nursing educational programs. One

group of Taiwanese researchers used a structured questionnaire to test beliefs and

knowledge of cancer pain and opioid analgesics in senior nursing students (N = 188).

They found that the correct response rate on average was 47.9% and these students had a

29

serious knowledge deficiency in pain management, especially in pharmacological

knowledge (Y.-H. Lai, Chen, Chang, Cheng, & Wei, 2000). Another group of Taiwanese

researchers reported that 63.2% of oncology nurses (N = 95) did not know how to assess

pain adequately. More than one-third of these nurses were concerned about patients

becoming drug addicted. Less than one-third of the nurses implemented

nonpharmacological intervention for pain management. These researchers recommended

that nurses receive better knowledge of analgesics and pain management (L.-C. Hsu,

Ling, Lai, & Chen, 2002). As a result, lack of knowledge in pain management and

misconceptions about opioid analgesics among doctors and nurses present significant

barriers to cancer pain management.

In summary, the current difficulties in controlling cancer pain in hospice patients are

biophysiological, psychological, and social in origin. The biophysiological issues include

the advanced stage of cancer involvement and impaired physical function. The

accumulation of comorbidities and debility are age-related. The psychological issues

include cancer-pain-induced psychological disturbance and emotional distress, and

concerns and misconceptions about pain management in hospice cancer patients and their

families. Socially, issues include a lack of understanding and congruent pain reporting

among patients, family and friends, and lack of adequate knowledge, facilitating attitudes,

and interdisciplinary collaboration in cancer pain management among hospice

professionals. Finally, culturally related beliefs in Taiwan also contribute a unique

dimension to cancer pain assessment and management in hospice cancer patients.

Anxiety

Anxiety in cancer patients is unpleasant subjective feelings of tension, fear,

30

irritability, and apprehension associated with the perception of a threat. Anxiety is an

evolutionarily maintained and is an unconditioned response that starts in the brain as the

activation of the hypothalamic-pituitary-adrenal axis. It results in other responses such

defensive behaviors, autonomic arousal, hypoalgesia, and potentiation of somatic reflexes

(LeDoux, 1996). Anxiety is an affective feeling, but can have cognitive, behavioral, and

somatic manifestations. Cognitively, patients may worry excessively or have difficulty

concentrating. Behaviorally, anxious patients may exhibit avoidant or compulsive

tendencies. Somatic symptoms of anxiety include muscle tension, restlessness, sleep

disturbance, and fatigue. Intense anxiety or panic can be manifested in more pronounced

symptoms such as palpitations, shaking, shortness of breath, chest pain or discomfort,

nausea, dizziness, numbness, lightheadedness, or feelings of choking. The physical

manifestations of anxiety are often more prominent than the psychological features and

frequently overlap with symptoms of cancer and the treatment effects (Tremblay &

Breitbart, 2001).

The common causes of anxiety in hospice cancer patients may result from

situational stressors, symptom-related events, drug-associated problems, metabolic

disturbances, and psychiatric disorders (Fisch, 2006). Pain, palpitations, and nausea are

common causes of anxiety in hospice cancer patients (Fisch, 2006). For example, patients

with lung cancer or metastasis to the lung can experience dyspnea that results in

increased anxiety (Chan, Richardson, & Richardson, 2005; Henocha, Bergmanb,

Gustafssona, Gaston-Johanssona, & Danielsona, 2007). Researchers in Taiwan have

shown that cancer patients (N = 151) with anxiety measured on the Hospital Anxiety and

Depression Scale (HADS) also had significantly higher emotional symptoms scores,

31

distress, and sadness, than patients without anxiety (M. L. Chen & Tseng, 2006). Anxiety

in palliative cancer patients also led to more difficulty falling asleep, less restorative sleep,

and nightmares (Mercadante, Girelli, & Casuccio, 2004).

Patients with advanced disease encounter situations that contribute to anxiety. They

have fears of disability, disfigurement, dependency, and a painful death (Georges, et al.,

2005). Anxious hospice cancer patients may also fear suffering, of the unknown after

death, of loneliness, of personal extinction, and of loss of autonomy. Unfinished business

can also weigh heavily on hospice cancer patients (Cicirelli, 2006; Conte, Weiner, &

Plitchik, 1982). Cancer patients have experienced levels of anxiety starting with their

cancer diagnosis. Upon entering the hospice care setting, cancer patients’ anxiety

commonly increases as they become aware that their medical treatments have been

ineffective in halting the disease and that their life expectancy is now limited. Symptoms

of anxiety frequently intensify when patients perceive that death is imminent (Cassileth,

Lusk, & Walshm, 1986; Sherif, Jehani, Saadani, & Andejani, 2001).

Pathophysiology and mechanisms of anxiety. Optimal activity in the anxiety

circuits is associated with a normal readiness to respond to situations and a flexible and

motivated state of being. Life-threatening challenges induce anxiety and result in the

permanent imprinting of the full emotional memory of the experience in the emotional

circuits through the amygdala. Associated cues are stored via the declarative memory

circuits that include the hippocampus. This center allows for associated cues to trigger

emotional memories of the trauma and bring them to conscious awareness (Davis, 1992).

The amygdala registers emotional stimuli and develops emotional memories. The

central nucleus of the amygdala has been proposed to mediate the anxiety response. The

32

various symptoms of anxiety depend on the output pathways of the central nucleus

(Davis, 1992). For example, the amygdala mediates conditioned or unconditioned stimuli,

projects directly to the lateral hypothalamus, and results in the activation of the

sympathetic autonomic nervous system that then induces tachycardia, galvanic skin

response, pallor, pupil dilation, and blood pressure elevation (Davis, 1992).

The medial prefrontal cortex is reciprocally connected with the amygdala for

cognitive control of the anxiety response. It allows self-imposed regulation of affect and

modulation of autonomic and neuroendocrine functions (Barkley, 1997). However, if the

challenge increases, control shifts from the prefrontal executive centers to primordially

lower centers such as the amygdala, where behaviors are guided by the previous

anxious/traumatic experiences (Arnsten, 1998).

Several neurotransmitters mediate the different components of anxiety, including

excitatory amino acids such as glutamate, inhibitory amino acids such as GABA, and

monoaminergic neurotransmitters such as catecholamines and indoleamines (Sinha,

Mohlman, & Gorman, 2004). Norepinephrine mediates emotionally traumatic memories

as they become imprinted in the amygdala through the β-adrenergic receptors.

Dopamine-1 in the amygdala mediates conditioned fear to facilitate declarative memory

associations through the hippocampus (Lamont & Kokkinidis, 1998). The currently

available pharmacological treatments for anxiety such as benzodiazepines and

serotonin-1A agonists, are focused on these neurotransmitters to relieve symptoms of

anxiety (Breitbart, Chochinov, & Passik, 2004; Jackson & Lipman, 2004).

Anxiety in hospice cancer patients. Fear of death in hospice cancer patients is a

frequent cause of situational or state anxiety. Researchers have studied fear of death or

33

death anxiety in relation to age, gender, spirituality/religion, and culture. Increased death

anxiety has been inconsistently related to age in numerous research studies. In an early

study, the researchers found that death anxiety scores were not significantly different

between 230 graduate students and elders in a senior center and nursing homes. Their

ages ranged from 30 to 82 years (Conte, et al., 1982). This was also true in cancer

patients. Researchers investigated 124 Taiwanese advanced cancer patients and reported

75.8% of these patients showed mild to moderate anxiety. However, age was not

associated with anxiety (L.-Y. Tsai, Ku, Chang, & Lai, 2001).

Researchers of one review article attempted to clarify the relationship between age

and fear of death. The researchers reviewed 49 articles that were focused on elders who

were older than 50 years and were hospitalized or lived in the community or in nursing

homes. The reviewer reported that death anxiety decreased from middle age to older age,

but stabilized during the final decades of life. They suggested that age is not a reliable

predictor of death anxiety in elderly populations (Fortner & Neimeyer, 1999). A later

study conducted in Taiwan (N = 224) found the severity of death fear in cancer patients

decreased after being admitted to the hospice, but older people ( > 65 years) presented a

significantly higher level of death fear than younger people at two days before death (J.-S.

Tsai, Wu, Chiu, Hu, & Chen, 2005). These findings are similar to a study (N = 192)

conducted in the United States (Cicirelli, 2006). However, other studies found that fear of

death tends to be greater among younger than older people (Thorson & Powell, 2000; K.

G. Wilson, et al., 2007). With the inconsistent findings of the relationship between the

age and death anxiety, age will be a factor to consider controlling for when studying the

effect of music on anxiety in hospice cancer patients.

34

There were also inconsistent findings in studies of gender differences in death

anxiety. Researchers in the United States and in Taiwan reported that there was no

difference in the level of death anxiety between males and females in both older adults

(Conte, et al., 1982; Fortner, Neimeyer, & Ryharezyk, 2000) and cancer patients (L.-Y.

Tsai, et al., 2001). However, other researchers reported that women had higher anxiety

levels when they were close to death (Harding, Flannelly, Weaver, & Costa, 2005;

Neimeyer & David, 1995). The authors suggest that one possible reason may be that men

tend to avoid thoughts of death and dying to a greater extent than women. That is, men

may deal with intrusive thoughts of their mortality more defensively than women deal

with theirs and women have a greater tendency to admit to having troubled feelings

(Wong, Reker, & Gesser, 1994). Therefore, gender will also be considered as a factor to

control for in the study when analyzing anxiety.

The relationship between spirituality or religious beliefs and death anxiety has also

provided mixed findings. Three research groups reported that in hospice cancer patients,

reports of being more religious were significantly associated with lower death anxiety

(Grumann & Spiegel, 2003; Pevey, Jones, & Yarber, 2008; L.-Y. Tsai, et al., 2001). They

reasoned that this was because religion may be comforting to dying hospice patients by

offering a relationship between God and the dying that gives hope of life after death

(Pevey, et al., 2008). These findings may not be true in Taiwan. Two thirds of the

Taiwanese population has either Buddhist or Taoist beliefs. These religious belief systems

can promote fear of death. For example, if ideas of anticipated judgement and

punishment are at the core of one’s belief system, one’s death anxiety may increase and

sometimes may become unbearable (Gonda & Ruark, 1984).

35

Multiple researchers have investigated spirituality or compared both religious beliefs

and spirituality in relation to anxiety in terminally ill patients. Religious belief is defined

as a particular institutionalized or personal system of belief and practices related to the

divine. It pertains to participation in organized rituals and practices (King, Speck, &

Thomas, 1995; Mytko & Knight, 1999). Spirituality is defined as individuals thinking

about the meaning of their existence and interpreting their inner values (Chao, 1998).

Although religious beliefs and spirituality are different, they may coexist and are not

necessarily mutually exclusive (Mytko & Knight, 1999). In some studies, spirituality was

negatively correlated with anxiety, indicating that hospice cancer patients with spiritual

beliefs had less anxiety than those without (C.-C. Li, Yu, & Hwang, 2006; McCoubrie &

Davies, 2006; Wittmann, Volimer, Schweiger, & Hiddemann, 2006). In other studies,

spiritual well-being was reported to be needed by hospice cancer patients (Hampton,

Hollis, Lloyd, Taylor, & McMillan, 2007; C.-C. Li, et al., 2006; Williams, 2006). In two

studies, hospice cancer patients reported that spiritual well-being helped them to

transform uneasy feelings, regrets, and sorrow into positive attitudes and peaceful

thoughts, and also helped them to search for meaning and enhanced natural acceptance

(Ando, Morita, Lee, & Okamoto, 2008; C.-C. Li, et al., 2006). In three studies,

researchers compared religion and spirituality among patients with advanced cancer. The

terminally ill cancer patients reported that spirituality was more important and

meaningful, and decreased their anxiety and fear of death better than their religious

beliefs (Grumann & Spiegel, 2003; Hampton, et al., 2007; McCoubrie & Davies, 2006).

However, no similar study was found in Taiwan, where the religious beliefs are different

from those in the United States.

36

Medications, such as bronchodilators, corticosteroids and β-adrenergic receptor

stimulants, are commonly used for chronic respiratory conditions in hospice care settings

and these drugs may cause anxiety, irritability, and tremulousness (Bruera, et al., 1995;

Levy & Catalino, 1985). Metabolic conditions, including hyperglycemia, hypoglycemia,

organ failure, electrolyte imbalance, nutritional failure and infection, which frequently

occur in hospice cancer patients, may lead to symptoms of anxiety (Massie, Holland, &

Glass, 1983). Finally, patients with a history of psychiatric disorders can have anxiety in

palliative care settings that results in delirium, depressive disorders, panic, posttraumatic

stress, phobias, and a generalized anxiety disorder (Fisch, 2006). In this study, opioid

analgesics used by the hospice cancer patients were documented and treated as a

potentially confounding variable for possible statistical control when analyzing both pain

and anxiety. Patients who are critically ill with diagnosed metabolic disturbances were

excluded from the study. Patients with present untreated psychiatric symptoms were also

be excluded from the study.

Cultural issues. Chinese patients, especially men, are reluctant to express or discuss

their feelings (Y. F. Tsai, 2007). Expressing personal feelings, such as anxiety, to anyone

outside of the family in the Chinese culture usually is considered showing personal

weakness and is inappropriate or culturally unacceptable (T. Y. Lin, 1983). However,

family members may be the communication bridge to initiate talking about the anxious

feelings of the hospice cancer patient to healthcare professionals. Familialism and filial

piety play the key role in this context. Familialism is considered the most important and

fundamental collectivist value (D. T. Tsai & Lopez, 1997). In Confucian teaching, the

family is always to be considered before the individual. Chinese people are closely bound

37

to their families. Personal feelings and thoughts are only shared within the family

(Wellish, et al., 1999). Family members are expected to care for each other and are

perceived as the most satisfying sources of support (G. K. Hong, 1989; Lan, 2002).

The traditional Chinese belief of filial piety accompanies familialism and has been

considered as the soul of traditional Chinese culture and the most important social value

for promoting caring relationships between children and parents (Yu, 1983). The

traditional expectation is that since parents take responsibility to help their children

through life, adult children, especially the males, are obligated to protect, take care of,

and respect their parents (Holroyd, 2003). As a result, the emotional expression and some

physical symptoms of anxiety of the hospice cancer patients may be observed by the

family members. The son may be the representative of the patient initially to

communicate with the healthcare professionals.

The question is raised as to whether Taiwanese patients will report anxiety to the

researcher. Severity of anxiety in Taiwanese cancer patients increased with the stages of

chemotherapy in one study. Researchers reported that the severity of anxiety (0 – 100 mm

VAS) in 32 cancer patients increased from mild anxiety (25 + 25.2) mm before

chemotherapy to moderate anxiety (40.1 + 26.0) mm on the third day (T.-W. Huang, et al.,

2001). Researchers of three other studies reported that hospitalized cancer patients on

average had moderate anxiety (P.-Y. Chen, et al., 1999; Hung, 2003; P. I. Peng, 2005).

One of these researchers used the State Anxiety Inventory to examine 25 patients with

hematological malignant cancer before using music for anxiety and reported that the

average of these patients’ anxiety was 49.9 points (SD = 9.25) (P. I. Peng, 2005).

Researchers of the other two studies of patients in different stages of cancer used the

38

Hospital Anxiety and Depression Scale (0 – 7 points = mild anxiety, 8 – 10 = moderate

anxiety, 11 – 21 = severe anxiety). One researcher reported that the average anxiety level

was clinically significant at 7.24 points (SD = 4.94) in 34 patients before using music for

anxiety; only 2 patients were using anxiolytics (Hung, 2003). The other research group

reported that the average anxiety was 7.78 points (SD = 3.37) in a correlational study of

90 cancer patients. The use of anxiolytics was not reported (P.-Y. Chen, et al., 1999).

Therefore, despite cultural norms, Taiwanese cancer patients do report mild to moderate

anxiety in research studies.

Although some studies have shown that people who are more religious have lower

death anxiety, researchers have pointed out that if one’s religious belief relates to an

anticipatory judgement and punishment after death, death anxiety may increase and

sometimes may become unbearable (Dezutter, et al., 2009; Gonda & Ruark, 1984). Even

though no research study was found in this area, researchers of one earlier study (N = 333)

in the US reported that strong belief in afterlife contributed to higher death anxiety

(Osarchuk & Tatz, 1973). As a result, it is assumed that religious beliefs may lead to

higher death anxiety among the Taiwanese hospice cancer patients than those who have

other religious beliefs. Unfortunately, death anxiety in the Chinese culture involves not

only religious beliefs but also a mixture of local folklore, superstition, and magical belief

systems, which may contribute to higher levels of anxiety among hospice cancer patients

(Yick & Gupta, 2002). For example, Buddhists believe in reincarnation. Depending on

the deeds people have done in this life, they may be punished by being reincarnated into

unfortunate and miserable people in the next life, or even become animals. They may be

tortured in the next life (Hsing Yun, 1983). Taoists believe that after death, the person’s

39

spirit/soul will go through ten gates in the Nether World and be judged by King Yian-Luo,

the Master of Hell. Based on records in the “Birth-and-Death Notebook,” the spirit/soul

may be punished in the underworld for the misdeeds or may be rewarded and go to

Heaven (D. K. Chung, 1995; S. Li, 1993).

In summary, anxiety in hospice cancer patients is caused by unpleasant subjective

feelings of tension, fear, irritability, and apprehension associated with the perception of a

threat. These affective feelings can have cognitive, behavioral, or somatic manifestations.

The common causes of anxiety in hospice cancer patients may result from situational

stressors, symptom-related events, drug-associated problems, metabolic disturbances, and

psychiatric disorders. Anxiety may have different influences on hospice cancer patients

depending on gender, age, and spiritual or religious beliefs. Furthermore, Chinese cultural

beliefs may influence Taiwanese hospice cancer patients to not express their anxiety to

people outside of the family. Furthermore, patients who have Buddhist or Taoist beliefs

may be more anxious about death than those who do not. Therefore, when hospice cancer

patients hesitated to express their anxiety at the first meeting with the researcher, she

talked with the families to determine the patients’ levels of anxiety. If anxiety was not

identified, the hospice cancer patients marked the level of their anxiety as “no anxiety”

on the anxiety VAS. If anxiety was identified, they marked their anxiety level on the

anxiety VAS.

Cancer Pain and Anxiety

Cancer pain and anxiety are common problems for patients in hospice, and patients

with pain seem to be at increased risk for anxiety compared with those without pain

(Thielking, 2003). It has been demonstrated that anxiety and cancer pain are highly

40

correlated in patients receiving palliative care (M. L. Chen & Tseng, 2006; D. K. Payne

& Massie, 2000). Cancer patients with more severe or breakthrough pain reported

significantly more anxiety and depression than those with mild or no pain (M.-L. Chen,

Chang, & Yeh, 2000; P.-Y. Chen, et al., 1999; L.-Y. Tsai, et al., 2001). Furthermore,

anxiety reduced patients’ tolerance for physical pain and substantially impeded overall

function (Noyes, Holt, & Massie, 1998). Researchers reviewed 165 patients who suffered

from chronic pain and reported that anxiety was negatively associated with coping with

chronic pain (McCracken & Gross, 1993). In addition, cancer pain and anxiety were

shown to have a significant impact on the desire for death or hastened death in hospice

cancer patients (Mystakidou, Rosenfeld, et al., 2005). Therefore, providing music and

nature sounds in addition to opioid medication may help hospice cancer patients to have

better pain relief and less anxiety.

Music for Pain and Anxiety

The healing power of music for pain and anxiety has been described in eastern and

western literature. In eastern countries, Chinese culture has been the mainstream. The use

of music for treating illness and other health conditions was documented in the Book of

Odes as early as the 10th century BC in China. The five tones used in Chinese music are

thought to resemble the five elements (metal, wood, water, fire, and earth) that the

Chinese people believe will keep them physically and mentally balanced, and reduce

their physical discomfort and psycho-emotional distress (Chuang, 2004). During and after

World War II, physicians in the west used music to distract injured soldiers from their

pain while they recovered from surgery and to calm soldiers who were suffering from

shell shock (Wigram, Pedersen, & Bonde, 2002). Our nursing pioneer, Florence

41

Nightingale (1969), recognized that different types of music resulted in different effects.

She indicated that wind instruments with continuous sound or an “air” had soothing

effects and would be beneficial to the sick, while music played on a piano-forte could

produce the reverse effect.

Music has been viewed as a science and an art because of its scientific structures

known as the elements of music and the aesthetic results from combining those elements

(Wigram, et al., 2002). Music is comprised of five major elements: pitch (frequency),

volume (intensity), timbre (tone color), interval, and rhythm (tempo or duration) (Alvin,

1975). The effect and the character of a piece of music depends on the relationships

among these elements (Chlan, 2006). For example, a high pitch with fast rhythm and high

volume may tense muscles, trigger body movement, or produce uncomfortable feelings.

In contrast, a low pitch with slow rhythm and steady volume may help people to relax

and slow down. The combination of the elements may be interpreted as consonance (a

combination producing a pleasant acoustical sensation) or dissonance (a combination

leading to an unpleasant sensation), and is strongly associated with training and culture

(Valentinuzzi & Arias, 1999). For example, jazz music may be perceived as consonance

by African Americans, but may be perceived as dissonance by Taiwanese people (Chiang

& Good in preparation; Good et al., 2000).

Mechanisms of music for pain and anxiety. When a person listens to music, the

sound waves are transmitted via the ossicles in the middle ear to the cochlear fluid in the

inner ear. The basilar membrane of the cochlea is the resonance region and responds to

various vibration frequencies. The cilia of hair cells are the sensory receptors that turn

these vibration frequencies into electrical signals and directly connect to the acoustic

42

nerve endings. The auditory nerves carry these signals to the auditory cortex in the

temporal lobe. The primary auditory cortex receives inputs and is involved in music

perception of pitch and melody, which is influenced by personal experiences. The

secondary auditory cortex further processes the interpretation of music patterns of

harmony, melody, and rhythm (Weinberger, 2004).

Multiple brain regions respond to music stimuli. Researchers found that pleasant

emotional responses to music evoke activity in the limbic system, thalamus, amygdala,

hippocampus, medial prefrontal cortex, midbrain, e.g., periaqueductal grey (PAG), and

ventral striatum, e.g., the nucleus accumbens (NAc) (Blood & Zatorre, 2001). The limbic

system, amygdala, hippocampus, and medial prefrontal cortex are associated with

emotion, anxiety response, and pain perception. When these regions are activated by

reward or positive motivation, the dopamine and opioid systems are also activated (Bardo,

1998; Berridge & Robinson, 1998; Gardner & Vorel, 1998). Both PAG and NAc are rich

in opioid receptors and are modulated by endorphin and enkephalin (endogenous opioids

peptides) (Bardo, 1998). Activation of PAG and NAc modulates pain transmission and

perception via the descending opioid-related pain inhibitory system (Fields & Basbaum,

1989). Thus, the perceptions of pain and anxiety are altered.

Effects of music on pain. The majority of current published randomized controlled

trials that used music for reducing pain were during medical or surgical procedures (55%)

and for postoperative pain (28%) (Cepeda, Carr, Lau, & Alvarez, 2006). Because the

purposed study is based on these studies tested on adult postoperative patients, the

literature review begins by focusing on this area.

Eleven studies testing the effect of music on postoperative pain were reviewed. Most

43

of the studies were conducted in the United States (Good, 1995; Good, Anderson, Ahn,

Cong, & Stanton-Hicks, 2005; Good, et al., 2001; Good, et al., 1999; Mullooly, Levin, &

Feldman, 1988; Nilsson, Rawal, Unestahl, Zetterberg, & Unosson, 2001; Voss, et al.,

2004), while two were conducted in Taiwan (Good & Chin, 1998; S. L. Hwang, et al.,

1996), and one each in South Korea (M. Good & Ahn, 2008) and in Phillippines (Locsin,

1981). Eight studies were pre- and posttest randomized controlled trials, while three

studies used quasi-experimental design (Good & Ahn, 2008; S. L. Hwang, et al., 1996;

Locsin, 1981). The sample size had a wide range, from 24 subjects (Locsin, 1981) to 500

subjects (Good, et al., 1999). The amount of time that postoperative patients listened to

music ranged from 15 minutes once for two days (Good & Chin, 1998) to 30 minutes

every two hours for 48 hours (Locsin, 1981).

Researchers of nine studies asked the participants to select the type of music they

preferred, while the participants in the other two studies did not select the type of music

(Mullooly, et al., 1988; Nilsson, et al., 2001). The majority of the researchers preselected

the music offered to participants, except one researcher who asked the subjects to bring

their own music (Locsin, 1981). The five types of music that were offered in seven of

these studies were the same (Good, 1995; Good & Ahn, 2008; Good et al., 2005; Good &

Chin, 1998; Good et al., 2001; Good et al., 1999; Voss et al., 2004). They were first used

in Good’s dissertation study (1992, 1995). However, the study conducted in South Korea

added some culturally specific music, offering both American and Korean music (Good

& Ahn, 2008).

Researchers of eight of the 11 studies reported that music reduced pain, while two

studies showed that music reduced pain on Day 2 but not Day 1 (Good & Chin, 1998;

44

Mullooly, et al., 1988), and one study showed that music did not reduce pain during the

first postoperative ambulation (Good, 1995). A researcher conducted systematic review of

42 randomized controlled trials to examine the effect of music on anxiety and pain in

surgical patients. She reported that pain was measured in 22 studies, and 13 of them (59%)

had significant findings on reducing pain (Nilsson, 2008).

Effects of music on pain in cancer and hospice patients. Music has been found to

be effective in decreasing cancer pain in six studies, that were conducted in the United

States (Beck, 1991; Curtis, 1986; Gallagher, et al., 2006; Gallagher & Steele, 2001; Krout,

2001; Zimmerman, et al., 1989), three in Taiwan (S. H. Huang, 2000; S. T. Huang, 2006;

Y. J. Lee, 2000a), and one in Germany (Reinhardt, 1999). Three studies were two-group

randomized controlled trials (S. T. Huang, 2006; Reinhardt, 1999; Zimmerman, et al.,

1989), one study had crossover design (Beck, 1991), one had a two-group

quasi-experimental design (Y. J. Lee, 2000a), and four studies had single group design

(Gallagher, et al., 2006; Gallagher & Steele, 2001; S. H. Huang, 2000; Krout, 2001).

Most of these studies had sample sizes of less than 100 (N = 9 to 80), and three had

a larger sample, from 126 to 345 participants (Gallagher, et al., 2006; Gallagher & Steele,

2001; S. T. Huang, 2006). The amount of time that cancer patients listened to music

ranged from 15 minutes only once (Curtis, 1986) to 45 minutes twice a day for three days

(Beck, 1991). The three studies conducted by music therapists ranged from a single

session once (Krout, 2001) to multiple sessions each with different lengths of time

(Gallagher, et al., 2006; Gallagher & Steele, 2001), and minutes spent on each session

were not specified. All the researchers reported significant effects of music for pain. Two

studies used the same participants as the control group (Beck, 1991; S. H. Huang, 2000).

45

Three studies had one-group pre- and posttest designs (Gallagher, et al., 2006; Gallagher

& Steele, 2001; Krout, 2001). The results from studies with quasi-experimental or single

group designs may be biased since they did not have a control group to detect whether or

not the effect was really from the treatment. The studies with small sample sizes or with

unequal numbers of music sessions would be more likely to be biased as well. Some of

the studies were conducted more than 10 years ago. Since then, the context, medication,

and technology used for treatment and care have changed and the results may be

outdated.

Effects of music on anxiety. Sixteen studies explored the effects of music on

anxiety in a variety of situations: for stress management (Hanser, 1985), after acute

myocardial infarction (White, 1999), after surgery (Good, 1992; Voss, et al., 2004; Yao,

1998), in short-term waiting for day surgery (Cooke, Chaboyer, Schluter, & Hiratos,

2005), while undergoing root canal treatment (H. -L. Lai, et al., 2008), during dressing

change (D. F. Lee, 1995), during delivery (S.-C. Chang & Chen, 2005; Liu, 2002), in

institutionalized elderly (Y. J. Lee, 2000b), in patients receiving mechanical ventilation

(O. K. A. Lee, Chung, Chan, & Chan, 2005), in abused women in shelters

(Hernandez-Ruiz, 2005), and during medical procedures (Bally, Campbell, Chesnick, &

Tranmer, 2003; Smolen, Topp, & Singer, 2002; Yilmaz, et al., 2003). A researcher

conducted systematic review of 42 randomized controlled trials to examine the effect of

music on anxiety and pain in surgical patients. She reported that anxiety was measured in

24 studies and 12 of them had significant findings on reducing anxiety (Nilsson, 2008).

Seven studies were reviewed for the effect of music on reducing anxiety in cancer or

hospice patients. Three were conducted in the United States (Bailey, 1983; Gallagher, et

46

al., 2006; Gallagher & Steele, 2001), three were done in Taiwan (Hung, 2003; S.-Y. Li,

2007; P. I. Peng, 2005), and one was in Australia (Horne-Thompson & Grocke, 2008).

Researchers of three studies used a two-group randomized controlled design

(Horne-Thompson & Grocke, 2008; Hung, 2003; P. I. Peng, 2005), two studies had

one-group pre- and posttest design (Gallagher, et al., 2006; Gallagher & Steele, 2001),

one study had a quasi-experimental design (S.-Y. Li, 2007), and another study had a

randomized comparative group design with no control group (Bailey, 1983).

Among the cancer and hospice patients, the sample sizes ranged from 21 to 345

participants, and the length of the music sessions varied from 25 minutes once (Bailey,

1983) to 30 minutes daily for seven days (Hung, 2003). Studies conducted by music

therapists ranged from 20 to 40 minutes once (Horne-Thompson & Grocke, 2008) to

multiple sessions without specifying length of time for each session (Gallagher, et al.,

2006; Gallagher & Steele, 2001). Although researchers of all seven studies reported that

anxiety was significantly reduced by listening to music, the studies without a control

group, with a small sample size, or with an unequal number of music sessions would be

more likely to be biased.

Related effects of music in hospice and cancer patients included improved mood (D.

S. Burns, 2001; Cassileth, Vickers, & Magill, 2003) and relaxation (S. J. I. Burns, Harbuz,

Hucklebridge, & Bunt, 2001; Curtis, 1986; Krout, 2001), and increased quality of life in

dying patients (Halstead & Roscoe, 2002; Hilliard, 2003). In palliative care settings, staff

members reported that music seemed most effective in the areas of patient satisfaction,

stress reduction, anxiety reduction, and patient receptivity to pain and other physical

discomfort (Gallagher, Huston, Nelson, Walsh, & Steele, 2001). Researchers who studied

47

music thanatology (defined as a prescriptive harp vigil) found that after listening to 25 to

95 minutes of harp music, dying hospice patients (N = 65) showed decreases in agitation,

wakefulness, and breathing effort (Freeman, et al., 2006). Music was also found to

facilitate the process of connecting psychological and spiritual well-being for patients in

palliative care (Salmoon, 2001). In two qualitative studies, researchers reported that

music was able to help dying patients to decrease depressive symptoms and social

isolation, increase communication and self-expression, stimulate reminiscence and life

review, and enhance relaxation (Clements-Cortes, 2004; Porchet-Munro, 1988). Kemper

and Danhauer (2005) stated that using music in end-of-life care can also create supportive

interactions between the dying patients and their loved ones. They explained that

increased communication and expression through music listening may be less threatening

than with verbal expression.

Selection of music. In order to decrease cancer pain and anxiety in hospice cancer

patients, the investigator chose selections of music that she thought were likely to have a

relaxing effect or distract patients from pain and anxiety. First, she asked participants to

choose music they liked or found familiar. Research has shown that preferred music is

more distracting (Parente, 1976) and produces better therapeutic effects than music that is

not preferred (Bruya & Severtsen, 1984). Preferred music reduced pain (Hekmat & Hertel,

1993), negative emotional states (Labbe, Schmidt, Babin, & Pharr, 2007), and increased

relaxation (Stratton & Zalanowski, 1984).

Second, the investigator chose sedative music. Researchers reported that tempo,

typically measured in beats per minute (bpm), is the element predominantly related to an

arousal effect, and that slow or meditative music induced a relaxing effect (Bernardi,

48

Porta, & Sleight, 2006). Other researchers reported that respiratory rate was changed by

the tempo of the music and that increased tempo resulted in muscle tension and other

physical responses (Khalfa, Roy, Rainville, Bella, & Peretz, 2008). Sedative music also

distracts people’s attention and was moderately correlated with alpha rhythm (Borling,

1981). Sedative music is characterized by 60 to 80 beats per minute in tempo, with a

general absence of strong rhythms or sudden high-pitch sounds (Gaston, 1951; Good,

1992).

Third, the investigator chose music that was culturally sensitive for Taiwanese

hospice cancer patients. Researchers compared cultural differences in music preference

for pain relief among three ethnic groups: Caucasians, African Americans, and Taiwanese.

They found that Caucasians frequently chose orchestra music, African Americans

preferred jazz, and Taiwanese selected harp music (Good, et al., 2000). Others found in

South Korea indicated that when both United States and Korean music were offered, 62%

of the postoperative women chose Korean music for reducing pain (Good & Ahn, 2008).

Researchers who were educated in the United States tested Good’s music (1992) in their

studies and reported that Taiwanese patients chose Western harp and piano music for pain,

but none chose jazz (Good & Chin, 1998). Good and Chin (1998) asked Taiwanese

participants to recommend other types of music they preferred, and they suggested

Buddhist hymns and Taiwanese popular songs. Another researcher reported that 50

Taiwanese elderly people preferred Chinese orchestra music and found it relaxing, but

also chose Western music (harp music was the most preferred) from Good’s study (1992,

1995) (Hui-Ling. Lai, 2004). A third researcher offered a choice of Taiwanese and

American music (from Good’s study) and reported that about two-thirds of the

49

participants chose Taiwanese music (S. T. Huang, 2006). Multiple studies conducted in

Taiwan also demonstrated that while most Taiwanese participants were offered different

types of music, while the majority of them selected Taiwanese or Chinese folk or popular

songs or religious music (Buddhist hymns) for relaxation purposes (S. H. Huang, 2000; S.

L. Hwang, et al., 1996; H. H. Lin, Chen, Kuo, Want, & Huang, 2007; H.-C. Wu & Chou,

2008). Therefore, culturally specific music was included in this study to reduce cancer

pain and anxiety hospice cancer patients.

Nature Sounds

Nature sounds are the sounds produced by natural phenomena, such as wind, rain,

ocean, streams, animals, and birds. Human beings are closely attached to the natural

world and contact with nature is beneficial to health (Frumkin & Louv, 2007). Wilson

(1984), a biologist and sociobiological theorist, described that the intimate emotional

connection human beings have to other living organisms as the concept of biophilia. He

hypothesized that humans possess a genetically based tendency to focus on and respond

to life and lifelike processes in the environment. An environment rich in biodiversity is

preferred by human beings. Expanding on this theory, other researchers suggested that an

affinity for nature may go beyond living things, including nature scenes and sounds

(Heerwagen & Orians, 1993).

Although human beings are closely bonded with nature, the therapeutic use of nature

sounds is understudied. Five studies that focused on the effect of nature sounds were

found (Dickhaus, et al., 2003; Diette, et al., 2003; Golletz, 1997; Tsuchiya, et al., 2003;

Williamson, 1992). Four of them were conducted in the United States, while one study

was done in Japan (Tsuchiya, et al., 2003). Three studies were conducted during clinical

50

procedures for flexible bronchoscopy (Diette, et al., 2003), rectal distention process

(Dickhaus, et al., 2003), and general anesthesia (Tsuchiya, et al., 2003). One study was

conducted on postoperative patients for sleeping problems (Williamson, 1992). The other

was an unpublished doctoral dissertation and conducted on undergraduate students for

managing anxiety and anger (Golletz, 1997). All the studies used a quasi-experimental

design to compare group differences. Sample size ranged from 29 to 128 adult

participants. Nature sounds used included ocean sounds (Golletz, 1997; Williamson,

1992), sounds of streams (Diette, et al., 2003; Golletz, 1997; Tsuchiya, et al., 2003), birds

singing (Diette, et al., 2003; Tsuchiya, et al., 2003), and soft wind (Tsuchiya, et al., 2003).

Researchers of one study did not report the type of relaxing nature sounds they used

(Dickhaus, et al., 2003). Researchers of these studies found that nature sounds were

effective in reducing pain (Diette, et al., 2003), decreasing anxiety and anger (Dickhaus,

et al., 2003; Golletz, 1997), lowering blood pressure and heart rate (Tsuchiya, et al.,

2003), and improving sleep experience (Williamson, 1992).

Nature sounds have effects similar to that of music. That is, nature sounds also have

different tempos, pitch, and rhythm. For example, birds singing may have a higher pitch

than the sounds of frogs. Larger ocean waves repeat in slow, rolling tempo with more

bass frequencies, while smaller lake waves lap sand and rocks in a much faster manner.

Sounds of streams often have a continuous rhythm, and sounds of rain may create a

playful rhythm. Moreover, personal preference will also play a key role. For example,

some people may feel that a thunderstorm has a relaxing effect, but others may feel

frightened by it. Therefore, the selection of nature sounds for testing in this study took

pitch, tempo, and rhythm into consideration. Nature sounds were selected if they are

51

sedative or generally slow in nature and with a general absence of strong rhythms or a

sudden high pitch.

Since Taiwan is an island with shores, mountains, and forests, using ocean waves

and birds singing are culturally appropriate. These sounds are also recommended by other

researchers (Dossey, 1995; Rhiner, Ferrell, Ferrell, & Grant, 1993). Other nature sounds

familiar to Taiwanese people were also selected, including the sounds of frogs, sounds of

nature night life, and sounds of forests. However, the sounds of stream and winds were

not used. Sounds of streams have been found to trigger the urge to urinate in listeners

(Diette, et al., 2003) and might have potentially caused discomfort for the hospice cancer

patients. Sounds of the wind in Chinese culture are traditionally associated with sadness,

loneliness, and negative feelings, so these were also not included in the nature sounds

used in the study.

Combination of Music and Nature Sounds

The combination of music and nature sounds consists of sedative music and nature

sounds. English and Chinese language studies that focused exclusively on testing the

combination of music and natures sounds were not found. Four studies conducted in

foreign countries used the combination of music and nature sounds as only one of the

types of music intervention (Harikumar, et al., 2006; Hung, 2003; S. Y. Lin, 2003;

Sorensen & Tybjerg, 2004).

A combination of music and nature sounds was used as one choice of music in a

randomized controlled trial of patients undergoing colonoscopies in India. The

researchers indicated that they used a soothing mixture of soft instrumental music with

nature sounds in the study, and it was the second preferred type of music (23%) chosen

52

by patients in the study (N = 78). They reported that patients who were in the music

group received less midazolam and had a lower discomfort score than those who did not

(Harikumar, et al., 2006).

The second study was done in Denmark with 30 psychiatric patients who suffered

from anxiety and distress. The researchers used a commercially made program

(MusiCure) to treat these psychiatric patients. They reported that 87% of the patients

experienced a positive effect from the treatment. They calmed down and some of them

fell asleep. However, the patients were assigned to treatment and control groups by

nurses based on their clinical judgement, and the number and length of treatments were

varied in each patient (Sorensen & Tybjerg, 2004).

The other two studies were master theses conducted in Taiwan. One researcher

provided the combination of music and nature sounds as one of the music choices for 11

pediatric cancer patients during chemotherapy to control for nausea and vomiting. The

study result did not reach a statistically significant level between treatment and control

groups. The researcher did not report the number of children who chose the combination,

so the effect of using a combination of music and nature sounds is unknown (S. Y. Lin,

2003). Another researcher also included the combination of music and nature sounds as

an option 16 adult cancer patients. Although she reported that five patients selected the

combination, it is not clear whether or not the combination was effective in decreasing

anxiety and depression and improving sleep quality (Hung, 2003).

Researchers argued that music frequently can be highly subjective. They suggested

the use of nature sounds with music may be more adequate since it crosses all language,

social, and cultural barriers (Harikumar & Kumar, 2007). Therefore, the criteria for

53

selecting the combination of music and nature sounds will be sedative in nature and with

a general absence of strong rhythms or sudden high pitch in music and nature sounds.

After reviewing studies of nature sounds and the combination of music and nature

sounds, several gaps were found. Researchers of these studies did not provide a definition

of nature sounds. Studies were generally done in a small sample size without

randomization design. Most of them used nature sounds or the combination of music and

nature sounds only as one type of music selection available to patients. The types of

nature sounds and the combination of music and nature sounds lacked variety. Some

studies included a combination of nature sounds and a picture of nature scenery, so the

pure effects of nature sounds and the combination of music and nature sounds were not

clear. Although studies provided statistically significant evidence on effects of these two

interventions on procedural pain, anxiety, and sleep experience in other population, the

effect of nature sounds and the combination of music and nature sounds on cancer pain

and anxiety in hospice cancer patients remain unknown. As a result, this investigator will

define and provide criteria for nature sounds and the combination of nature sounds in the

study. Nature sounds and the combination of music and nature sounds will be separated

to two intervention groups in order to examine the effect of these two interventions.

Threats to Internal Validity

Threats to internal validity can occur in experimental designs and may result in

biased outcomes. History is an event that happens between the beginning of the treatment

and the posttest that can produce the observed outcome in the absence of that treatment

(Shadish, Cook, & Campbell, 2002, p. 56). For example, if a family member of a study

participant turned on the television, or a cell phone rings during the treatment, it may

54

influence the effect of the intervention. To prevent or minimize this problem, the

researcher will ask the family member to leave the room and come back after the

intervention is done, and turn off the television and the cell phone during the intervention

session. A sign was posted on the door of the patient’s room to help prevent unexpected

disturbances. Opioid analgesics and anxiolytics prescribed during the data collection

period are also a threat to history. The name, route, dose, frequency, time given, and

whether medication was “in effect” were recorded and controlled statistically.

Maturation is the natural changes that could occur even without the treatment, such

as growing older or gaining more knowledge or experience (Shadish, et al., 2002). The

hospice cancer patients in the study may become weaker as their illness progresses, and

this will affect their ability to actively listen to the tape and to express pain and anxiety

accurately. It would be difficult to control for the progress of their illness, so maturation

was minimized by randomization.

Attrition or experimental mortality refers to participants who drop out of the study

during the data collection period (Shadish, et al., 2002). Hospice cancer patients may

have a higher experimental mortality rate than other populations because their life

expectancy is less than six months when entering hospice care. Attrition can also happen

when the participants transfer to other units or healthcare facilities. Participants in the

control group may not like to wait for three days to receive the treatment and decide to

drop out early. If participants in one treatment group dropped out more than those in the

other groups, the outcome would be influenced by the group number differences.

Therefore, in order to have a sufficient sample size in each group, more participants were

recruited and randomized to until each group had 31 participants in it. The data collected

55

from participants who dropped out of the study was analyzed as a separate group and

compared to those who completed the data collection process. The attrition rate and

reasons for dropout from the study were recorded and reported.

Instrumentation occurs when using the same instrument for repeated measurements.

That is, when taking the same measurement twice, the second score will be influenced by

the first score (Shadish, et al., 2002). Pain and anxiety was measured with 100-mm VAS

scales three times in this study, and participants may have become familiar with the scale.

The participants may have changed their score after the treatment, and the change of the

pain score may not be due to the treatment effect. To minimize the threat of

instrumentation, pretest and posttest measures were presented to the participants on

separate pages to reduce the chance of memory of previous scores biasing response. The

use of randomization also controlled for the threat of instrumentation.

Selection bias occurs when participants are allocated purposefully into groups

(Shadish, et al., 2002). If the participants are assigned to groups based on their choice or

based on the researcher arrangement, selection bias may occur. For example, participants

may choose the combination group because they consider that music with nature sounds

represents a double dose of treatment, and believe that the combination would be more

helpful for their pain and anxiety than the other treatment group. The use of

randomization may help to minimize selection bias to ensure that participants assigned to

each group are comparable.

Diffusion of treatments may occur when participants in the control group have

access to the real or similar treatment (Shadish, et al., 2002). In this study, interventions

were shared between participants if participants in the same room were assigned to

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different groups. This was minimized by arranging it so that participants who shared the

same room were in the same group. Unit nurses and physicians were told not to take the

MP3 players to other patients.

Compensatory equalization occurs when the treatment provides desirable outcomes

and the healthcare professional cannot tolerate the inequality. They might insist the

control group also receive treatment or provide other treatment than usual care (Shadish,

et al., 2002). For example, the staff nurse may provide other treatment, such as massage,

to those participants in the control group. In order to minimize these threats to internal

validity, healthcare providers were told not to change their usual care and to which group

the participants were assigned. The control group was provided with a CD on the fourth

day, so the healthcare providers ensured that every participant was provided with a

treatment.

Compensatory rivalry is when participants in the control group try to demonstrate

that they are able to do well even with no treatment (Shadish, et al., 2002). For example,

when participants in the control group know that they are assigned to the control group,

they may try to use other methods, such as meditation or self-guided imagery, to show

that their pain and anxiety can also be decreased even with no treatment. The researcher

told the control group that they would be in the data collection phase first and then

receive interventions on the fourth day. To minimize this threat, the control group

received music, nature sounds, or a combination of music and nature sounds based on

their preference when the data collection was completed.

Resentful demoralization can occur among participants in the control group. They

may feel resentful and demoralized because of receiving no or less treatment, so they

57

react by withdrawing from the study, becoming angry, or it may affect their ratings of

pain and anxiety (Shadish, et al., 2002). For example, if the participants in the control

group notice that they are not receiving any treatment, they may decide to withdraw from

the study. Therefore, the researcher told the control group that they would be in the data

collection phase first and then receive an intervention on the fourth day. To minimize the

chance that participants in the control group might find out they were in the control group,

clustered randomization of conditions to rooms was used rather than using simple

randomization at a personal level.

Summary of Literature Review

Cancer pain and anxiety are multidimensional phenomena and are difficult to be

managed effectively by current treatments. Their reciprocal effect may result in decreased

quality of end-of-life in hospice cancer patients. Music has been identified as a

nonpharmacological intervention to reduce pain and anxiety in different populations.

However, studies reviewed had limitations, including lack of randomization, small

sample sizes, and outdated methods. Additionally, nature sounds and the combination of

nature sounds may be culturally preferred by Taiwanese people, but are understudied in

current research. As a result, the study used sedative music and explored nature sounds

and the combination of music and nature sounds in hospice cancer patients to reduce

cancer pain and anxiety. Threats to validity were controlled by randomization, study

design, and statistical tests.

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Chapter Three

Method

In this chapter, the methodology of the proposed study is presented. The study

design and randomization procedure are described first, followed by the sampling setting.

The experimental intervention, measures, potentially confounding variables, procedure,

and protection of human subjects are described. Finally, the procedures used for data

management, screening, and analysis plan are provided.

Design

A four-group, pre- and posttest experimental design with repeated measures was

used to study the effect of music and nature sounds on cancer pain and anxiety.

Participants in the treatment groups listened to 20 minutes of their assigned intervention

between the pretest and the posttest measures, once a day for three continuous days.

Participants in the control group rested in bed or in a chair for 20 minutes between the

pretest and posttest measures at the same time points. A convenience sample was selected

from two hospice units in two hospitals in Kaohsiung, Taiwan. One had 20 beds, and the

other had 11 beds. The first hospice unit contained eight patient rooms: three single

rooms, four 2-bed rooms, and two 4-bed rooms. The second hospice unit contained five

patient rooms: three single rooms and two 4-bed rooms. The single and 2-bed rooms are

for those who were willing to pay for them. The 4-bed rooms sometimes had both males

and females staying in the same rooms.

The randomization scheme was a combination of cluster randomization of existing

groups (rooms) and adaptive randomization to equalize the number of participants in each

group. Treatments were randomized to rooms (Friedman, Furberg, & DeMets, 1998;

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Kalish & Begg, 1985). This was expected to prevent diffusion of treatments within the

2-bed and 4-bed wards. The investigator used an online randomization program

(Randomization.com) with a block size of four for ten blocks, one for each room, to

generate a sequence for assigning treatment condition to room: control (CT), music alone

(MU), nature sounds alone (NS), or the combination (CB) ( Table 1).

Table 1.

Example of Sequence for Assigning Treatment Conditions to Room

Block (Room) Sequences 1 2 3 4 5 6 7 8 9 10

1 CB NS MU CT NS CT MU CB CB NS 2 CT MU CB NS MU CT MU CT NS CB 3 MU CB NS CT NS MU CT CB CB NS 4 MU CT MU CB NS CT NS CB CT MU

Note. More sequences were run using Randomization.com than are shown in this example.

According to hospital protocol, cancer patients who were admitted to the hospice

were assigned rooms by the Chief Resident (CR) in the Department of Family Medicine

assigned to the hospice. The CR assigned patients to the wards based on information in

the computer system. Hospital protocol specifies that newly admitted patients are

assigned by gender to the room with the least number of patients. Due to the availability

of beds, both male and female patients may be assigned to the same room upon the

agreement of the patient and family.

The investigator used the randomization scheme initially to randomly assign

treatment conditions to all rooms in the hospice (Table 1). For each sequence in the table,

treatment conditions were printed on pieces of paper that were folded and sealed in

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brown opaque envelopes. The ten brown envelopes (without numbers) in each sequence

were shuffled by the committee chair of the investigator and placed in sealed white

envelopes. The white envelopes were also shuffled and numbered sequentially by the

investigator’s committee chair. The investigator selected the white envelope marked “1”

and blindly selected one brown envelope from the white envelope to randomly assign

treatment conditions to rooms in Taiwan. If at any time there were no study participants

in a room, the investigator blindly selected one brown envelop from the same white

envelope. The process was repeated until all brown envelopes have been used in the

white envelope marked “1.” Then, as rooms become empty, the white envelop marked “2”

was used.

As new cancer patients were admitted to the hospice rooms and referred to the

investigator, she would approach them about the study. Patients would not be told the

treatment condition before consent so as to not bias their willingness to participate;

however, they were told that the treatments were randomly assigned to rooms, that is, by

chance, like rolling a dice.

The randomization program (Randomization.com) with a block size of four for 10

blocks was used five times in order to generate sequences for assigning room to treatment

conditions. This procedure not only ensured the blindness of room assignment, but also

increased the likelihood that all conditions would be assigned and experimental group

sizes would approach similarity. The Chief Residents were not told the treatment

assignments, and the treatment assigned to each room changed over time; therefore, the

rooms and newly admitted patients were assigned to rooms blindly and by chance.

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Sampling

The sampling frame was cancer patients who had pain and anxiety and received

hospice care in two large hospitals in southwest Taiwan. A convenience sample was

selected from the Kaohsiung Medical University Chung-Ho Memorial Hospital (KMUH)

and St. Joseph Hospital (SJH) in Kaohsiung City, which has a population of 1.5 million

people. The KMUH has a 20-bed hospice unit and a hospice collaborative care program,

while the SJH has an 11-bed hospice unit. All patients were diagnosed with terminal stage

cancer and had an expected life expectancy of less than six months.

Sample size estimation. Sample size was calculated for achieving a power of .80

and an alpha of .05, in four groups with three repeated measures. A medium effect size of

f = .25 (Cohen, 1992) was used based on a randomized controlled trial of patients with

chronic pain that also used a one-dimension VAS pain measure and three groups

(Siedlecki & Good, 2006). The effect size f was .26, which was calculated on the basis of

adjusted mean differences in post-treatment scores between three groups (M1 = 5.95, M2

= 5.84, M3 = 7.01; SDpooled = 2.01). Based on power analysis, using the G-power 3.0.10

program (Faul, Erdfelder, Lang, & Buchner, 2007), a sample size of 124 patients (31 per

group) was calculated.

Inclusion and exclusion criteria. Included were persons who (1) had at least one

documented cancer pain score in the past 24 hours; (2) had a regularly scheduled (versus

prn) analgesic schedule to control for fluctuations in pain that occur with prn schedules;

(3) were oriented to person, place, and time, and in the researcher’s judgment were of the

physical and mental status that would enable the individual to participate in the study; (4)

were cognitively intact to understand and follow study procedures; (5) could read and

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speak Chinese, Taiwanese, or English, and (6) were at least 18 years of age, because the

music was designed for adults. Both genders were included in the study. At the bedside,

two additional screening questions were asked: whether the person liked to listen to

music and whether they felt it was appropriate to listen to music while they were sick and

in the hospital. Patients who answered “yes” to both questions and met the other criteria

were included.

Excluded were patients who had (1) delayed developmental status documented on

the chart; (2) difficulty hearing; and (3) severe visual deficiency to control for inability to

mark the VAS scales. The subject screening form is shown in Appendix A.

Setting

Kaohsiung Medical University Chung-Ho Memorial Hospital is one of the largest

hospice settings in the southern area of Taiwan. Approximately 400 patients were

admitted to the hospice unit in 2008 and 2009, and the average occupancy rate of beds

was about 85 % (Personal conversation with the unit head nurse, 9/28/2010). The KMUH

also has a hospice collaborative care program. This program provided hospice care to

cancer patients who were staying in other units of the KMUH while waiting for a bed

available in the hospice unit. Patients who were in the hospice collaborative care program

received care from both the unit and the hospice team. The average length of stay in the

hospice unit was 12 days. The major reason for discharge from the hospice unit was death

or in the active dying process because some people believe that they should die at home

in order to bring good luck to their offspring. The information about the length of stay

and the major reason for discharge from the collaborative care program were not

available for the researcher to collect.

63

St. Joseph Hospital is a large hospital and the first to provide hospice care in

Kaohsiung. Approximately 200 patients were admitted to the hospice unit in 2008 and

2009; the average occupancy rate was about 65 %. The average length of stay in the

hospice unit was 12 days (Personal conversation with the unit head nurse, 12/20/2010).

The major reason for discharge was death or in the active dying process. In both hospice

sites, staff nurses assessed pain regularly, but not anxiety.

In Taiwan, all hospitals are regulated by the Department of Health and receive

reimbursement from the National Health Insurance Program. These hospice units are

accredited annually by the Taiwan Academy of Hospice Palliative Medicine annually.

Therefore, many factors are similar across all the hospice units in the country. These

included the settings, forms used, medical treatments, medication management,

composition of the hospice care team and their hospice care-related education, and the

nurse-patient ratio. In addition, the accreditation committee requires that at least one

caregiver (either a family member or a nurse’s aide) is with the patient at the bedside at

all times. Other family members are encouraged to visit the patient before 10 p.m. Most

visitors come to the unit in the morning or in the evening.

Neither hospice units had music therapists to provide music therapy to the patients.

Although some nurses may have had some knowledge of nonpharmacological therapies

from their continuing education programs, music is not widely used as a therapy for

hospice patients. Patients in the unit could listen to music by request. Three CD players

were available in the KMUH hospice unit, while the SJH only had one CD player. Some

CDs were available in both hospice units and were either purchased by the nursing staff

or donated by the families or religious groups. Patients also could bring their own music

64

device and borrow music CDs from the unit.

Experimental Interventions

The experimental interventions were music, nature sounds, and music combined

with nature sounds. These interventions were selected and/or edited by the investigator

and were saved on the investigator’s laptop according to the intervention group and

choices offered. There were separate folders for different types of music, nature sounds,

or the combination of music and nature sounds. Each intervention played for a similar

amount of time. Because of the limited availability, there was less variety in types of

nature sounds and combination of music and nature sounds compared to music only.

To choose music for the study, participants who were assigned to each group

listened to 20-second excerpts of their assigned intervention: eight different types of

music, five types of nature sounds, or five types of combined music and nature sounds.

The selections that were offered as choices were chosen by the investigator and evaluated

for appropriateness by the dissertation committee chair, Marion Good, PhD, RN, FAAN,

and a professional music therapist, Deforia Lane, PhD, MT-BC.

Music. The music was expected to reduce pain and anxiety through distraction

and/or relaxation and fulfilled several criteria: it was nonvocal and generally sedative,

with a rate of 60 to 80 bpm, low volume, and included minimal strong rhythms or

percussion (Gaston, 1951; Good, 1992). Eight types of music were selected for this study:

orchestra, piano, harp, religious music (Christian or Buddhist), Chinese music, Taiwanese

music, and easy listening music. Orchestra, piano, and harp music were selected from

Good et al.’s music tapes (Good, et al., 2010; Good, et al., 1999) because they were liked

by Taiwanese people (Good & Chin, 1998) and were effective in populations with

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postoperative patients (Good, et al., 2010; Good & Chin, 1998; Good, et al., 1999; Voss,

et al., 2004), nonmalignant chronic pain (Siedlecki & Good, 2006), and cancer pain (S.-T.

Huang, Good, & Zauszniewski, 2010). Some Christian music selected from Good’s

religious music collection (Good, et al., 2010) was labeled Christian religious music.

Buddhist religious music was selected from CDs familiar to Taiwanese people, suggested

by Taiwanese patients (Good & Chin, 1998), found effective for Taiwanese cancer

patients (S. T. Huang, 2006), and culturally appropriate for this population. Easy listening

music, Chinese music, and Taiwanese music were selected as preferred music by

Taiwanese patients in several previous studies (S. H. Huang, 2000; Y. C. Huang, 2003;

H-C. Wu, 2007). Therefore, these four types of music plus Buddhist religious music were

selected by the investigator based on the same criteria of nonvocal, generally sedative, 60

to 80 beats per minute, and with minimal strong rhythms, loud sections, or percussion.

The music selected for this study is shown in Appendix B.

Nature sounds. Nature sounds were expected to produce distraction and/or

relaxation and thereby decrease cancer pain and anxiety. No studies have provided

detailed instruction or description for selecting nature sounds for clinical use. Taiwanese

people live close to nature and the sea. Nature sounds selected for this study included

those thought to be familiar to them. The nature sounds included that of birds singing,

ocean waves, frogs, night life of nature, and forests. These sounds were commercially

produced by Wind Records from sounds collected in Taiwan. The nature sounds selected

for this study are shown in Appendix B. The nature sounds were generally sedative in

nature with minimal loud sections, strong rhythms, or sudden high-pitch sounds.

66

Combination of music and nature sounds. The combination of music and nature

sounds was based on the same criteria for selecting music and nature sounds. The music

in the combination condition was that used on commercially produced CDs of music and

nature sounds and was composed by Taiwanese musicians. No studies were found that

focused on this type of intervention. The types of music and sounds were taken from

commercially available CDs by Wind Records. The combination of music and nature

sounds selected for this study is shown in Appendix B. These included piano with bird

songs, sounds from night life and new age music with sounds of ocean waves, the forest,

and frogs. The nature sounds were collected in Taiwan and are familiar to Taiwanese

people.

The researcher told the control group that they were in the data collection phase first

and then would receive interventions on the fourth day to avoid the threat to internal

validity of resentful demoralization in this group. During the intervention period, the

control group was asked to stay in their beds or chairs in a comfortable position for 20

minutes once a day for three days. On the fourth day they were invited to select one

commercially made CD of sedative music, nature sounds, or the combination, to listen to

and keep. The selections of these CDs are shown in Appendix B with asterisks by the

CDs’ names.

Equipment. The equipment used in this study included an MP3 player, headset, and

a speaker. The Transcend MP330 MP3 player was selected for its small size, light weight,

easy use, and 2-year warranty. The YongLe clip-on headsets and the Sonpre Capsule

S020 speakers were chosen for their small size, light weight, easy use, and relatively

good sound transmission. All the equipment was marked with stickers with information

67

on them so that the investigator could organize and keep track of the devices. The stickers

had the investigator’s name, contact phone number, and an identifying letter to match all

the equipment in the set. The equipment sets were put in 4.5 x 6-inch plastic pouches

with paper clips that the participants could use to attach the pouches onto their bed sheets

or pillow cases when they listened to the intervention (Figure 3).

Figure 3.

Equipment Used in This Study

a. b.

Figure 3. Equipment used in the study is shown individually and labeled by numbers in picture (a) and assembled in the pouch in picture (b). In picture (a), number 1 is a 4.5 x 6-inch plastic pouch with a zipper shown on the left side and a binder clip on top; number 2 is the MP3 player; number 3 is the clip-on headset; number 4 is the speaker; and number 5 is the USB connector cable to connect the MP3 player and the speaker.

Measures

Cancer pain. Cancer pain in this study was defined as a subjective feeling of an

unpleasant sensory and emotional experience associated with the growth and/or treatment

of a tumor. Cancer pain was measured with the one-dimensional Pain VAS scale, a

100-mm horizontal line anchored by “no pain” and “most pain imaginable.” When using

the 100-mm Pain VAS with Taiwanese hospice cancer patients, these descriptive words

were set in the same horizontal direction as the Chinese written language, from left to

1 2

3

4

5

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right. That is, “no pain” was placed on the left side and “most pain imaginable” was on

the right side. The investigator explained to participants that it is a ruler-like instrument to

measure their current cancer pain. Participants were asked where they had pain at the

time of measurement. If multiple pain locations were identified, participants were

instructed to mark the location of the most severe current pain on a diagram of the human

body, and to mark the VAS at the point representing the most severe pain. The Pain VAS

was scored by measuring in millimeters the distance from the side marked “no pain” to

the center of the mark made by the participant. Possible scores ranged from 0 to 100 mm.

Higher scores indicated greater pain intensity (M. McCaffery & Pasero, 1999). In the

event that patients were alert but could not use their hands to make a mark, the

investigator would have used her index finger as a pointer on the 100-mm Pain VAS scale.

She would have put her index finger at the “no pain” end as the start point and then

moved it slowly toward to the “most pain imaginable” end. When the patient said “stop”

at the correct level, the researcher would have put the tip of a pen on the VAS scale by the

tip of the researcher’s index finger and ask the patient again if it was the correct pain

level. If the patient had answered “yes,” the researcher would mark the Pain VAS scale at

the exact place indicated. If the patient had answered “no,” the researcher would resume

the process until the correct level was determined. However, no participants required this

assistance.

The one-dimension Pain VAS has support for test-retest reliability in multiple

studies. In one longitudinal study of chronic pain, researchers reported the test-retest

reliability of the Pain VAS over three different time intervals from two weeks to four

months. Reliability ranged from .55 to .84, with a median of .81 (M. P. Jensen, Turner,

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Romano, & Fisher, 1999). In a systematic review of 164 articles focused on the reliability

and validity of pain instruments in adult cancer patients, four studies supported the

test-retest reliability of the Pain VAS. The time interval ranged from five minutes to one

week. The average test-retest reliability was .80. The Pain VAS was sensitive enough to

detect change in cancer pain across different times or treatments in 11 studies. In support

of concurrent validity, the Pain VAS had strong associations (r > .70) with other pain

intensity measures in 13 studies. However, Jenson reported two studies with a correlation

with other pain rating scales that were less than .70, but did not provide citations (2003).

Construct validity of the Pain VAS was reported as strong, r = .85, p < .001, with a

Numeric Rating Scale (NRS) in 50 cancer patients (Paice & Cohen, 1997). Concurrent

validity of the Pain VAS with the Brief Pain Inventory (BPI) Pain Interference subscale

(N = 388) was good in oncology medical (r = .71, p < .01) and surgical patients (r = .73,

p < .01) (Tittle, McMillan, & Hagan, 2003).

The Pain VAS scale was used before and after each the scheduled tests of the

interventions. The intervention and control conditions were provided to participants three

times, i.e., once a day for three days. Thus, the Pain VAS scale was marked by each

participant a total of six times. The Pain VAS is shown in Appendix C.

Anxiety. Anxiety in this study was defined as an unpleasant subjective feeling

associated with the perception of a threat. Anxiety was measured with the Anxiety VAS

scale. The Anxiety VAS is a 100-mm horizontal line anchored at either end by descriptive

words of “no anxiety” and “most anxiety imaginable.” When using the 100-mm Anxiety

VAS with Taiwanese hospice cancer patients, these descriptive words were set in the

same horizontal direction as Chinese written language, from left to right. That is, “no

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anxiety” was placed on the left side and “most anxiety imaginable” was on the right side.

The investigator would explain to participants that anxiety can be a worrisome, uneasy, or

restless feeling, and the scale is a ruler-like instrument to measure their current anxiety.

Participants were instructed to mark the line at the point representing the intensity of their

anxiety at that time. The Anxiety VAS was scored by measuring in millimeters the

distance from the side marked “no anxiety” to the center of the mark made by the

participant. Possible scores range from 0 to 100 mm. Higher scores indicated greater

anxiety intensity. In the event that patients were alert but could not use their hands to

make a mark, the investigator would have used her index finger as a pointer on the

100-mm Anxiety VAS scale, in the same manner she was prepared to do for the Pain VAS

scale; however, no patients required this assistance either.

Test-retest reliability of the Anxiety VAS scale was supported by studies in the

United States and Taiwan. In the United States, Voss (2001) used the Anxiety VAS with

10 cardiac patients and reported a 15-minute interval test-retest reliability correlation of r

= .82. In Taiwan, researchers used the Anxiety VAS in 32 cancer patients with a

three-hour interval and reported the test-retest reliability correlation of r = .92 (T.-W.

Huang, et al., 2001). Validity of the Anxiety VAS was examined by multiple researchers.

The Anxiety VAS was found to have a strong positive correlation (r = .70) with the

State-Trait Anxiety Inventory (STAI) in Elliott’s study of 56 patients with acute ischemic

heart disease (1993), and with the STAI in women in a specialist breast clinic ( r = .78, p

< .01) (Davey, Barratt, Butow, & Deeks, 2007). The Anxiety VAS was moderately

correlated with the STAI in ten postoperative cardiac patients (r = .41) (Voss, 2001). The

anxiety VAS was moderately correlated with STAI scores in 685 preoperative patients (r

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= .55, p < .01) (Kindler, Harms, Amsler, Ihde-Scholl, & Scheidegger, 2000). In Taiwan,

one researcher tested the concurrent validity of the Anxiety VAS with the STAI in

patients with hematological malignancy and reported moderate to strong correlations of r

= .59 to .74 for trait and state anxiety, respectively (P. I. Peng, 2005). The Anxiety VAS

scale was used before and after the assigned intervention or control condition twice a day

for three days for a total of six times. The Anxiety VAS is shown in Appendix C.

Demographic measures. The demographic measures included age, gender, race/

ethnic background, primary language used, primary religious belief, education, marital

status, number of children and significant others, cigarette and alcohol intake, and income.

The information was recorded from the hospital record (Appendix C).

Types of music and nature sounds generally liked.

To measure the types of music and nature sounds that the participants generally liked, the

question was asked at the bedside after consent was obtained. The researcher read a list of

22 types of music and nature sounds that she believed familiar to Taiwanese people.

Participants answered “yes,” “no,” or “don’t know” to respond to each item, and the

researcher checked off the answers. If the participant liked a type of music that was not

on the list, the answer was put in the space of “other.” The purpose of asking about the

types of music and nature sounds Taiwanese cancer patients like was to explore the types

of music and nature sounds Taiwanese hospice cancer patients prefer. The findings could

provide information for music and nature sounds selections for future hospice patients

(Appendix C).

Experience with complementary and alternative therapies. Participants were

asked about their experience with complementary and alternative therapies. There were

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14 of these therapies the researcher believed were familiar to Taiwanese people.

Participants answered whether or not they had experienced any of these therapies and

whether they were using them currently. The purpose was to understand what other

nonpharmacological therapies the participants have used. If they were currently using any

of these therapies, it could be a potentially confounding variable and might need to be

statistically controlled as a covariate (Appendix C).

The investigator asked the participants at the end of the final visit whether or not

they liked the assigned intervention (music, nature sounds, and the combination) and

provided their comments about the study. The participants answered this question by

using a five-point Likert type scale (1 = disliked; 5 = liked very much). Because nature

sounds and the combination of music and nature sounds were relatively novel

interventions, this would serve as the basis for one of the research questions to be

answered. The findings would contribute to future use of these interventions on different

populations and trigger further research studies.

Length of time and reasons for independent listening. Participants who were

assigned to the treatment groups were encouraged to use the intervention independently

between tests to possibly reduce their pain and/or anxiety between the treatment sessions.

The researcher checked the MP3 player before each pretest to record the information

about the length of time the patient listened. For example, every song had its length of

time. The researcher had listed each song in sequence and included the playing time of

each song in the MP3 players. At the end of each treatment period, the researcher

accessed the name of the last song played and recorded the song’s name on the data

collection instrument. Before the pretest of the next treatment period, the researcher

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checked the song’s name on the MP3 player and asked the participant if the MP3 player

was used between treatment sessions. The song’s name was recorded on the data

collection instrument, and the researcher would know from the sequence how many and

which songs were played between tests. The minutes were calculated by adding the

minutes of all the songs that had been played. In addition, patients were asked about the

reasons for independent listening. The findings were expected to provide a better

understanding about the length of time and the reasons for patients to use the intervention

(Appendix B).

Potentially Confounding Variables

Analgesic and anxiolytics intake. Medication may reduce the intensity of cancer

pain and anxiety and become a confounding variable. The use of analgesics and

anxiolytics, including name, route, frequencies, dose, time given, and if “in effect” at the

time of the tests were recorded from the patient’s chart by the researcher daily. “In effect”

was defined as the medication’s duration of effectiveness; for example, when morphine is

administered to a patient, the medication is in effect for four to six hours in the patient’s

system. The hospice cancer patients took prescribed analgesics around the clock for

symptom control in accordance with the WHO three-step analgesic ladder (Taiwan

Cooperative Oncology Group, 2007). The use of both scheduled and prn drugs was

recorded in the nurses’ notes and the researcher extracted these data daily and recorded

them on the data collection instrument. Pain medicine was categorized into three groups,

weak opioids, strong opioids, and nonopioids. Currently available and frequently

prescribed weak opioid analgesics in both hospice units included Codeine, Tramadol,

Darvocet, and Ultracet; the strong opioids Morphine, Fentanyl, MST Contin, and

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Temgesic; and the nonopioids Acetaminophen, Baclofen, Cataflam, Celecoxib,

Chlorzoxzone, Clonazepam, Etoricoxib, Ibuprofen, Ketorolac, Mefenamic, Naproxen,

Neurontin, Steroids, Tegretal, Tofranil, and Urogen (Taiwan Cooperative Oncology

Group, 2007).

Although the Cochrane review of anxiolytics for hospice cancer patients reported

that there was no sufficient evidence to determine whether current methods of

pharmacological management of anxiety are beneficial or harmful to terminally ill

patients, medications such as anxiolytics, antidepressants, and antipsychotics have been

frequently prescribed for patients with anxiety or other symptoms in hospice (Jackson &

Lipman, 2004). The anxiolytics available in Taiwan included Alprazolam, Lorazepam,

Bromazepam, Chlordiazepoxide, Flunitrazepam, Estaxolam, Britielam, Midazolam,

Clonidine, Triazolam, and Zolpidem (Taiwan Cooperative Oncology Group, 2007).

Therefore, the use of analgesics and anxiolytics was recorded and were considered as

potentially confounding variables (Appendix C).

Environmental disturbances. During the tests, disturbances could be a potentially

confounding variable. The participants might have been disturbed by routine care and

treatment, visitors, phone calls, and electronic devices. This was prevented as described

in the procedure section.

Religious chanting box. Based on the researcher’s personal experience and her

observation as a nurse, people who are Buddhists or Taoists sometimes listen to chanting

music played by a religious chanting box, especially during the dying process. Listening

to the religious chanting box was considered history that could threaten the validity of the

study. A religious chanting box might have from six to more than 20 chanting music

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selections, with and without scripture. It is believed that by listening to the chanting box,

the person is able to clear the mind and cleanse the soul, and eventually go to the Eastern

Wonderland or Heaven. Some patients listen to the music chanting box periodically,

while some patients and/or their families prefer to play it 24 hours a day for continuous

blessing. Although some of the music in the chanting box is monotone and slow in tempo,

some of the music contains varied rhythms, sudden high pitch sounds, and relatively fast

tempos (faster than 80 bpm). Therefore, the music chanting box may produce a different

effect and become a confounding variable for the study. As a result, those patients who

used the music chanting box and wanted to participate in the study were asked to refrain

from listening to it during the three days they were in the study. Those patients who were

assigned to the music group were able to select Buddhist music as one of the choices.

Those who were not willing to temporarily stop listening to the music chanting box were

excluded or dropped from this study.

Procedure

Case Western Reserve University Cancer Institutional Review Board (IRB), the

Kaohsiung Medical University Chung-Ho Memorial Hospital, and St. Joseph Hospital

provided IRB approval to conduct this study. The investigator received permission from

the head nurse of the units and set up a meeting to explain the study purpose and

procedures to all members of the medical and nursing staff and obtained their cooperation

during the data collection period. The staff nurses in the hospice unit screened patient

charts for eligibility. After preliminary identification of potential participants, the staff

nurse requested the patients’ permission for the investigator to talk with them. The

investigator completed the screening process at the bedside. Each eligible participant was

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invited to participate and was asked to provide informed written consent. Once enrolled,

the demographic data were collected from the chart and at the bedside. First, participants

were asked questions about the kinds of music and nature sounds they liked, and then

were told their group assignment. Participants who were assigned to the intervention

groups then listened to 20-second excerpts of each kind of music, nature sounds, or the

combination of music and nature sounds. Then they selected one type of music, nature

sounds, or the combination they liked and found the most relaxing. The first visit with the

participant was completed (Day 0).

An MP3 player with the type of intervention they selected was provided to the

participants the next day (Day 1). The investigator scheduled adequate time with the

participant to provide the first intervention. She also checked with the primary nurse to

make sure the scheduled time was appropriate to avoid interruption during either patient

care or the intervention session.

The investigator instructed participants on the use of the MP3 player (start, stop, and

volume) and the headsets or speakers. If family caregivers were present in the room with

the participant, they were also taught to use the MP3 player to help the participant listen

to the music at times other than the scheduled time. Then, the investigator explained the

use of the VAS scales, demonstrated their use, and allowed time for practice. Participants

in the control group received similar instruction and practice on using the VAS scales.

Since the control group was in a separate room from the treatment groups, they did not

receive intervention until Day 4. The scheduled intervention test was 20 minutes once a

day to minimize the burden on the hospice cancer patients. The scheduled intervention

testing was carried out for three continuous days.

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Before delivering the intervention, the researcher checked the name of the song on

the MP3 player and recorded the name of the song on the data collection instrument.

Participants were asked to rate their pain and anxiety levels on the pretest VAS scales.

They were instructed to lie in their bed or sit in their chair in a comfortable position. The

investigator assisted those in the intervention group with putting on the headset or setting

up the speakers, making sure the MP3 player was functioning, and adjusting the volume

to a comfortable level. She drew the curtain around the patient’s bed and stayed outside

of the curtain in the room during the intervention. Family members of all patients in the

room were asked to go out for a break and come back after the session. If they chose to

stay, they were asked not to talk to the participant and to stay outside of the curtain with

the investigator. Those patients and family who shared the same room and were not in the

study were asked not to talk during the intervention. After the intervention session,

participants were asked to rate their pain and anxiety levels again on the posttest VAS

scales.

In order to provide intervention integrity, the time selected for testing the

intervention were after routine care and treatment was completed. The participants’

primary care nurses were asked to schedule their work before or after the intervention,

but to consider the priority of the care and treatment. While providing the intervention or

control condition, interruptions from visitors who wished to see the participant were

avoided. Upon the agreement of the patients, the door of their room had an appropriate

sign to help prevent unexpected disturbances. Phone lines in the patients’ room were

temporally disconnected and the television was turned off by the investigator.

Participants who were assigned to intervention groups were given the opportunity to

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change the type of music, nature sounds, or the combination of music and nature sounds

within their assigned group. For example, participants in the music group could select

piano music on the first day, change to religious music on the second day, and listen to

orchestra music on the third day. However, they were not permitted to change to a

different intervention, e.g., from music to nature sounds. The investigator encouraged

participants to use the MP3 players between tests as needed for pain and anxiety. The

investigator recorded time and reasons for the extra use of the intervention by asking the

participants, their family members, or their primary care nurses before the treatment each

day. She also checked the MP3 player for the song’s name and recorded it on the data

collection instrument. If the intervention was used by the participants, minutes of

independent listening time were calculated by summing the time listed for each song on

the MP3 player. Table 2 shows the data points.

Table 2.

Data Points Table

Day 0 Day 1 Day 2 Day 3

Demographic X

Type of MU/NS liked X

100-mm Pain VAS Xox xox xox

100-mm Anxiety VAS Xox xox xox

Minutes of Independent Intervention Use X X

Liked Assigned Intervention X

Note. MU = Music; NS = Nature Sounds; X = measure; O = treatment; xox = pretest, 20 min treatment, posttest

Those in the control group rated their pain and anxiety on the pretest VAS scales, for

20 minutes resting in their beds with the curtains drawn or sitting in their chairs quietly,

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and rated their pain and anxiety again on the respective VAS scale for the posttest. Their

families received the same instruction as the intervention group. After the three-day data

collection period, participants in the control group were asked to select one commercial

CD of music, nature sounds, or the combination of music and nature sounds that the

intervention was selected from in the study, and they could keep the CD for personal use.

To help them to decide what CD they would like to have, they listened to the 20-second

excerpts first, then chose the CD that the 20-second excerpt was from. The procedure of

the study is shown in Figure 4.

Figure 4. The Study Procedure

Figure 4. VAS = Visual Analogue, CD = Compact Disk.

Patients assigned to room by administration

Screening

Recruitment

Demographic and Baseline

Pretest of Pain and Anxiety VAS

20 min Combination

20 min Music

20 min Nature sounds

20 min rest in bed or chair quietly

QD for 3 days

Posttest of Pain and Anxiety VAS

Select one CD to keep Listen to intervention as desired

Room randomly assigned to condition

Combination Music Nature sounds Control

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Protection of Human Subjects

The Belmont report establishes the ethical principles relevant to the protection of

human subjects for research. These include respect for human dignity (right to

self-determination and full disclosure), beneficence (freedom from harm and

exploitation), and justice (fair treatment and privacy) (The National Commission for the

Protection of Human Subjects of Biomedical and Behavioral Research., 1979). The

investigator gave every participant oral and written descriptions of the research purpose,

procedures, risks, benefits, and assurances of privacy, anonymity, and confidentiality.

Participants had the chance to ask questions and were given answers. They were

informed that they could voluntarily choose to participate or not, and that they had the

right to withdraw from the study at any time without affecting their care.

Participants were asked to return the informed consent form to the investigator, and

those who signed the form were given a copy of it in the same day. The investigator kept

a list of the names, bed number, and study IDs of all patients who met the inclusion

criteria and who returned consent for participating in the study. The study IDs did not

reflect hospital ID. The list was used to identify participants during the study. This list

was locked in a separate drawer from the other data. When the data collection and

analysis were completed, this list was shredded. Each data collection form with the date

and ID number was prenumbered. All data collection forms were stored in a locked

cabinet to keep the information confidential. Data coding instructions were included

within the data collection instrument.

Although side effects rarely occurred when using music and nature sounds

interventions, caution was still necessary. In past studies, some participants did not like

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music nature sounds or the music/nature sounds selected by the investigator (Bruya &

Severtsen, 1984; Hui-Ling. Lai, 2004). Therefore, during screening in the present study,

patients were asked whether or not they liked music/nature sounds and whether or not

they think listening to music/nature sounds is appropriate. This was done as part of

screening for eligibility. Those who did not like music/nature sounds or felt that listening

to them was not appropriate while they were sick in the hospice unit, or those who had an

uncomfortable response to music or nature sounds in the past, were excluded from this

study. Participants who disliked the music/nature sounds that they originally chose were

invited to change the type of music/ nature sounds within the categories of the assigned

intervention or withdraw from the study.

Some contraindications, such as musicogenic epilepsy and hypersensitivity to sound

are rare, but could happen during any study (Brust, 2001; Kaplan, 2003; Wieser,

Hungerbuhler, Siegel, & Buck, 1997). Musicogenic epilepsy is a neurological condition

in which the patient has seizures that are induced by certain sounds or music.

Hypersensitivity to sound is a condition in which sound becomes painful and produces

headaches in some patients (Allen & Good, 2000; Wieser, et al., 1997). The screening

questions assessed for those who have had uncomfortable responses in the past. If the

condition had unexpectedly happened, the music would be turned off immediately, a safe

environment would be created, and medical treatment would have been summoned. No

incidents of this nature occurred during the study

Data Management

Although the investigator was the only data collector, a clear instruction was written

on the data collection instrument to keep the data collection process consistent and

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confidential. The investigator checked the completeness of the data before leaving the

patient’s room to avoid any missing data (Roberts, Anthony, Madigan, & Chen, 1997).

Data were coded and entered into the investigator’s computer. The questionnaire was

stored in a locked cabinet and only the investigator and research-related personnel had

access to these files. After all the entered data were double-checked again and errors were

corrected by the investigator, the data set was saved in a computer as well as on two

backup portable hard drives with password protection.

Data Cleaning

The investigator proofread the original data collection form against the entered

computer data file to ensure accuracy of the data file. Frequencies, descriptive statistics,

and graphic representations of the variables were used to identify errors in the data file.

For example, unusually small or large, or out-of-range scores on a given variable would

be examined for potential errors in coding. If errors were found, the original data

collection form was pulled and the miscoded data were corrected immediately

(Tabachnick & Fidell, 2007).

Assumptions of Statistical Tests

Repeated measures analysis of variance (RM ANOVA) has four major statistical

assumptions. First, samples in each group should be independent. Since the rooms were

randomly assigned to the four groups and patients were assigned to rooms by someone

who was blind to the room assignment of groups, they were considered to be independent.

Second, the dependent variables in each group are normally distributed. This assumption

was checked by using frequencies (numeric) for the skewness and kurtosis and graphs

(plots and histograms) of the dependent variables for each treatment group (Field, 2005;

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Tabachnick & Fidell, 2007). To support multivariate normality, the skewness should be <

|3| and the kurtosis should be < |8 − 20|(Curran, West, & Finch, 1996). In a large

sample with continuous variables, skewed distribution generally is not expected, although

opioid medication may result in a negative skew. Normality will be met based on central

limit theorem (Tabachnick & Fidell, 2007).

Third, homogeneity of variance-covariance matrices tests whether the

variance-covariance matrices of the different groups are equal. A nonsignificant result of

Levene’s test represents homogeneity of variance matrices among groups. Box’s M test

would be used to test homogeneity of covariance matrices. A nonsignificant result of

Box’s M test means that the matrices among groups are the same. When violation of

homogeneity occurs, a more stringent alpha level will be used. If the violation is

moderate, the alpha level will be set as .025; if the violation is severe, the alpha level will

be .01 (Field, 2005; Tabachnick & Fidell, 2007). Sphericity is the equality of variances of

the differences between treatment levels in a repeated-measure ANOVA and is considered

as a part of the assumption of homogeneity of variance in between-group ANOVA. A

nonsignificant Mauchly’s test for sphericity means that the variances of the differences

between conditions are equal. If Mauchly’s test is significant, the Greenhouse-Geisser

correction should be used. If the Greenhouse-Geisser estimate is greater than .75, the

Huynh-Feldt correction should be used. However, if the Greenhouse-Geisser estimate is

less than .75, the Greenhouse-Geisser correction should be used (Field, 2005).

Fourth, linearity of the relationships among dependent variables is assumed.

Pearson’s correlations (numeric) and bivariate scatterplots (graphic) were used for the

linear relationships among continuous variables. Bivariate regression was also used to

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examine the relationship between two continuous variables by adding a line of fit

correlation coefficient squared (R2) linear, R2 quadratic, and R2 cubic to partial plots and

check for 2% differences between these lines. Violation of linearity could reduce the

power of the statistical tests. The skewed variables would not be transformed because by

doing so, the meaning of the variable would be changed (Tabachnick & Fidell, 2007).

Data Analysis

Descriptive analysis was used for demographic data, types of music liked, experience

with complementary/alternative therapy, minutes of independent use of the intervention

between tests, outcome variables, and each variable in the set to examine the

characteristics of participants, variability, central tendency, dispersion, and normality. The

reasons that participants withdrew from the study were described. The pain and anxiety

scores of those who withdrew were compared to those who remain in the study. Based on

the previous studies in which music or nature sounds decreased cancer pain and anxiety,

this study used one-tailed test with a significance level of .05 (Diette, et al., 2003; Golletz,

1997; S. T. Huang, 2006).

Pearson’s product moment correlations and Spearman’s correlation were used to

identify the covariates. Possible covariates included age, gender, those with pain

medications and anxiolytics “in effect” during treatment, and pain and anxiety at each

pretest. Therefore, if the correlation between the potential covariate and pain and anxiety

scores was higher than r = .30 (p < .05), they were used as covariates (Cook & Campbell,

1979; Tabachnick & Fidell, 2007).

Hypotheses testing. Hypotheses 1 and 2 were tested using a priori orthogonal

contrasts (Table 3). Contrast 1 compared the three intervention groups to the control

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group. Contrast 2 compared the music and nature sounds groups to the combination

group. Contrast 3 compared the music group to the nature sound group. Additionally, the

polynomial contrast tests were also used for trends over time in six pre-posttest measures

(Field, 2005).

Table 3.

Orthogonal Contrasts Table

Contrasts MU NS CB CT

Contrast 1 1/3 1/3 1/3 -1

Contrast 2 1/2 1/2 -1 0

Contrast 3 1 -1 0 0

Note. MU = Music; NS = Nature sounds; CB = Combination; CT = Control

To test Hypothesis 1, that hospice cancer patients who listened to sedative music,

nature sounds, and sedative music combined with nature sounds will have less cancer

pain than control when controlling for baseline, repeated-measures analysis of covariance

(RM ANCOVA) across the three pain posttests while controlling for the Day 1 pretest and

any identified covariates was used. To test Hypothesis 2, proposing that hospice cancer

patients who listened to sedative music, nature sounds, and sedative music combined with

nature sounds will have less anxiety than control when controlling for baseline,

repeated-measures analysis of covariance (RM ANCOVA) across the three anxiety

posttests while controlling for Day 1 pretest and any identified covariates was used. For

these two hypotheses, sedative music, nature sounds, and sedative music combined with

nature sounds were independent variables, while the pain and anxiety scores at posttests

were dependent variables.

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Research questions. To answer Research Question 1 about what types of music and

nature sounds are generally liked by the Taiwanese hospice cancer patients, frequencies

were obtained for the 22 categories on the list used on day 0. To answer Research

Question 2 about how much Taiwanese hospice cancer patients liked their assigned

intervention, music, nature sounds, and the combination of sedative music with nature

sounds, frequencies were obtained for the single question at the end of the study. To

answer Research Question 3 about how many minutes music, nature sounds, and the

combination of sedative music with nature sounds were used independently between

testing times, frequencies were obtained for the single question at the end of the study. To

answer Research Question 4 about the relationship between cancer pain and anxiety in

hospice cancer patients, the relationship between cancer pain and anxiety pretests and

posttests scores were analyzed at Day 1, Day 2, and Day 3 with multiple regression

analysis in the Statistic Program of Social Science (SPSS). Since both pain and anxiety

scores are continuous variables, three primary statistical assumptions for regression,

adequate variance, absence of influential cases, and linearity were tested prior to using

the regression technique. When using pain and anxiety scores in regression, one can be

the independent variable while the other can be the dependent variable; and the results

not only presented the relationship between cancer pain and anxiety, but also provided the

explained variance between these two variables.

Summary

The effect of music, nature sounds, and the combination of music and nature sounds

on cancer pain and anxiety in 123 hospice cancer patients were examined by a

randomized four-group, pre-post test experimental design with repeated measures.

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Participants in the experimental groups listened to 20 minutes of the assigned

intervention once a day for three days, while those in the control group in their beds or

chairs quietly for the same length of time. Cancer pain and anxiety were measured by

100-mm VAS scales, before and after the intervention at three time periods. Whether or

not the participants liked the assigned intervention was asked at the end of the study. Data

were analyzed by RM ANCOVA, frequencies, Pearson’s product moment correlations,

and regression.

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Chapter Four

Results

This chapter provides the results of the four-group randomized controlled clinical

trial to determine the effect of music, nature sounds, and the combination of music and

nature sounds on pain and anxiety in hospice cancer patients. The sample, the settings,

and descriptive data are described. Then, the results of hypothesis testing are presented.

The four research questions are then analyzed. Finally other descriptive findings are

presented.

Sample

The sample consisted of 117 terminal cancer patients, 64 men and 53 women, aged

from 21 to 87. They were chosen from the cancer patients in two hospice units of two

large hospitals in Kaohsiung, Taiwan, Kaohsiung Medical University Hospital (KMUH)

and St. Joseph Hospital (SJH). The two hospice units were compared in terms of seven

criteria, admissions, discharges, length of stay, occupancy rate, nurses’ age, and years of

experience in the hospital and hospice. The KMUH hospice unit had significantly more

admissions, discharges and a higher occupancy rate than SJH, but there was no

significant difference in length of stay between both units, and no significant difference

in the nurses’ ages and years of working in hospital or hospice (Appendix D).

Between October 1, 2010 and May 8, 2011, a total of 309 patients were screened for

eligibility. There were 150 patients who did not meet the inclusion criteria, and 159

eligible patients who were invited to participate in the study. A total of 123 patients

agreed and signed the consent, and 36 declined. The refusal rate was 22.64%; two thirds

were male (n = 24, 66.67%). The reasons for refusal were: too weak or too tired (n = 13),

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did not want to sign the consent form or their families did not want them to sign (n = 6),

were not in the mood for music (n = 5), were not interested in this study (n = 4), did not

like music (n = 2), only wanted to listen to the chanting box (n = 2), did not want to be

disturbed (n = 2), only wanted Japanese music (n = 1), and wanted to spend more time

with family (n = 1).

Participants were randomly assigned to one of four groups: three treatment groups

that received music (n = 30), nature sounds (n = 34), or the combination of music and

nature sounds (n = 29), and a control group that received usual care (n = 30). Three

participants died before the data collection was completed. Three participants’ condition

deteriorated and requested to withdraw from the study. The attrition rate was 4.88%.

Because all 123 participants were tested on Day 1, that number was used for the

descriptive data. There were 119 participants on Day 2 and 117 on Day 3, which is the

sample size used for the repeated measures analyses. Using Chi-square, there were no

significant differences in number of participants among four groups on each day.

Demographic characteristics. Ages ranged from 21 to 87 years with a mean of

60.54, SD = 14.74 years, and a median of 60. The majority were male (55.3%), married

(69.9%), Taiwanese (95.1%), primarily spoke Taiwanese (80.5%), had no regular income

(65.8%), and did not use a chanting box (90.2%). Two-thirds had never smoked (n = 82,

66.7%). Of the 41 smokers, all quit smoking an average of 1.9 years ago (SD = 3.82), but

they had smoked a mean of 1.31 packs per day (SD = 1.09) for 32.56 years (SD = 14.20)

before they quit. Nearly three-fourths (n = 89, 72.4%) did not drink alcohol. Of the 34

alcohol users, 13 participants drank socially and 21 participants drank daily. Using

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Chi-square, gender, cigarette usage and alcohol usage were significantly different among

the four groups (Table 4). The control group had more males, smokers, and alcohol users.

Participants had an average of 3 children, M = 2.75, SD = 1.65, with a range of zero

to nine. The number of significant others ranged from one to eleven people, M = 2.41, SD

= 1.72, and 49 had more than one. The significant others included children (n = 69),

spouse (n = 59), siblings (n = 21), parents (n = 10), in-laws (n = 7), partner (n = 5),

friends (n = 3), and grandchildren (n = 2). The reasons for discharge from the hospice

unit after participating in the study were that participants died (n = 56), went home for

continuous care (n = 38), were transferred to another facility for continuous care (n = 17),

and were discharged against medical advice (n = 6).

Experience with complementary and alternative therapies. All participants were

asked whether they had experience with each of 14 complementary and alternative

therapies and whether they were currently using them (Table 5). Only eight types of

complementary and alternative therapy had been used by the participants. Herbal

remedies were the most frequently used, followed by massage, and a few had used

acupuncture or aromatherapy. Eighty three (67.48%) of them had used complementary/

alternative therapy in the past, but only 20 participants (22.73%) were still using the

complementary/ alternative therapy. Chi square indicated no significant differences

among the groups.

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Table 4.

Demographic Characteristics of the Participants (N = 123)

Groups Χ2

Total MU (n=30) NS

(n=34) CB (n=29) CT

(n=30)

Characteristics n % n % n % n % n % Gender 8.72*

Male 68 55.3 14 11.4 19 15.5 12 9.7 23 18.7 Female 55 44.7 16 13.0 15 12.2 17 13.8 7 5.7

Primary language used 3.69 Taiwanese 99 80.5 24 19.5 29 23.6 20 16.3 26 21.1 Chinese 24 19.5 6 4.9 5 4.1 9 7.3 4 3.3 Religion 17.61

Folklore cultural beliefs 41 33.3 4 3.3 15 12.2 10 8.2 12 9.8 Buddhism 36 29.3 10 8.1 4 3.3 11 8.9 8 6.5 Taoism 23 18.7 9 7.2 9 7.3 4 3.3 4 3.3 Christian 16 13.0 6 4.9 3 2.4 3 2.4 4 3.3 None 5 4.1 1 0.8 1 0.8 1 0.8 2 1.6 Catholic 2 1.6 0 - 2 1.6 0 - 0 -

Education 20.41 Self study (0 yr) 6 4.9 3 2.4 2 1.6 1 0.8 0 - Elementary (1-6 yrs) 43 35.0 11 8.9 14 11.4 6 4.9 12 9.8 Junior high (7-9 yrs) 20 16.3 5 4.1 5 4.1 3 2.4 7 5.7 Senior high(10-12 yrs) 31 25.2 6 4.9 10 8.1 13 10.6 8 6.5 College (13-16 yrs) 22 17.9 4 3.3 3 2.4 6 4.9 3 2.4 Master (17-19 yrs) 1 0.8 1 0.8 0 - 0 - 0 -

Marital status 12.21 Never married 8 6.5 0 - 1 0.8 4 3.3 3 2.4 Married 86 69.9 26 21.1 23 18.7 21 17.1 17 13.8 Widowed 14 11.4 3 2.4 4 3.3 3 2.4 4 3.3 Divorced 15 12.2 2 1.6 6 4.9 1 0.8 6 4.9

Race 7.57 Taiwanese 117 95.1 28 22.8 34 27.6 3 2.4 29 23.6 Chinese 5 4.1 1 0.8 0 - 26 21.1 1 0.8 Mainlander 1 0.8 1 0.8 0 - 0 - 0 -

Income 6.36 No income 81 65.8 20 16.3 25 20.3 18 14.6 18 14.6 No stable income 2 1.6 0 - 0 - 1 0.8 1 0.8 < 10,000 NT 1 0.8 0 - 1 0.8 0 - 0 - Do not care to provide 39 31.7 10 8.13 8 6.50 10 8.1 11 8.9

Cigarette usage 9.85* No 82 66.7 22 17.9 26 21.1 21 17.1 13 10.6 Yes 41 33.3 8 6.5 8 6.5 8 6.5 17 13.8

Alcohol usage 14.02*

No 89 72.4 24 19.5 24 19.5 25 20.3 16 13.0 Yes, socially 21 17.1 5 4.1 8 6.5 1 0.8 7 5.7 Yes, daily 13 10.6 1 0.8 2 1.6 3 2.4 7 5.7

Note. MU = Music; NS = Nature sounds; CB = Combination of music and nature sounds; CT = Control. * p < .05

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Table 5.

Experience with Complementary and Alternative Therapy (N = 123)

Past Experience Current Usage No Yes No Yes

Therapy n % n % n % n % Acupuncture 115 93.5 8 6.5 6 4.88 2 1.63 Acupressure 122 99.2 1 0.8 1 0.8 0 - Aromatherapy 118 95.9 5 4.1 1 0.8 4 3.25 Art therapy 123 100 0 - Biofeedback 123 100 0 - Chi Kung 123 100 0 - Guided imagery 122 99.2 1 0.8 1 0.8 0 - Healing touch 123 100 0 - Herbal remedy 68 55.3 55 44.7 50 40.65 5 4.1 Hypnosis 122 99.2 1 0.8 1 0.8 0 - Massage 112 91.1 11 8.9 2 1.63 9 7.32 Music therapy 123 100 0 - Chiropractic 123 100 0 Dietary 122 99.2 1 0.8 1 0.8 0 Never used 40 32.52

Primary sites of cancer. Because all hospice cancer patients had multiple sites of

metastases, only the primary cancer site was recorded (Table 6). Of the 123 participants,

the most frequent sites were colon/rectal (n = 20), lung (n = 18),

nasopharyngeal/esophagus area (n = 14), oral cavity (n = 13), and liver (n = 13). Two

participants had multiple metastases at the first visit to their doctors and “unknown

original sites” was documented in their medical record.

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Table 6.

The Primary Sites of Cancer (N = 123)

Cancer Type n % Colon/Rectal 20 16.3 Lung 18 14.6 Nasopharyngeal/Laryngeal/Esophagus 14 11.4 Liver 13 10.6 Oral 13 10.6 Kidney/Ureter/Bladder 8 6.5 Breast 7 5.7 Cervical/Uterine 7 5.7 Digestive/Gastrointestinal 6 4.9 Pancreas 5 4.1 Prostate 3 2.4 Hematological/Blood 2 1.6 Thyroid 2 1.6 Unknown primary 2 1.6 Brain 1 0.8 Ovarian 1 0.8 Spine 1 0.8

Cancer pain and anxiety in hospice patients. Pain was assessed and documented

regularly by staff nurses at least every four to six hours daily in both hospice units. A pain

event was documented in the medical record when a patient complained about pain and

nursing assessment and intervention were provided. The investigator obtained

information about pain from the medical record during the 24 hours prior to the test of the

intervention on Day 1. The range of the number of documented pain events in the 24

hours preceding the Day 1 pretest was from 1 to 17 with an average of 3.24 (SD = 2.07)

times. The highest pain score in the 24 hours previous to the Day 1 pretest ranged from

3 – 10 points (0 – 10 scale) with an average of 5.32 points (SD = 1.86). The lowest pain

score in the previous 24 hours ranged from 0 – 6 points (0 – 10 scale) with an average of

1.26 points (SD = 1.25). Only 33 participants had a documented breakthrough pain event;

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the breakthrough pain scores ranged from 5 to 10 with an average pain of 8.18 points (SD

= 1.45).

All the breakthrough pain events that were documented in the medical records were

“described as at an intolerable point.” Most of the records stated that the breakthrough

pain had a sudden onset, while two said the pain increased gradually. The possible causes

included position change (n = 4), dressing change (n = 1), drinking or eating (n = 2), and

unknown reason (n = 14). The locations of the breakthrough pain in the body were

abdomen (n = 13), legs (n = 4), back (n = 3), whole body (n = 2), face (n = 2), oral cavity

(n = 1), neck (n = 1), arms (n = 1), and waist (n = 1). The symptoms other than pain

included abdominal distension (n = 3), cold sweating (n = 2), stiffness of the whole body

(n = 2), and shortness of breath (n = 1). These participants were crying (n = 3), moaning

(n = 3), and feeling angry (n = 1). No participants were having breakthrough pain at the

time of testing.

Unfortunately, the staff nurses did not assess and document anxiety regularly in both

hospice units. Only eight of 123 medical records contained documented anxiety events.

There were no documented records of anxiety disorders or anxiety events in the past 24

hours. Of the eight most recent anxiety events prior to the Day 1 pretest, six were related

to thoughts of death, dying, and the unknown underworld after death. Four were related

to pain and shortness of breath. Two said they were anxious about the ghosts who visited

them during the night and in their dreams. One said that pain was related to the progress

of cancer on his face. Some participants reported more than one cause of their anxiety.

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Medication Usage

One of the inclusion criteria was that hospice cancer patients were taking prescribed

analgesics around the clock for pain control. All participants had opioid medication “in

effect” during the tests: weak or strong opioids or both. Many also had non-opioid pain

medication along with the opioids. Anxiolytics were prescribed only on an as-needed

basis and only a small percentage of participants were receiving them (Table 7).

Chi-square analysis indicated no significant differences among the groups in analgesics

and anxiolytics “in effect” at each test.

Analgesics and Anxiolytics Used by Participants

The most frequently used weak opioid was Ultracet, followed by Codeine, Tramadol,

and Darvocet. Four strong opioids were prescribed. Nearly two-thirds of the participants

received Morphine and one-third received Durogesic. Many had non-opioid pain

medication along with the opioids to reduce inflammatory pain. The most frequently

non-opioids used were steroids, Tegretal, and Acetaminophen. Three major types of

anxiolytics were Alprazolam, Lorazepam, and Fluoxetin. Frequencies of those with

analgesics and anxiolytics each day are in Appendix E.

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Table 7.

Participants with Analgesics and/or Anxiolytics “in Effect” During Each Test

MU NS CB CT X2

Medication n % n % n % n % p

Day 1 (N=123) n = 30 n = 34 n = 29 n = 30 Weak opioid 6 20.0 13 38.2 10 34.5 5 16.7 5.27 .15 Strong opioid 25 83.3 22 64.7 23 79.3 24 80.0 3.73 .29 Non-opioid 20 66.7 24 70.6 15 51.7 20 66.7 2.73 .44 Anxiolytics 4 13.3 5 14.7 3 10.3 5 16.7 0.53 .91 Day 2 (N=119) n = 30 n = 31 n = 29 n = 29 Weak opioid 8 26.7 12 38.7 8 27.6 5 17.2 3.47 .32 Strong opioid 25 83.3 21 67.7 23 79.3 23 79.3 2.37 .50 Non-opioid 17 56.7 22 71.0 16 55.2 19 65.5 2.15 .54 Anxiolytics 4 13.3 4 12.9 3 10.3 5 17.2 0.61 .90 Day 3 (N=117) n = 29 n = 31 n = 28 n = 29 Weak opioid 7 24.1 12 38.7 8 28.6 5 17.2 3.68 .30 Strong opioid 24 82.8 21 67.7 22 78.6 23 79.3 2.16 .54 Non-opioid 19 65.5 22 71.0 16 57.1 19 65.5 1.25 .74 Anxiolytics 4 13.8 4 12.9 4 14.3 5 17.2 0.25 .97 Note. MU = Music; NS = Nature sounds; CB = Combination of music and nature sounds; CT = Control; The n in each column represents the number of participants who received the medication; some participants were taking more than one analgesic and/or anxiolytics. Pain and Anxiety Pretests and Posttests

Cancer pain and anxiety were measured by the 100-mm Pain and Anxiety VAS

before and after each 20-minute test. The majority had average pain and anxiety scores of

less than 30 mm, except for the combination group in which Day 1 pretest pain and

anxiety and Day 2 pretest anxiety were a little greater (Table 8). The standard deviations

for both pain and anxiety were small and closely clustered about the mean, although the

standard deviations for anxiety was wider than that of pain. Using analysis of variance

analyses, there were no significant group differences in pain or anxiety at each pretest.

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Table 8.

Pain and Anxiety Pretests and Posttests at Each Test (N = 117)

MU NS CB CT Variable M SD M SD M SD M SD F p

Day 1 n = 29 n = 31 n = 28 n = 29 Pain pretest 29.41 7.12 29.29 7.79 31.50 9.06 28.93 8.04 .66 .58 Pain posttest 23.72 6.71 25.65 8.67 24.89 7.12 27.86 8.53 .31 .82 Anxiety

pretest 28.55 13.21 28.45 11.38 32.93 14.98 27.62 11.02 .92 .43

Anxiety posttest 24.90 11.58 26.16 10.77 27.64 12.40 26.86 10.56 .18 .91

Day 2 n = 29 n = 31 n = 28 n = 29 Pain pretest 28.17 9.34 26.03 8.25 29.57 9.42 28.45 5.71 2.16 .10 Pain posttest 22.66 8.44 22.90 7.69 24.57 7.72 28.31 6.41 .77 .51 Anxiety

pretest 27.10 13.95 26.65 10.92 30.07 13.13 27.17 9.95 1.21 .31

Anxiety posttest 22.21 10.69 23.39 9.88 24.14 9.87 27.31 10.85 .13 .95

Day 3 n = 29 n = 31 n = 28 n = 29 Pain pretest 22.62 7.28 23.61 8.27 27.00 8.68 29.31 6.19 1.09 .35 Pain posttest 17.31 6.38 20.52 7.31 22.04 6.30 28.21 7.06 .44 .72 Anxiety

pretest 22.21 10.09 23.19 9.80 25.29 9.12 27.66 10.87 .37 .77

Anxiety posttest 17.34 7.82 20.68 9.52 20.64 8.33 26.83 10.98 .82 .48

Note. MU = Music; NS = Nature sounds; CB = Combination of music and nature sounds; CT = Control. Pain and anxiety were measured by the 100-mm Pain and Anxiety VAS scales.

Correlations

Pearson’s product moment correlations and Spearman’s correlation were used to

identify possible covariates. Those proposed included age, gender, pain and anxiety at

pretests, and pain medications and anxiolytics “in effect” during treatment. These

variables were used as covariates if the data were obtained before the pretest on Day 1

(Tabachnick & Fidell, 2007) and if correlations were greater than r = .30 (p = .05). Using

Pearson’s product moment correlations, age and gender were not correlated with pain and

anxiety post tests at r > .30, so age and gender were not used as covariates. Spearman’s

correlation was used to test the relationship between pain medications and anxiolytics “in

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effect” during treatment and the dependent variables. The results showed that there were

no significant correlations between pain medications and anxiolytics “in effect” and pain

and anxiety posttests. Therefore, the analgesics and anxiolytics were not treated as

covariates.

Day 1 pain pretest was strongly and positively correlated with posttests for Day 1

pain and anxiety, and Day 2 pain. Day 1 pain pretest was moderately and positively

correlated with posttests for Day 2 anxiety, and Day 3 pain and anxiety. The correlations

with Day 1 pretests ranged from r = .41 to .70, p < .001. Day 1 anxiety pretest was

strongly and positively correlated with posttests for Day 1 and Day 2 pain and anxiety

posttests, and Day 3 anxiety. The correlations ranged from .47 to .94, p < .001. Although

Day 2 pain and anxiety pretests, and Day 3 pain and anxiety pretests were all strongly

correlated with the pain and anxiety posttests, they were measured after the treatment was

initially given. Therefore, only Day 1 pain pretest and anxiety pretest were used as

covariates (Table 9).

Table 9.

Correlations between Pain and Anxiety Pretests and Posttests

Day 1 Day 2 Day 3 Pain Anxiety Pain Anxiety Pain Anxiety Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post Day 1 (N=123) Pain pretest - .70 .58 .51 .67 .52 .50 .42 .68 .48 .53 .41 Pain posttest - .52 .59 .60 .66 .49 .54 .62 .63 .54 .54 Anxiety pretest - .94 .65 .55 .85 .74 .63 .47 .78 .63 Anxiety posttest - .60 .59 .81 .78 .59 .52 .78 .71 Day 2 (N=119) Pain pretest - .88 .83 .74 .83 .62 .73 .57 Pain posttest - .75 .79 .83 .76 .73 .68 Anxiety pretest - .91 .70 .55 .89 .73 Anxiety posttest - .69 .64 .92 .88 Day 3 (N=117) Pain pretest - .86 .78 .67 Pain posttest - .72 .76 Anxiety pretest - .90 Anxiety posttest - Note. Pre = Pretest; Post = Posttest; all correlations between tests had a significant level, p < .001.

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Hypothesis Testing

Hypothesis 1 was tested using a priori reverse Helmert contrasts with

repeated-measures analysis of covariance (RM ANCOVA) across the three pain posttests,

while controlling for Day 1 pain pretest. The results showed that pain was significantly

different among four groups, F(5.98, 223.38) = 4.36, p < .001. Contrast #1 indicated that

while controlling for Day 1 pretest pain, the pain posttests were significantly lower in the

music, nature sounds, and combination groups, taken together, than in the control group,

p < .001, 95% CI [4.08, 8.09]. However, contrast #2 indicated no significant differences

in pain when comparing the individual groups, music and nature sounds, taken together,

to the combination group, p = .66, 95% CI [-1.68, 2.63]. Contrast #3 showed no

significant difference in pain when comparing the two individual groups, music and

nature sounds, p = .13, 95% CI [-0.55, 4.28]. The observed power for the contrasts was

1.0. Post-hoc analyses of RM ANCOVA were conducted with a Bonferroni adjustment

controlling for Day 1 pain pretest. Each treatment group had significantly lower pain

across the three tests than the control group. Hypothesis 1 was supported.

HO 1: Hospice cancer patients who listen to sedative music, nature sounds, or sedative

music combined with nature sounds will have less cancer pain than those who do not

when controlling for baseline.

On Day 1 medium effect sizes were found for music and the combination, while a

small effect size was found for nature sounds. On Day 2 all three interventions had

medium effect sizes. On Day 3, all three intervention s had large effect sizes (Table 10).

Thus across the three days, pain in the control group remained the same as the pretest,

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while the effect sizes for the music and combination groups increased from Day 2 to Day

3 and for the nature sounds group they increased each day (Figure 5).

Table 10.

Effect Sizes of Pain and Anxiety by Groups

MU CB NS Symptom Day Partial η2 ES Partial η2 ES Partial η2 ES Pain 1 .08 M .09 M .03 S

2 .10 M .07 M .09 M 3 .34 L .18 L .21 L

Anxiety 1 .07 M .11 M .02 S 2 .09 M .11 M .06 M 3 .23 L .18 L .12 M

Note. MU = Music, CB = Combination of music and nature sounds, NS = Nature sounds, ES = Effect size, S = Small, M = Medium, L = Large Figure 5. Pain Day 1 Pretests and Three Posttests by Group (N = 117)

Figure 5. Day1pre = Day 1 pretest; The three pain posttests mean scores were compared by treatment groups on Day 1, Day 2, and Day 3. The posttest means were adjusted by Day 1 pain pretest score.

15

17

19

21

23

25

27

29

31

Day1pre Day 1 Day 2 Day 3

100

mm

Pai

n VA

S

Music

Nature Sounds

Combination

Control

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Hypothesis 2 was tested using a priori reverse Helmert contrasts with

repeated-measures analysis of covariance (RM ANCOVA) across the three anxiety

posttests, while controlling for Day 1 anxiety pretest. The results showed that anxiety was

significantly different among four groups, F(5.42, 202.50) = 4.04, p = .001. Contrast #1

indicated that while controlling for Day 1 pretest anxiety, the anxiety posttests were

significantly lower in the music, nature sounds, and combination groups, taken together,

than in the control group, p < .001, 95% CI [3.57, 7.53]. However, contrast #2 indicated

no significant differences in pain when comparing the individual groups, music and

nature sounds, taken together, to the combination group, p = .25, 95% CI [-3.37, 0.89].

Contrast #3 showed no significant difference in pain when comparing the two individual

groups, music and nature sounds, p = .10, 95% CI [-0.39, 4.37]. The observed power for

the contrasts was 1.0. Post-hoc analyses of RM ANCOVA were conducted with a

Bonferroni adjustment controlling for Day 1 anxiety pretest. Each treatment group had

significantly lower anxiety across the three tests than the control group. Hypothesis 2 was

supported.

HO 2: Hospice cancer patients who listen to sedative music, nature sounds, or sedative

music combined with nature sounds will have less anxiety than those who do not when

controlling for baseline.

For anxiety, on Day 1 medium effect sizes were found for music and the

combination, while a small effect size was found for nature sounds. On Day 2 all three

interventions had medium effect sizes. On Day 3 music and combination had large effect

sizes, while the nature sounds continued to have a medium effect size (Table 10). Thus

across the three days anxiety in the control group remained essentially the same as the

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pretest, while the effect sizes for the music and combination groups increased from Day 2

to Day 3 and for the nature sounds group they increased from Day 1 to Day 2 (Figure 6).

Figure 6. Anxiety Day 1 Pretests and Three Posttests by Group (N = 117)

Figure 6. Day1pre = Day 1 pretest; The three anxiety posttests mean scores were compared by treatment groups on Day 1, Day 2, and Day 3. The posttest means were adjusted by Day 1 anxiety pretest score.

In the initial interview, the investigator read a list of 22 types of music and nature

sounds and asked participants to identify the kinds they generally liked. Participants

answered “yes” if they liked that type, “no” if they did not like that type, and “do not

know” if they were not sure how to respond to the item. If the participant liked a certain

type of music or nature sounds that was not listed, it was noted under “other” (Table 11).

Light music (n = 106) and Taiwanese folk music (n = 106) were the most frequently liked

types of music, followed by nature sounds from the forest (n = 105), stream (n = 105),

ocean waves (n = 101), night life (n = 100), and Taiwanese popular music (n = 97). The

majority did not like blues (n = 117), followed by jazz (n = 115), traditional Chinese

Research Question 1: What types of music, nature sounds are generally liked by

Taiwanese hospice cancer patients?

15 17 19 21 23 25 27 29 31 33

Day1pre Day 1 Day 2 Day 3

100m

m A

nxie

ty V

AS

Music

Nature Sounds

Combination

Control

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orchestra (n = 112), school folk music (n = 100), and classical music (n = 93), and

Western popular music (n = 93).

Table 11.

Types of Music, Nature Sounds Liked at Onset of the Study (N = 123)

Yes No Do Not Know Types n % n % n %

Light music 106 86.2 15 12.2 2 1.6 Taiwanese folk music 106 86.2 16 13 1 0.8 Forest 105 85.4 12 9.8 6 4.9 Stream 105 85.4 14 11.4 4 3.3 Ocean waves 101 82.1 18 14.6 4 3.3 Night life of nature 100 81.3 18 14.6 5 4.1 Taiwanese popular music 97 78.9 25 20.3 1 0.8 Birds 95 77.2 22 17.9 6 4.9 Frogs 95 77.2 22 17.9 6 4.9 Wind 72 58.5 48 39 3 2.4 Religious 79 64.2 43 35 1 0.8 Crystal music 65 52.8 53 43.1 5 4.1 Chinese folk music 59 48 63 51.2 1 0.8 New age 56 45.5 66 53.7 1 0.8 Chinese popular music 52 42.3 70 56.9 1 0.8 Western popular music 29 23.6 93 75.6 1 0.8 Classical 28 22.8 93 75.6 2 1.6 School folk music 21 17.1 100 81.3 2 1.6 Traditional Chinese orchestra 10 8.1 112 91.1 1 0.8 Jazz 7 5.7 115 93.5 1 0.8 Blues 5 4.1 117 95.1 1 0.8 No preference 2 1.6 121 98.4 0 - Other (n = 9)

Japanese songs 5 4.1 0 - 0 - Ditty 1 0.8 0 - 0 - Mainland China evolutional music 1 0.8 0 - 0 - Taiwanese opera 1 0.8 0 - 0 - Radio station 1 0.8 0 - 0 -

Note. The types of music and nature sounds were answered individually if the participants liked, did not like, or did not know. If the type they liked was not on the list, it was noted as “Other.”

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Participants in the intervention groups (MU, NS, and CB) were asked how much

they liked the intervention they received on the third day after marking the posttest. The

question had a five-point Likert type rating scale (1 = disliked very much; 2 = disliked; 3

= neutral; 4 = liked; 5 = liked very much). Eighty eight participants answered the

question and the mean score was 4.40 (SD = 0.7). More than half of the participants (n =

46) liked their intervention very much, more than one-third (n = 31) liked it, and a few

rated it as neutral (Table 12). The music group rated their intervention the highest, M =

4.79, SD = 0.41; the combination group was next, M = 4.64, SD = 0.49; and the nature

sounds group was third, M = 3.81, SD = 0.70. There was a significant difference in liking

the intervention among three intervention groups, F(2, 85) = 27.85, p < .001. A

Bonferroni adjustment showed that the music group liked the intervention significantly

more than the nature sounds group, p < .001, 95% CI [0.64, 1.34], so did the combination

group compared to the nature sounds group, p < .001, 95% CI [0.48, 1.19]. However,

there was no significant difference in liking the intervention between the music group and

the combination group.

Research Question 2: How much did Taiwanese hospice cancer patients like their

assigned intervention?

105

Table 12.

Intervention Liked by the Participants

Total MU

(n = 29) NS (n = 31) CB

(n = 28)

Rating Amount liked n % n % n % n % F 5.55***

3 Neutral 11 12.5 0 - 11 12.5 0 - 4 Liked 31 35.2 6 6.8 15 17 10 11.4 5 Liked very much 46 52.3 23 26.1 5 5.7 18 20.5

Note. The Likert type rating scale is from 1 to 5, but 1 (disliked very much) and 2 (disliked) were not rated by the participants. MU = Music; NS = Nature sounds; CB = Combination of music and nature sounds; CT = Control. *** p < .001

The types of the assigned intervention that were selected by the participants were

recorded on daily basis (Table 13). Because the participants in the intervention groups

were allowed to change different types of music/nature sounds, some decided to listen to

a different type of music/nature sounds on either Day 2 or Day 3. In the music group,

Taiwanese music was the most frequently selected, followed by easy listening music and

Buddhist music. The most frequently selected nature sounds were forest and then ocean

waves in the nature sounds and the combination groups. In the combination group, none

of the participants selected the music with frogs or night life sounds. On Day 2, five

participants in the music group changed their selection, two in the combination group,

and one in the nature sounds group. On Day 3, seven participants in the nature sounds

group changed their selection, four the combination group, and two in the music group.

Participants’ Suggestions

Twenty three participants provided their suggestions for use of the intervention after

they completed the study. Of these, seven (30.43%) said that the nature sounds were a

little bit monotonous. They suggested having a broader selection of nature sounds and/or

106

combining several types of nature sounds together. Four (17.39%) suggested including

Japanese music among the selections. Three suggested that the intervention should be

provided to more people for a longer period of time. Three participants and their families

suggested that the investigator provide the title of the CD so they could use the same

music when they were discharged from the hospital. Three participants’ families wished

the intervention could be provided for the family, so the family could relax from the

stress of taking care of their loved ones and could remember them after they die. One

participant wanted to listen to music with lyrics. One suggested including Taiwanese

music played on a harp, while one suggested having Taiwanese music combined with

nature sounds.

Table 13.

Types of Music and Nature Sounds Selected by Participants by Day

Day 1 Day 2 Day 3 Type n % n % N %

Music n = 30 n = 30 n = 29 Taiwanese 12 12.9 11 12.2 11 12.5 Easy listening 6 6.5 2 2.2 4 4.5 Christian 4 4.3 4 4.4 2 2.3 Harp 3 3.2 3 3.3 3 3.4 Buddhist 2 2.2 5 5.6 5 5.7 Chinese 2 2.2 2 2.2 2 2.3 Orchestra 1 1.1 1 1.1 0 - Piano 0 - 2 2.2 2 2.3 Nature sounds n = 34 n = 31 n = 31 Forest 20 21.5 20 22.2 13 14.8 Ocean 9 9.7 8 8.9 8 9.1 Birds 4 4.3 0 - 1 1.1 Frogs 1 1.1 2 2.2 7 8.0 Night life 0 1 1.1 2 2.3 Combination n = 29 n = 29 n = 28 Forest 19 20.4 20 22.2 16 18.2 Birds 5 5.4 3 3.3 2 2.3 Ocean 5 5.4 6 6.7 10 1.4 Frogs 0 - 0 - 0 - Night life 0 - 0 - 0 - Note. MU = Music; NS = Nature sounds; CB = Combination of music and nature sounds; CT = Control. Participants could change to different types of music/nature sounds; some chose a different type on Day 2 and/ or Day 3.

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The length of time that the hospice patients listened to the interventions

independently between tests was measured in minutes and is presented in Table 14.

Between Day 1 and Day 2, the range was from 21 to 569 minutes with a mean of 250.58

minutes (SD = 126.39). Between Day 2 and Day 3, was from 29 minutes to 568 minutes

with a mean of 234.65 minutes (SD = 124.76). There was a statistically significant

difference among three intervention groups between Day 1 and Day 2, F(2, 88) = 19.32,

p < .001 and between Day 2 and Day 3, F(2, 81) = 12.06, p < .001. Taken together, the

music and the combination groups listened to the intervention significantly longer than

the nature sounds group at both times, M = 293.04, SD = 50.18, p < .001, CI [170.61,

415.48], M = 214.68, SD = 50.63, p < .001, CI [91.14, 338.22] minutes longer

respectively. The minutes of independent intervention use between testing times were not

significantly correlated with the pain and anxiety posttests across each days.

Research Question 3: How many minutes were music, nature sounds, and the

combination of sedative music with nature sounds independently used between

testing times?

Table 14.

Minutes of Independent Intervention Use Between Testing Times

Day 1 to Day 2 Day 2 to Day 3 n M SD n M SD

Music 29 314.62 128.42 29 300.34 125.03 Nature Sounds 33 159.45 67.90 29 161.55 73.21 Combination 29 290.24 117.98 26 251.92 122.77 Note. a Between Day 1 and Day 2, one participant withdrew and one did not find time to listen to the intervention. b Between Day 2 and Day 3, two participants withdrew and five did not find time to listen.

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The Reasons for Independent Use

The participants had a variety of reasons for using the intervention independently

between tests. The main reason on Day 1 and Day 2 was that they wanted to relax (n =

83). Other reasons were that they liked the intervention (n = 46), felt pain (n = 15), were

curious about the collection in the MP3 player (n = 7), felt anxious (n = 6), could not

sleep (n = 2), and tried to kill time (n = 1). Between Day 2 and Day 3, the main reason

was also that they wanted to relax (n = 79). Other reasons were that they liked the

intervention (n = 51), felt pain (n = 9), felt anxious (n = 6), were curious about the

collection in the MP3 player (n = 5), wanted to sleep (n = 3), and tried to kill time (n = 1).

Pain and anxiety pretests and posttests were positively and strongly correlated with

one another at a significant level at each test: Day 1 pretest r = .58, Day 1 posttest, r = .59,

Day 2 pretest r = .83, Day 2 posttest, r = .79, Day 1 pretest r = .78, Day 1 posttest, r = .76,

p < .001. To determine the amount of variation in anxiety that was related to pain,

miltuple regression was used: pain was the independent variable and anxiety was the

dependent variable. The results showed that Day 2 pain accounted for the most variation

in Day 2 anxiety, followed by Day 3 and then Day 1, p < .001 (Table 15).

Research Question 4: What is the relationship between cancer pain and anxiety in

hospice cancer patients?

Table 15.

Adjusted R Square between Pain and Anxiety Pretests and Posttests by Day

Adjusted R2

Day 1 Day 2 Day 3 Pain pretest – Anxiety pretest .34 .68 .61

Pain posttest – Anxiety posttest .35 .62 .58

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Summary

Pretest pain and anxiety in the 123 participants in two hospice units was ≦ 32 mm

and was not significantly different among the music, nature sounds, combination, or

control group, nor were most demographic characteristics. The control group had more

males, smokers, and alcohol users, but correlations between demographic and dependent

variables were < .30. Day 1 pain and anxiety pretests were used as covariates. Orthogonal

a priori reversed Helmert contrasts with repeated measured ANCOVA and pretest control

indicated that pain and anxiety posttests were significantly lower in the music, nature

sounds, and combination groups together, than the control group. Comparison of each

intervention group with the control group supported these findings with some increased

effect sizes over time. Contrast #2 and #3 were not significant for either variable. Light

music, Taiwanese folk songs, the sounds of the forest and the stream were most

frequently liked types of music and nature sounds at the onset of the study by the

participants. The majority of participants liked their intervention very much. The most

frequently selected music was Taiwanese music, while the most frequently selected

nature sounds was the sounds of the forest. The minutes of independent intervention use

were significantly different among three treatment groups and the music and combination

groups listened to the intervention significantly longer than the nature sounds group

between the two time periods, with longer listening by those in the music and

combination groups than the nature sounds group at both times. Pain and anxiety in

hospice cancer patients were positively, strongly, and significantly correlated.

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Chapter Five

Discussion

This chapter presents a summary of the study, the comparison of the findings from

this study with the literature, and the rationale for differences in the findings. The

limitations of the study and implications of the findings for theory, research, and practice

are then discussed.

Summary of the Study

Cancer has been the leading cause of death in Taiwan for more than 20 years.

Cancer patients who receive hospice care frequently suffer from pain and anxiety. The

purpose of the study was to test the effects of sedative music, nature sounds, and the

combination of music and nature sounds on cancer pain and anxiety in hospice cancer

patients in Taiwan. A middle-range theory of acute pain was used as the conceptual

framework because it proposed using nonpharmacological modalities for pain

management (Good & Moore, 1996). A four-group randomized controlled trial with

repeated measures was conducted in two hospice units (N = 117). Participants in the

intervention groups listened to the assigned intervention and the control group rested in

the bed or the chair quietly for 20 minutes per day for three continuous days. Pain and

anxiety were measured on 100 mm VAS scales before and after the test and were

positively, strongly, and significantly correlated.

The results showed that while controlling for the Day 1 pain and anxiety pretests,

participants in the intervention groups had significantly less pain and anxiety than those

in the control group. Music and combination had medium effect sizes on both Days 1 and

2, which increased to large effect sizes by Day 3. For pain, nature sounds resulted in a

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small effect size on Day 1, which increased to a medium effect size on Day 2, and a large

effect size on Day 3. For anxiety, nature sounds resulted in a small effect size on Day 1

which increased to a medium effect size on Days 2 and 3. The participants reported they

liked light music, Taiwanese folk songs, and sounds of the forest and sounds of the

stream most frequently when surveyed at the onset of the study. Among the choices

offered to the intervention groups the most frequently selected were Taiwanese music and

the sounds of the forest. The majority liked their intervention very much. Independent use

of the interventions between testing times averaged nearly four hours, and was

significantly longer in the music and combination groups than in the nature sounds group.

Comparison with the Literature

The effect of music on pain. Music effectively decreased pain in hospice cancer

patients in contrast to findings of a few studies of post-operative pain (Good, 1995; L. K.

Taylor, Kuttler, Parks, & Milton, 1998) and procedural pain (Bally, et al., 2003;

Kwekkeboom, 2003). These findings were consistent with 19 previous studies of seven

different types of pain. Music was effective in decreasing post-operative pain (Good &

Ahn, 2008; Good, et al., 2010; Good, et al., 2005; Good, Anderson, Stanton-Hicks, Grass,

& Makii, 2002; Good & Chin, 1998; Good, et al., 1999; Locsin, 1981; Mullooly, et al.,

1988; Voss, et al., 2004), labor pain (Phumdoung & Good, 2003), cancer pain (Beck,

1991; Gallagher, et al., 2006; Gallagher & Steele, 2001; S.-T. Huang, et al., 2010; S. H.

Huang, 2000; Krout, 2001; Zimmerman, et al., 1989), chronic pain (R. McCaffery &

Freeman, 2003; Siedlecki & Good, 2006).

Music was provided for 20 minutes daily for three days, and pain was significantly

reduced. Compared to other randomized controlled trials, the three days in hospice

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patients was shorter than three previous longitudinal studies. Siedlecki and Good (2006)

had participants with chronic pain to listen to one hour of music for seven days;

McCaffery and Freeman (2003) asked the elderly who had osteoarthritis pain to listen to

20 minutes of music for 14 days. Lai and Good (2006) had older adults who had sleeping

problems to listen music for 45 minutes each night for three weeks. All researchers of

these studies reported decreased pain or increased sleep quality, but two studies showed

that the effect of music continued to increase as time went on (R. McCaffery & Freeman,

2003) and sleep (Hui-Ling Lai & Good, 2006). The effects of the present study were

consistent with these studies, although the length of time and days were varied. Thus,

based on this literature, it is possible that when patients with chronic symptoms listen to

music for more than one day, the music may have a cumulative effect.

In present study, music had medium to large effect sizes on pain. There were small

to medium effect sizes on pain following abdominal surgery (Good, et al., 2010; Good, et

al., 2005; Good, et al., 2002), medium effect sizes on cancer pain (S.-T. Huang, et al.,

2010) and chronic pain (Siedlecki & Good, 2006), and a large effect size following open

heart surgery (Voss, et al., 2004). In two studies the participants listened to music 15

minutes for two days (Good, et al., 2005; Good, et al., 2002), and in two others the

participants listened for 30 minutes of music one time (S.-T. Huang, et al., 2010; Voss, et

al., 2004), while in one study the participants listened to music for one hour a day for

seven days (Siedlecki & Good, 2006). The effect sizes in these studies varied and

therefore may be influenced by the types of pain, the sample size, and the timing and the

types of music provided in the study.

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The effect of music on anxiety. Music effectively decreased anxiety in hospice

cancer patients, in contrast to the findings of two studies of medical procedures (Bally, et

al., 2003; Yilmaz, et al., 2003). However, the finding was consistent with 15 previous

studies of eight different patient populations. Music was effective in decreasing anxiety

before or after surgery (Bringman, Giesecke, Thorne, & Bringman, 2009; Cooke, et al.,

2005; Pandmanabhan & Hildreth, 2005; Voss, et al., 2004), in the intensive care unit (O.

K. A. Lee, et al., 2005; White, 1999), during cesarean delivery (S.-C. Chang & Chen,

2005), during kangaroo care (H. -L. Lai, et al., 2006), dental procedure (H. -L. Lai, et al.,

2008), and in shelters for abused women (Hernandez-Ruiz, 2005). Music also decreased

anxiety in cancer patients (Bailey, 1983) and hospice patients (Gallagher, et al., 2006;

Gallagher & Steele, 2001; Horne-Thompson & Grocke, 2008; Nakayama, Kikuta, &

Takeda, 2009).

Music was provided 20 minutes daily for three days in the present study and it

significantly decreased anxiety. Of nine randomized controlled trials, researchers of eight

studies provided a single music session ranged from 20 to 60 minutes (S.-C. Chang &

Chen, 2005; Cooke, et al., 2005; Horne-Thompson & Grocke, 2008; H. -L. Lai, et al.,

2008; O. K. A. Lee, et al., 2005; Padmanabhan & Hildreth, 2005; Voss, et al., 2004;

White, 1999). Only one study was found in which the participants listened to music for

60 minutes daily for three consecutive days (H. -L. Lai, et al., 2006). The researchers

reported that maternal anxiety significantly improved daily. Based on the findings from

that study and the present study, it is possible that when patients with an ongoing

condition listening to music for more than one day, music may have an accumulated

effect.

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Music has a medium to large effect sizes on anxiety. Few researchers reported the

effect size of music on anxiety. There was a medium effect size on anxiety in patients

undergoing dental procedures (H. -L. Lai, et al., 2008), and a large effect sizes on

mothers during kangaroo care (H. -L. Lai, et al., 2006) and following open heart surgery

(Voss, et al., 2004). Music was provided for 30 minutes once to 19 post operative patients

(Voss, et al., 2004), 60 minutes once to 22 dental patients (H. -L. Lai, et al., 2008), and 60

minutes a day for three days to 15 new mothers (H. -L. Lai, et al., 2006). Voss et al. (2004)

provided a choice among six types of music for cardiac surgery patients, while no choice

was provided to the dental patients (piano) and the mothers (lullaby). The differences in

effect sizes among these studies may be influenced by the sample size, the sources of

anxiety, the length of music listening, and the type of music.

The effect of nature sounds on pain. There are fewer studies of the effect of nature

sounds. Only one previous study with a quasi-experimental design showed that listening

to sounds of streams reduced pain during the flexible bronchoscopy procedure (Diette, et

al., 2003). There are no known studies of the effect of nature sounds on cancer pain and

none at the end of life. Thus the findings of this study provide new information that

nature sounds significantly lowered pain across three posttests compared to the control

group. Nature sounds had a small effect size on Day 1, a medium effect size on Day 2,

and a large effect size on Day 3. Researchers of the previous studies only provided one

type of nature sounds to their participants, while a choice among five different types of

nature sounds were offered to participants in this study. Choice among a variety of

selections may satisfy individual preferences, which may be based on familiarity with the

nature sounds offered. Although nearly one-third of participants in the nature sounds

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group felt “neutral” about how much they liked the intervention and a few felt the sounds

were a little bit monotonous, the majority did not offer negative comments and reported

that they liked the sounds they received.

The effect of nature sounds on anxiety. In this sample of hospice cancer patients,

nature sounds were effective in lowering anxiety across the three daily posttests and the

effect sizes increased from small to medium. Few studies have explored the effect of

nature sounds on anxiety. The results are in contrast to one study that found no effect on

patients undergoing flexible bronchoscopy (Diette, et al., 2003). The results were

consistent with two studies, one in college students (Golletz, 1997) and one in adults

receiving medical procedures (Dickhaus, et al., 2003). However, none of the three

previous studies randomized their subjects, and the types and severity of anxiety in

previous studies is probably different from hospice cancer patients who have anxiety

associated with pain and dying. Therefore, the findings in this study add new information

to current knowledge of the effect of nature sounds on anxiety.

The effect of the combination on pain and anxiety. No studies were found of the

effect of the combination on pain and anxiety. Four previous studies used the

combination of music and nature sounds as only one of the types of music intervention on

patients during colonoscopy for discomfort and anxiety (Harikumar & Kumar, 2007), on

psychiatric patients for anxiety and distress (Sorensen & Tybjerg, 2004), on pediatric

cancer patients for chemotherapy induced nausea and vomiting (S. Y. Lin, 2003), and on

adult cancer patients for anxiety, depression and sleep quality (Hung, 2003). None of the

researchers reported the effect of the combination in their study since the combination of

music and nature sounds was only one of the choice of the music intervention. As a result,

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the findings of the study provided new information that the combination of music and

nature sounds significantly reduced both pain and anxiety in hospice cancer patients, and

that the effect sizes increased from medium effect sizes to large. The hospice cancer

patients listened to 20 minutes of the combination daily for three days that pain and

anxiety decreased daily. Like music, it is possible that when patients listen to the

combination of music and nature sounds for more than one day, it may have a cumulative

effect.

Preferences for music, nature sounds, and combination. The top three types of

music the participants selected during the survey at the start of the study were Taiwanese

music, easy listening music, and religious music (either Christian or Buddhist). Few

studies have asked this question of participants, and it was done to gain information about

preferences to offer in the future. A researcher in Taiwan asked the elderly people about

their musical preferences and reported that Chinese orchestral music was the most

preferred music among the other six music selection (Hui-Ling. Lai, 2004). Also Ahn

conducted a pilot study where she asked patients their favorite type of music from a list

(Good & Ahn, 2008). Many investigators simply reported the participants choice between

the few types of music offered for testing. The top choices of Taiwanese folk music and

easy listening music found in this study were consistent with previous studies (Good &

Chin, 1998; S.-T. Huang, et al., 2010; S. H. Huang, 2000; Y. C. Huang, 2003; H-C. Wu,

2007).

The participants in the music group liked their intervention more than those in the

nature sounds group or the combination group. They also listened to music independently

between testing times the longest, nearly a half hour longer than the combination group

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and more than two hours than the nature sound group. This may imply that the

participants in the music group actually obtained the types of music they liked. The

preselected music in this music collection may be culturally appropriate and may have

offered sufficient choice for hospice cancer patients in Taiwan, except that some would

have liked to have heard Japanese music.

For nature sounds, all the sounds were liked by nearly all participants at onset of the

study. This is interesting, considering that after listening for three days, fewer people

seemed to like them. The nature sounds group had the lowest score on the amount they

liked the intervention they received and listening time was nearly two hours less than in

the music and the combination groups. In the initial survey, nearly all participants in both

the nature sounds and the combination groups chose the sounds of forest, followed by the

sounds of ocean waves and birds. The musical component in the combination may have

made nature sounds more enjoyable than nature sounds alone, and nearly two-thirds of

participants in the nature sounds group liked their intervention.

Length of independent listening. The independent use of music, nature sounds, and

combination between testing times indicated that the music and the combination groups

listened significantly longer than the nature sounds group. One study recorded the length

of independent listening to music in postoperative patients: it ranged from 15 to 480

minutes with a mean of 156 minutes, or two and a half hours, which is shorter than in the

present study (Good, 1992). Between the testing times, the music group listened nearly

five hours, the combination group listened more than four hours, and the nature sounds

group listened more than two hours. Nearly all participants used the intervention

independently because they wanted to relax and more than half used the intervention

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because they liked the intervention. The long hours of independent use of the intervention

may imply that the preselected music, nature sounds, and combination have a soothing

effect that help participants to relax and are enjoyable when listening to them. Longer

listening may also be because the equipment was portable and easy to use, so participants

were able to listen to music or nature sounds in other places rather than only in their room.

They were often able to reach and operate the equipment by themselves. Hospice cancer

patients may have less energy to perform physical activity or they may be less interested

in the available TV programs, so the intervention provided an alternative leisure for them

and also relieved their symptoms.

Relationship between pain and anxiety. In this study, pain and anxiety were

positively, strongly, and significantly correlated. The findings were consistent with other

studies in palliative care (M. L. Chen & Tseng, 2006; D. K. Payne & Massie, 2000).

Cancer pain and anxiety often have a reciprocal effect, and both may exacerbate other

physical symptoms and psychosocial distress (Lancee, et al., 1994). Since pain in these

hospice units was generally managed to be at a low level, the anxiety may reflect the

good control of the pain.

Rationale for the Outcomes of Music, Nature Sounds, and Combination

Music, nature sounds, and the combination of music and nature sounds were found

to have significant effects in hospice cancer patients in this study. The findings may be

because the interventions were preferred and generally liked and the sedative effect of

music and nature sounds helped them in relaxation and distraction. Research has shown

that preferred music can produce better therapeutic effects and more distraction than

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music that is not preferred (Bruya & Severtsen, 1984; Parente, 1976). Slow and sedative

music increases a relaxing effect (Bernardi, et al., 2006; Stratton & Zalanowski, 1984).

When a person listens to preferred music or sounds, pleasant emotional responses

evoke activity in the limbic system, amygdale, hippocampus, and medial prefrontal

cortex, which are associated with emotion, anxiety response, and pain perception (Blood

& Zatorre, 2001). The dopamine and opioid system are also activated to alter the

perceptions of pain and anxiety (Bardo, 1998). Thus, when hospice cancer patients can

choose from among the preselected music or nature sounds, they are then able to listen to

music that they prefer, which may have contributed to the significant effects.

There was no significant difference in pain and anxiety between the music and the

nature sounds group, which may have been influenced by the similar selection criteria:

sedative in nature and with volume control and no sudden high pitched sounds. However,

there were descriptive differences between the two groups. The music group liked the

intervention most and they listened longest between testing times. The nature sounds

group liked their intervention least and had a shorter listening time between tests. Perhaps

this was because the music had been developed and tested more. Three of the music types

had been shown to be liked and effective in Taiwanese people (Good & Chin, 1998; S.-T.

Huang, et al., 2010), while the other five types of music were selected based on the

suggestions of these and other Taiwanese researchers (S. H. Huang, 2000; Y. C. Huang,

2003). Conversely, the nature sounds intervention had only been tested for pain and

anxiety in few studies and there were fewer recordings and less information available for

selecting among them. Further music consists of a variety of rhythms, timbre, and

intervals, while the nature sounds offered consisted of one type of sound throughout the

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listening time. Finally, participants were randomly assigned to the nature sounds and

some may not have liked them as much as they liked music, but were willing to give it a

try.

There was also no significant difference in pain and anxiety between the

combination group and the individual intervention groups. One might expect that

combining two interventions would be more effective than using single modalities. The

combination included a variety of music with the sounds of nature. However, it was not

more effective than the single interventions. This finding may be influenced by the

similarity of the interventions, which were selected based on same criteria, sedative, 60 to

80 beats per minute, with no sudden high pitch and volume. The three interventions

probably increased relaxation and distraction, but there may be a limit to the body’s

autonomic response to relaxation and the interventions (Personal communication with M.

Good, 8/17/2011).

The effect sizes were mainly medium to large in hospice patients, and were larger

than those in a study of postoperative pain (Good, et al., 1999). The reason may be that

pain and anxiety in hospice patients were lower and more consistent than in previous

studies. This may due to the policy of the hospice units that patients’ pain should be

controlled to less than 3 points on a 0 to 10 scale after patients are admitted to the unit.

The pain of postoperative patients decreases with wound healing and is controlled with

diminishing amounts of opioid in patient controlled analgesia.

Pretest VAS anxiety levels in the hospice cancer patients were much lower than

pretests in two previous studies (S.-C. Chang & Chen, 2005; Voss, et al., 2004). Further,

pain and anxiety were strongly correlated and pain was controlled to less than 30 mm;

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good pain control plus the effects of consistent opioid intake may be why anxiety in the

hospice cancer participants was lower than the participants in the previous studies. The

types of anxiety and the intensity of pain may also have influenced the anxiety scores.

Limitations

The results are reflective of effects of interventions designed for hospice patients in

southern Taiwan, and because participants were not randomly selected from the

population, they are not generalizable beyond the sample itself. Other hospice patients

may have had different responses to the interventions: those who did not have the

opportunity to be invited to participate and those who were excluded by the criteria or did

not want to participate. Most participants had mild pain and anxiety and the effects might

have been different if these symptoms were more severe.

It is not possible to blind conscious participants to auditory interventions.

Participants were told the purpose of the study in the consent form and that they would be

randomly assigned to receive music, nature sounds, the combination, or data collection

first (control). Therefore, participants in all groups might have responded to the pain and

anxiety VAS scales in accordance with their knowledge of the investigator’s expectations.

However, the control group may not have responded as a control because they were not

told they were in a control group. They were told they were in a delayed intervention

group and they would receive an intervention after three days of data collection.

Patients in the control group might have been resentful if they had been without an

intervention for weeks and if they knew others in the study received theirs earlier, but this

was avoided in a short 3-day study with randomization to rooms rather than to

individuals.

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Compensatory equalization might have occurred if the nurses saw that some patients

had an MP3 player while some did not and if the nurses could not tolerate the inequality.

They may unconsciously compensated by giving participants in the control group extra

attention or other treatment (Shadish, et al., 2002). To minimize this threat of internal

validity, the staff nurses were told in their orientation and reminded of the need to do their

usual care. They had previous experience with researchers collecting data in the unit, and

were used to following the researcher’s instructions. They did not know the method of

random assignment to rooms, so if they noticed that patients did not have an MP3 pouch

in the bedside, they might have assumed that those patients were not participants. On the

other hand, nurses might have seen the investigator collecting data at the bedside of

someone in the control group and might have guessed that they were controls. Thus

precautions were taken to minimize the threats to validity, but undocumented possibilities

may have existed.

The randomization scheme was a combination of cluster randomization of

conditions to rooms and adaptive randomization. Treatments were randomized to rooms

to prevent diffusion of treatments in the 2-bed and 4-bed wards. Because random

assignment does not always balance the groups on all variables, the control group had

more males, smokers and alcohol drinkers, although these were not different among four

groups. A limitation of the randomization scheme was that the group size could vary. This

occurred if a participant stayed in a room for a long time, so there was low turnover in

that group and if there was higher turnover in other rooms/groups because the hospice

kept admitting new patients who were then recruited. For example, the nature sounds

group had greater turnover and more participants than the other groups, although there

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was no significant difference in group size.

Two major problems in data collection were difficulties of getting consent in hospice

cancer patients and recruiting sufficient numbers. These problems were similar to those

of another researcher of cancer patients in Taiwan (S. T. Huang, 2006). There were

problems of insufficient strength to sign the consent, past experiences in signing

documents, and family reluctance to sign. It was not clear whether the refusal of patients

or families was related to the cultural background or personal reasons, or both.

Another problem was slow referral from the staff nurses. The staff nurses in the

hospice units were very busy and frequently had little time to refer possible patients to

the investigator. To improve the accrual rate, the investigator participated in their

morning meetings and asked the primary care nurses about potential participants and

whether they could refer them to the study. During the last three months of the data

collection period, the staff nurses may have felt more familiar with the study. In addition,

some said they had heard positive feedback from patients or families or saw that the

interventions had an observable effect on some of the participants, so they began to refer

potential participants more actively. Due to the slow progress of recruitment, a second

hospice unit in another hospital was added to increase the sample size.

Implications for Theory

The Good and Moore (1996) middle range theory of acute pain, a balance between

analgesic and side effects, proposes that nonpharmacological interventions, such as music,

will reduce acute pain. This study extended the theory to terminally-ill hospice cancer

patients; it supported music as an adjuvant modality to reduce not only cancer pain but

also alleviate anxiety. The findings also extend the domain of nonpharmacological

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adjuvants to include nature sounds and the combination of music and nature sounds,

which also reduced pain and anxiety. Further, the interventions were carefully chosen for

their familiarity to the Taiwanese population. The results support the effectiveness of this

cultural adaptation. Considering patients’ cultural preferences for music is important

when using music in a specific locality (Good, et al., 2000). This is the first study of

nature sounds thought to be culturally appropriate in people a specific place; in this case

it was people in the island of Taiwan.

Implications for Research

It is recommended that future studies be conducted with longer use of the

interventions to determine whether the effects would continue to improve pain and

anxiety over four or more days in hospice cancer patients. In addition to only hospice and

hospice collaborative care cancer patients, the interventions may be beneficial to cancer

patients who receive hospice home care. A study can examine the feasibility and test the

effects of carrying the interventions from the hospice unit to the home for ongoing

self-care.

Although more varieties of music, nature sounds, and combination were offered to

select from than in previous studies, the choices can be expanded further, based on the

preferences and suggestions from the present study. It is recommended that for older

Taiwanese patients, Japanese music and the sounds of streams be offered. Questions

about how much they liked the intervention can be asked and brief verbal suggestions and

comments can be recorded.

In future studies, it is recommended that a pilot study be conducted for the effect of

these interventions on sleep in hospice cancer patients, followed by a randomized

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controlled trial that includes sleep as an outcome variable along with pain and anxiety. In

this study, pain and anxiety were the only two outcome variables of interest. However, a

few participants also used their assigned intervention for sleep. Music has been shown to

be effective for sleep in Taiwanese cancer patients (Hung, 2003) and older adults

(Hui-Ling Lai & Good, 2006; Y. J. Lee, 2000b). Sedative music, nature sounds, and the

combination may be useful in providing a relaxing effect and sleep in some of the hospice

cancer patients.

A qualitative design or component of a randomized controlled trial could be used to

obtain verbal descriptions of the perceptions and experiences of music, nature sounds,

and the combination. This may provide more insight into the meaning of the music or

nature sounds to the person, their relaxing or distracting effects, and the scene and the

memories in the patient’s mind. Such insight may help researchers to select music or

nature sounds that are familiar to people in the participant’s age range and can be used for

those who are unable to express themselves but may benefit from listening to music and

nature sounds.

The family members of the hospice cancer patients suffer from the physical burden

of taking care of their family and the emotional stress from deterioration and anticipated

loss of their loved one. Some family members wished that the intervention could be

provided for them too. Therefore, it is recommended that studies be conducted with the

family members to test the effectiveness of the interventions. A longitudinal design can

also be used to follow up the effect of the interventions on the family members during

their grieving process after the patient dies.

126

This study was conducted in two hospice units in the southern Taiwan. The

interventions that were effective in one part of this country may not necessarily be

effective in other hospice units in different cities. The study can be replicated in other

hospice units with the same study design and interventions to explore the similarities and

differences among hospice units in Taiwan.

Implications for Practice

Music, nature sounds, and the combination of both were effective in decreasing pain

and anxiety in hospice cancer patients. A total of 18 types of music and nature sounds (8

for music, 5 each for nature sounds and combination) were preselected for the middle

aged hospice cancer patients in Taiwan to choose from and were then provided to

participants. Nature sounds and the combination were preselected based on the

suggestions from researchers who conducted studies in other countries. Nurses can use

the music and nature sounds tested in this study as a starting point to treat their hospice

cancer patients for pain and anxiety (See Appendix B for selections used). It is also

recommended that nurses in the hospice unit consider patients’ preferences, age, and

cultural background when selecting music, nature sounds, or combination choices for

their patients.

Interventions were provided by a MP3 player, a clip-on headset or a small speaker

(Figure 3). Hospice cancer patients frequently bring many personal belongings which

occupy most of their bedside table. When space is limited, a traditional CD or audio tape

player is too big for the bedside table and is not portable when patients want to move

around. It is recommended that nurses use small MP3 players, place all the equipment in

a small pouch (Figure 3), and clip it to the side of the patient’s pillow case, put in the

127

pocket of their jacket, or hung on the IV stand. This increases the mobility of the hospice

patient rather than occupying limited space on the bedside table. It is recommended that

nurses provide small speakers with enough volume for the participants to hear but low

enough that it would not disturb other patients in the same room. This will avoid the

burden of earphones or ear buds in patients’ ears. The capacity of all MP3 players

currently in the market is large enough to store more songs than the traditional CDs or

audiotapes. It is recommended that nurses consider portable, light weight, and easy to use

equipment when selecting a device to play music and nature sounds in hospice settings.

This study provided a detailed description of the method used to select music, nature

sounds, and the combination, the audio device selection, and the instruction and

delivering of the intervention to hospice patients. The findings of this study could easily

be incorporated in practice. It is recommended that nurses can use the information

presented here to develop an instruction manual for hospice patients in their working

environment.

Conclusion

Music, nature sounds, and the combination if both reduced pain and anxiety, which

is consistent with most studies. The sample size, design, length of the intervention, types

of interventions available for choice, and equipment were possible contributors to the

medium to large effect size in this study. The interventions provided were generally liked

and frequently used for relaxation purpose by the hospice cancer patients. Sedative

effects plus having preferred music and nature sounds may increase the relaxing and

distracting effects and contribute to decreased pain and anxiety. Studies with longer use

of the intervention, expanding the study to home hospice and family members, providing

128

more types of music and nature sounds, and collecting qualitative information are

recommended for future research. This study contributed new knowledge by using an

innovative randomization scheme, including a delayed-start control group, providing

various music/nature sounds selections, and using current media technology. Staff nurses

can select cultural and age appropriate music and nature sounds and offer choices to

hospice patients. Portable, light weight and easy to use equipment will facilitate their use

for pain and anxiety along with medication. Nurses can develop an instruction manual

based on the procedure and the findings of the study for their hospice settings.

129

Appendix A

Date: ____________ (yy/m/d) Medical Record # ___________

The Effects of Music/Nature Sounds on Cancer Pain and Anxiety in Hospice

Patients Inclusion and Exclusion Criteria Form

CONFIDENTIAL

NOTE：If all of the responses are marked with a *, the person is not eligible to be in this study

Inclusion & Exclusion Criteria Yes No

1. Documented cancer pain at least one in past 24 hours *___ 2. Regularly scheduled (versus prn) analgesics *___ 3. A physical and mental status that would enable the individual to participate in the study *___ 4. Cognitively intact (oriented to person, place, and time) *___ 5. Understand Chinese, Taiwanese, or English *___ 6. At least 18 years of age *___ 7. Documented delayed developmental status *___ 8. Hearing difficulty *___ 9. Severe vision deficiency *___ 10. Known history of musicogenic epilepsy or hypersensitivity to sound *___

Note. *= Not eligible

Music and nature sounds related screening questions 1 Would you like to listen to recorded music or nature sounds while you are here? Yes___ *No___ 2 Do you feel it is appropriate to listen to recorded music or nature sounds while

you are sick and in the hospice center? Yes___ *No___

Eligible Yes___ *No___ Consented Yes___ *No___

Participation status

Agree to participate the study……………………………………………………………Group# ___________ Reason for refusal………………………………………..……………….......................................___________ 1. Not interested 2. Too tired to participate in the study 3. Too much going on in the life 4. Has already in another study 5. Do not want to be bothered 6. Had known musicogenic epilepsy or hypersensitivity to sound (circle the one) 7. No reason 8. Other (specify) _____________________________________________________________

130

Appendix B

Selections of Music, Nature Sounds, and Combination

Music – Chinese

Selection CD Artist 1 I only care about you Dream in the Afternoon Unknown 2 Dream a life time for love Piano and Violin- Dream a life Time

for Love Unknown

3 Bamboo ballad 童話 童畫 巴洛克獨奏家樂團 4 What is in front of my

home? 童話 童畫 巴洛克獨奏家樂團

5 The dream of the red chamber

Dream in the Afternoon Unknown

6 Look back again Piano and Violin- Dream a life time for love

Unknown

7 Love me or love me not Piano and Violin- Dream a life time for love

Unknown

8 Forget who I am 純真年代—橄欖樹 Trio 最好的時光三重奏 9 The forgotten moments 被遺忘的時光 Trio 最好的時光三重奏 10 Drinking with the past Piano and Violin- Dream a life time for

love

11 Like your tenderness 純真年代—橄欖樹 Trio 最好的時光三重奏 12 Daily blue 中國交響世紀—浮世戀情 1 俄羅斯國家交響樂團 13 It’s over 中國交響世紀—戀戀琴聲 1 俄羅斯國家交響樂團 14 Sea waves 中國交響世紀—流金歲月 1 俄羅斯國家交響樂團 15 Another unforgettable love

affair 被遺忘的時光 李哲藝&林天吉&歐陽慧

擩 16 Falling flowers 中國交響世紀—浮世戀情 2 上海交響樂團 17 Could it be a flower 中國交響世紀—浮世戀情 2 上海交響樂團 18 What west wind says 中國交響世紀—浮世戀情 2 上海交響樂團 19 Farewell 中國交響世紀—浮世戀情 2 上海交響樂團 20 Lady Meng-Jiang 中國交響世紀—大地春夢 上海交響樂團 21 Flowing water 中國交響世紀—浮世戀情 2 上海交響樂團 22 So much to say 中國交響世紀—流金歲月 1 中央歌劇芭蕾舞劇院交響

樂團 23 Farewell, Cambridge

(Re-edit) 中國交響世紀—流金歲月 2

中央歌劇芭蕾舞劇院交響

樂團 24 Home sickness Dream in the Afternoon Unknown 25 Dream and poem Dream in the Afternoon Unknown 26 Pieces of autumn poem

(Re-edit) 中國交響世紀—流金歲月 1 中央歌劇芭蕾舞劇院交響

樂團

131

Music – Easy Listening

Selection CD Artist 1 The unforgetting heart The Unforgetting Heart Michael Hoppe 2 Vaya con dios Guitar by Candlelight* Gray Bartlett 3 If I fell/My life Counting the Ways* Ed Gerhard 4 Lake of heart Crystal Glory* Sheng-Di Wang 5 Imagine Guitar by Candlelight Gray Bartlett 6 Quietness Crystal Glory Sheng-Di Wang 7 Moving like a could Chinese Massage for Heart* Xu-Dong Wang 8 Waltz for the lonely Guitar by Candlelight Gray Bartlett 9 Under the moonlight Crystal Glory Sheng-Di Wang 10 Maria Elena Counting the Ways Ed Gerhard 11 Pacifying your heart Chinese Massage for Heart Xu-Done Wang 12 The rose Guitar by Candlelight Gray Bartlett 13 Not a dream Sleep for Body and Mind* Xu-Dong Wang, Jian-Min

Wang 14 Thoughts Crystal Glory Sheng-Di Wang 15 Vincent Guitar by Candlelight Gray Bartlett 16 Wild mountain thyme Counting the Ways Ed Gerhard 17 Printless Crystal Glory Sheng-Di Wang 18 Love me tender Guitar by Candlelight Gray Bartlett 19 Cavatina Guitar by Candlelight Gray Bartlett 20 Renouncement The Unforgetting Heart Hoppe, Michael 21 Clear mirror Crystal Glory Sheng-Di Wang 22 Song of silence Crystal Innocence* Sheng-Di Wang 23 Can’t help falling love Counting the Ways Ed Gerhard 24 Childhood memories The Unforgetting Heart Michael Hoppe 25 Deep thinking Crystal Glory Sheng-Di Wang 26 Let it be me Guitar by Candlelight Gray Bartlett 27 The water is wide Counting the Ways Ed Gerhard 28 To you my friend Guitar by Candlelight Gray Bartlett 29 To all the girls Guitar by Candlelight Gray Bartlett 30 Spring tract Mirror of Water Wang Shun 31 The music of the night Guitar by Candlelight Gray Bartlett

132

Music – Harp

Selection CD Artist 1 Genossienne #5 Fresh Impressions Georgia Kelly 2 Arrane ghelbee Body: Art of Meditation Unknown 3 Aeolian temple music Seapeace Georgia Kelly 4 Chinese sunrise Seapeace Georgia Kelly 5 Can’t help lovin’ that man Harpo Harpo Marx 6 The nightingale Harpestry: A Contemporary

Collection Unknown

7 Nilapadma (Blue lotus) Seapeace Georgia Kelly 8 Bi a los aim chroise Body: Art of Meditation Unknown 9 Young William Plunkett Celtic Harp Patrick Ball 10 Carolan’s ramble to cashel Celtic Harp Patrick Ball 11 Blind Mary Celtic Harp Patrick Ball 12 Carolan’s welcome Celtic Harp Patrick Ball 13 Walters ancient memories Harpestry: A Contemporary

Collection Unknown

14 Give me your hand Celtic Harp Patrick Ball 15 Greensleves Celtic Harp Patrick Ball 16 Yano Mori (Yugoslavian Traditional) A Journey Home Georgia Kelly, Dusan

Bogdanovic 17 Bilyana (Yugoslavian Traditional) A Journey Home Georgia Kelly, Dusan

Bogdanovic 18 Morning calm Harp of Branciswhiere Sylvia Woods 19 The quiet garden Harp Philip Boulding

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Music –Orchestral

Selection Composer/ CD Artist 1 Symphony #6 Pastorale Beethoven Cleveland Orchestra 2 Clair de lune Debussy Philadelphia Orchestra 3 Air on the G string from Suite #3 in D Bach Bach Festival Chamber 4 Nocturne from a midsummer night’

dream Mendelssohn Cleveland Orchestra

5 Greensleaves Traditional from World Hits

Mantovanil

6 Symphony #1 second movement Brahms London Philharmonic 7 Pachebel: Canon Pachehel English Chamber Orchestra 8 Valse triste Sibelius Berglund Philharmonic 9 Romanze Eine Klein Nachtmusik Mozart Liszt Ferenc Chamber

Orchestra 10 Reverie Debussy Philadelphia Orchestra 11 The swan Classics by candlelight Unknown 12 Wind Serenade No.12, c miinor, K.388 Mozart Effect – Sleep Harnoncourt; Wiener

Mozart-Blaser 13 Piano Concerto, No.24, c minor,K.491 Mozart Effect – Sleep Daniel Barenboim: Berlin

Philharmonic Orchestra 14 Clarinet Concerto, A Major, K.622 Mozart Effect – Sleep Kam, Faerber 15 Horn Concerto, E-flat, K.495 Mozart Effect – Sleep Pyatt, Marriner 16 Serenade In G Major _Eine Kleine

Nachtmusik_ Romance_ Andante Time life classics for kids St. Petersburg Musical Theatre

134

Music –

Piano

Selection CD Artist 1 Gigi, Mona Lisa Nadia’s Theme Roger Williams 2 By the time I get to Pheonix The Best of Paul Cramer Paul Cramer 3 Theme for Elvira Nadia’s Theme Roger Williams 4 You need me The Roger Williams Collection Roger Williams 5 Thanksgiving December George Wiston 6 Nocturne in B Major Chopin Favorites Vladmir Ashkenazy 7 Tammy Roger Williams’ Greatest Roger Williams 8 You’ll never walk alone Somewhere in Time Roger Williams 9 Try to remember The Best of Floyd Cramer Floyd Cramer 10 Almost persuaded Almost Persuaded Floyd Cramer 11 Reflection Winter into Spring George Wiston 12 Unchained melody The Best of Floyd Cramer Floyd Cramer 13 Last date The Best of Floyd Cramer Floyd Cramer 14 Lady The Roger Williams Collection Roger Williams 15 The first time ever I saw your face Peter Nero’s Greatest Hits Peter Nero 16 Piano sonata no. 14 in C minor 2nd

movement adagio cantabile 100 Piano Masterpices Erik Satie

17 Piano sonata no. 8 in C minor 2nd movement

100 Piano Masterpices Unknown

18 Somewhere in time Somewhere in Time Roger Williams 19 Sonata for 2 pianos, D major, K448 100 Piano Masterpices Unknown

135

Music – Religious-Buddha

Selection CD Artist 1 Enlightenment 古箏佛讚(十二)照人清涼 閻愛華 2 Respondance 古箏佛讚(十二)照人清涼 閻愛華 3 Compassion 古箏佛讚(十二)照人清涼 閻愛華 4 Freshness 古箏佛讚(十二)照人清涼 閻愛華 5 Walking with breeze Mirror of water 王珣 6 Cool breeze in summer Mirror of water 王珣 7 般若波羅蜜多心經 古箏佛讚(六)心經* 王珣 8 南無本師釋迦牟尼佛 古箏佛讚(六)心經 王珣 9 雲水禪心 古箏佛讚(七)雲水禪心 王珣 10 靈山梵音 古箏佛讚(七)雲水禪心 王珣 11 Deep woods of Zen 古箏佛讚(七)雲水禪心 王珣 12 禪院鐘聲 古箏佛讚(七)雲水禪心 王珣 13 佛門鐘聲 古箏佛讚(七)雲水禪心 王珣

136

Music – Religious_Christian

Selection CD Artist 1 我寧願有耶穌 Piano for quiet time Vol. 2 Unknown 2 明亮的天路 Piano for quiet time Vol. 1 Unknown 3 歌頌救贖主 Piano for quiet time Vol. 2 Unknown 4 至善聖靈 Piano for quiet time Vol. 1 Unknown 5 今來就主 Piano for quiet time Vol. 2 Unknown 6 靠恩得救 Piano for quiet time Vol. 1 Unknown 7 AveMaria Unknown 8 你總要依靠寶血 Piano for quiet time Vol. 2 Unknown 9 讚慕美地(甜蜜的變奏曲) Piano for quiet time Vol. 1 Unknown 10 為將我們將從罪就贖 Piano for quiet time Vol. 2 Unknown 11 面對面 Piano for quiet time Vol. 1 Unknown 12 向高處行 Piano for quiet time Vol. 2 Unknown 13 雖然四面狂風大作 Piano for quiet time Vol. 1 Unknown 14 When you walk through the dark hold your

head high Unknown

15 暫時旅住世上 Piano for quiet time Vol. 1 Unknown 16 看那!快樂的家 Piano for quiet time Vol. 2 Unknown 17 歸我更美家鄉 Piano for quiet time Vol. 1 Unknown 18 萬古盤石 Piano for quiet time Vol. 2 Unknown 19 在天國相見 Piano for quiet time Vol. 1 Unknown 20 我貧窮之福到寶貴之城 Piano for quiet time Vol. 2 Unknown 21 我有最好朋友 Piano for quiet time Vol. 1 Unknown 22 結束世上苦難 Piano for quiet time Vol. 2 Unknown 23 How great thou art Unknown 24 向前直往錫安 Piano for quiet time Vol. 2 Unknown 25 永遠的榮耀 Piano for quiet time Vol. 1 Unknown 26 寶血大權能 Piano for quiet time Vol. 2 Unknown

27 荒蕪之地變玫瑰園 Piano for quiet time Vol. 1 Unknown 28 聖哉聖哉 我知誰掌管明天 至好朋友就是耶

穌 Good’s Tape- Inspirational Unknown

29 Jesus is my shepherd Good’s Tape- Inspirational Unknown 30 與主接近 Piano for quiet time Vol. 2 Unknown

137

Music – Taiwanese

Selection CD Artist 1 No one understand what I feel 純真年代-海海人生 Trio 最好的時光三重奏 2 June Jasmine 純真年代-海海人生 Trio 最好的時光三重奏 3 Wife 純真年代-海海人生 Trio 最好的時光三重奏 4 Little Egret 璀璨西灣 巴洛克獨奏家樂團 5 When I open the door to my

heart The Unforgettable Love Affair Trio 最好的時光三重奏

6 A white peony 中國交響世紀-台灣幻想曲 1 Chinese Orchestra 7 The flower in raining night 中國交響世紀-台灣幻想曲 1 Chinese Orchestra 8 The crying of homeless birds 中國交響世紀-台灣幻想曲 1 Chinese Orchestra 9 Moonlight sorrow 中國交響世紀-台灣幻想曲 1 Chinese Orchestra 10 Life 純真年代-海海人生 Trio 最好的時光三重奏 11 Dream of riverside 純真年代-海海人生 Trio 最好的時光三重奏 12 The taste of love The Unforgettable Love Affair Trio 最好的時光三重奏 13 The gloomy night Faraway on a Moonlit Night Stamic Quartet/New Prague

Trio 14 Red in the snow 中國交響世紀-戀戀情深-2 中央歌劇芭蕾舞劇院交響

樂團 15 Pillow for couple 中國交響世紀-戀戀情深-2 中央歌劇芭蕾舞劇院交響

樂團 16 Love like thread and needle 中國交響世紀-戀戀情深-2 中央歌劇芭蕾舞劇院交響

樂團 17 Recalling the past The Unforgettable Love Affair Trio 最好的時光三重奏 18 Faraway on a moonlit night Faraway on a moonlit night Stamic Quartet/New Prague

Trio 19 When the gong’s sound raises 中國交響世紀-台灣幻想曲 2 北京中央交響樂團 20 The unforgettable love affair 中國交響世紀-台灣幻想曲 2 北京中央交響樂團 21 Weeding broken net 中國交響世紀-台灣幻想曲 2 北京中央交響樂團 22 Raining night with autumn wind 中國交響世紀-台灣幻想曲 2 北京中央交響樂團 23 Nocturne of southern city 中國交響世紀-台灣幻想曲 2 北京中央交響樂團 24 Awaiting your early return

(Re-edit) 中國交響世紀-台灣幻想曲 2 北京中央交響樂團

25 Lovesick when the spring breeze blew (Re-edit)

中國交響世紀-台灣幻想曲 2 北京中央交響樂團

138

Nature Sounds – Birds

Selection CD Artist 1 晨曦霧影(Re-edit) 最近的天堂-生態現場 廖東坤 2 議論-小彎嘴/山紅頭(Re-edit) 最近的天堂-生態現場 廖東坤 3 晨鳥之歌(Re-edit) 森林狂想曲 吳金黛 4 Wild birds in Taiwan-1 (Re-edit) 野鳥鳴唱 風潮唱片 5 Wild birds in Taiwan-2 (Re-edit) 野鳥鳴唱 風潮唱片 6 Wild birds in Taiwan-3 (Re-edit) 野鳥鳴唱 風潮唱片 7 Wild birds in Taiwan-4 (Re-edit) 野鳥鳴唱 風潮唱片 8 晨鳥之歌-2 (Re-edit) 野鳥鳴唱 風潮唱片 9 最近的天堂鳥之生態 (Re-edit) 野鳥鳴唱 風潮唱片 10 Wild birds in Taiwan-5 (Re-edit) 野鳥鳴唱 風潮唱片 11 Wild birds in Taiwan-6 (Re-edit) 野鳥鳴唱 風潮唱片 12 Wild birds in Taiwan-7 (Re-edit) 野鳥鳴唱 風潮唱片 13 Wild birds in Taiwan-8 (Re-edit) 野鳥鳴唱 風潮唱片

139

Nature Sounds – Forests

Selection CD Artist 1 Monterey magic (Re-edit) The Blue Mountains Experience Unknown 2 Rivers run deep (Re-edit) Body: Art of Meditation Unknown 3 Wenworth falls (Re-edit) The Blue Mountains Experience Unknown 4 Mountain Life (Re-edit) The Blue Mountains Experience Unknown 5 Spirits of the forests (Re-edit) The Blue Mountains Experience Unknown 6 Sounds of the forest (Re-edit) Forest Mitsuhiro 7 Poem of the forest (Re-edit) Forest Mitsuhiro 8 Forest sonata (Re-edit) Forest Sonata 吳金黛 9 Sleeping forests (Re-edit) Forest Sonata 吳金黛 10 Song of autumn stream (Re-edit) 青蛙四季唱遊 風潮唱片 11 Winding (Re-edit) 最近的天堂-生態現場 廖東坤

140

Nature Sounds – Frogs

Selection CD Artist 1 早春的太魯閣山林(Re-edit) 青蛙四季唱遊 風潮唱片 2 陽明山的春之夢幻(Re-edit) 青蛙四季唱遊 風潮唱片 3 拜訪溪頭竹林的春天(Re-edit) 青蛙四季唱遊 風潮唱片 4 阿里山的四月(Re-edit) 青蛙四季唱遊 風潮唱片 5 池畔(Re-edit) 最近的天堂-生態現場 廖東坤 6 初夏的嘉義農場(Re-edit) 青蛙四季唱遊 風潮唱片 7 嘉南平原的青蛙精靈(Re-edit) 青蛙四季唱遊 風潮唱片 8 虎山溪的夏天(Re-edit) 青蛙四季唱遊 風潮唱片 9 樹蛙之歌(Re-edit) 森林狂想曲 吳金黛 10 花東稻田之歌(Re-edit) 青 四季唱遊 風潮唱片 11 石門水庫大頭蛙的秋天(Re-edit) 青蛙四季唱遊 風潮唱片 12 擁擠(Re-edit) 最近的天堂-生態現場 廖東坤 13 發現水窪(Re-edit) 最近的天堂-生態現場 廖東坤 14 溫泉鄉的青蛙(Re-edit) 青蛙四季唱遊 風潮唱片 15 台灣青蛙之一(Re-edit) 青蛙四季唱遊 風潮唱片 16 群蛙暢鳴 1 (Re-edit) 青蛙四季唱遊 風潮唱片 17 群蛙暢鳴 2 (Re-edit) 青蛙四季唱遊 風潮唱片 18 群蛙暢鳴 3 (Re-edit) 青蛙四季唱遊 風潮唱片 19 群蛙競鳴 Frogs chirping (Re-edit) 青蛙四季唱遊 風潮唱片

141

Nature Sounds – Night Life

Selection CD Artist 1 Dusk(Re-edit) 夜的節目單 風潮唱片 2 Country evening breeze(Re-edit) 夜的節目單 風潮唱片 3 Starry night(Re-edit) 夜的節目單 風潮唱片 4 Silvery hills(Re-edit) 夜的節目單 風潮唱片 5 Summer night of Shan-Ping(Re-edit) 青蛙 四季唱遊 風潮唱片 6 Autumn night of Fu-Shan(Re-edit) 青蛙 四季唱遊 風潮唱片 7 The beginning of winter in

Wu-Lai(Re-edit) 青蛙 四季唱遊 風潮唱片

8 Free time(Re-edit) 最近的天堂 生態現場 廖東坤 9 Ano Nuevo(Re-edit) 腦內革命 Unknown 10 Hot summer (Re-edit) 夜的節目單 風潮唱片 11 In the night(Re-edit) 夜的節目單 風潮唱片 12 Night lullaby (Re-edit) 夜的節目單 風潮唱片 13 Nocturnal(Re-edit) 夜的節目單 風潮唱片 14 Dream(Re-edit) 夜的精靈 風潮唱片

142

Combination – Ocean

Selection CD Artist 1 三貂角 Shandau corner (Re-edit) 台灣海聲實錄 吳金黛 2 九棚(Re-edit) 台灣海聲實錄 吳金黛 3 和平島 Peace island (Re-edit) 台灣海聲實錄 吳金黛 4 戲水 Play in the ocean (Re-edit) 台灣海聲實錄 吳金黛 5 流星的夜空 Night of shooting stars (Re-edit) On the Beach Unknown 6 海之聲 1 Ocean sounds-1 (Re-edit) On the Beach Unknown 7 海之聲 2 Ocean sounds-2 (Re-edit) On the Beach Unknown 8 海之聲 3 Ocean sounds-3 (Re-edit) On the Beach Unknown 9 海之聲 4 Ocean sounds-4 (Re-edit) On the Beach Unknown 10 海之聲 5 Ocean sounds-5 (Re-edit) On the Beach Unknown 11 白砂枋山四草(Re-edit) 台灣海聲實錄 吳金黛 12 豐濱 Fengbin (Re-edit) 台灣海聲實錄 吳金黛 13 都蘭 Sulan (Re-edit) 台灣海聲實錄 吳金黛 14 龜山島+蘭嶼(Re-edit) 台灣海聲實錄 吳金黛

143

Combination – Birds

Selection CD Artist 1 Poem of forest Forest Mitsuhiro 2 Fragrance of wind Daydream in the grove 廣橋貞紀子 3 Green Air Daydream in the grove 廣橋貞紀子 4 Sensitive Plants It’s Summer Time 螢火蟲 5 Breeze of cloud Daydream in the grove 広橋貞紀子 6 Fog festival-the other side of the forest Forest Mitsuhiro 7 Autumn Breeze 三顆貓餅乾 繪本音樂專輯 8 Morning visit Forest Mitsuhiro 9 Dots of sunlight Songbirds 吳金黛 10 Songs of water birds Songbirds 吳金黛 11 Morning songs 森林狂想曲 吳金黛 12 Love song for birds 森林狂想曲 吳金黛 13 Nature song of birds-1 (Re-edit) The Nature- Birds Unknown 14 Nature song of birds-2 (Re-edit) The Nature- Birds Unknown 15 Nature song of birds-3 (Re-edit) The Nature- Birds Unknown

144

Combination – Forests

Selection CD Artist 1 Beyond The Reef(Re-edit) 腦內革命 Unknown 2 Overture-The Mist(Re-edit) 最近的天堂 林海 3 Point Lobos(Re-edit) 腦內革命 Unknown 4 Your Warm Shaded Forest(Re-edit) MIND art of meditation Various Artists 5 Summer dream(Re-edit) Sea Relieving Stress –On the

Beach 6 Spirits of forests(Re-edit) Daydream in the grove 廣橋真紀子 7 Natures Creation (Re-edit) The Blue Mountains

Experience Ken Davis

8 Shining waves(Re-edit) 春物語 Mitsuhiro 9 Monterey Magic(Re-edit) 腦內革命 Unknown 10 Rivers Run Deep(Re-edit) Body Art of Meditation Various Artists 11 New green of forest(Re-edit) 春物語 Mitsuhiro 12 Greensleves(Re-edit) 腦內革命 Unknown 13 Tranquil Garden (Re-edit) The Blue Mountains

Experience Ken Davis

14 Falling leaves(Re-edit) 山居歲月 螢火蟲 15 Morning, subtropical(Re-edit) 森林狂想曲 吳金黛 16 Water path(Re-edit) 森林狂想曲 吳金黛 17 Sleeping forests(Re-edit) 森林狂想曲 吳金黛 18 Tree of hope(Re-edit) 山居歲月 螢火蟲 19 Misty Morning (Re-edit) Isotonic sound- Rain Unknown 20 Southern dreamer-Forests(Re-edit) The Unforgetting Heart Michael Hoppe` 21 The Wind through the rainforests

(Re-edit) 最近的天堂 小莊

145

Comibnation – Frogs

Selection CD Artist 1 Gabriel’s oboe(Re-edit) Into the Mist David Agnew 2 Song for Sarah(Re-edit) Touching Beauty Michael Hoppe` 3 Summer of 300 years(Re-edit) Touching Beauty Michael Hoppe` 4 Summer dusk Summer Mitsuhiro 5 Summer shadow Summer Mitsuhiro 6 Spring finally Spring Mitsuhiro 7 Looking at each other(Re-edit) Looking at Each Other 黃愛蓮 8 Autumn(Re-edit) 青蛙四季唱遊 風潮唱片 9 Invitation from autumn Autumn Mitsuhiro 10 Autumn sky Autumn Mitsuhiro 11 Brown avenue(Re-edit) Autumn Mitsuhiro 12 The smell of happiness(Re-edit) Moon Light, lavender Cincin Lee 13 Dancing snow on the

hills(Re-edit) Winter Unknown

146

Combination – Night Life

Selection CD Artist 1 Evening(Re-edit) 夜的精靈 風潮唱片 2 Sunshine, silence(Re-edit) 山居歲月 螢火虫 3 A Night Banquet With Pan(Re-edit) 最近的天堂 彭靖 4 Autumn night Autumn Mitsuhiro 5 And, again Autumn Mitsuhiro 6 Starry night(Re-edit) 夜的精靈 風潮唱片 7 An Encounter(Re-edit) 最近的天堂 楊錦聰 8 Ano Nuevo Body: Art of Meditation unknown 9 Afro Cuban Lullabye(Re-edit) Body: Art of Meditation unknown 10 Silver hills(Re-edit) 夜的精靈 風潮唱片 11 Dream(Re-edit) 夜的精靈 風潮唱片 12 Secrete garden(Re-edit) 風和 日麗 螢火虫 13 Lightning Isotonic Sound-Rain Unknown 14 Dancing in the night(Re-edit) 夢的延長線 范宗沛 15 Norwegian lakes and woods(Re-edit) Fantasia of Tuscany Cincin Lee 16 Cloud, and the sky Summer Mitsuhiro 17 Sea of clouds(Re-edit) It’s Summer Time 螢火蟲

147

Combination – Ocean

Selection CD Artist 1 Gymnopedie No. 1&3(Re-edit) MIND art of meditation Various Artists 2 White Sand On the Beach Unknown 3 Playing in the ocean My Ocean 吳金黛 4 Blue horizon Isotonic Sound Sea 高垣直美 5 Lighten Up Ocean Dreams Dean Evenson 6 My ocean My Ocean 吳金黛 7 Tall ships 腦內革命 Unknown 8 Yellows tone 腦內革命 Unknown 9 Summer dream On the Beach Unknown 10 Deep blue My Ocean 吳金黛 11 Missing the far away On the Beach Unknown 12 Deeper Sanctuary Ocean Dreams Dean Evenson 13 Night of shooting stars On the Beach Unknown 14 Recalling the Past Voyage to Paradise Matthew Lien 15 Lapping on the beach Summer Mitsuhiro 16 Ocean watching My Ocean 吳金黛 17 Lightly Salted Ocean Dreams Dean Evenson 18 Light of dusk My Ocean 吳金黛 19 Smooth Drifting Ocean Dreams Dean Evenson 20 Island of star My Ocean 吳金黛 21 Sand print My Ocean 吳金黛 22 Coral dance(Re-edit) 海洋嬉遊記 吳金黛

148

Appendix C

The Effects of Music/Nature Sounds on Cancer Pain and Anxiety in Hospice Patients Demographic Data Questionnaire

CONFIDENTIAL

NOTE: Code missing data: 999; N/A: 888; not able to answer(NAA): 777 1. Admission Date (yy/m/d)..………………………………………..……………2. Date of withdrawal (yy/m/d)…………………………….…………………….______________

______________

3. Primary reason for withdrawal……………..…………………………..........______________ 1. Died 2. Condition deteriorated 3. Not interested 4. Too tired to participate in the study 5. Too much going on in their life 6. Does not want to be bothered 7. Did not like the intervention (MU, NS, CB) 8. No reason 9. Other (specify ___________________________________________________)

4. Date discharged from the unit (yy/m/d)…………………………………….______________ 5. Reason for discharge ………………………………..………...........................______________

1. Died 2. AAD (Against Advise Discharge) 3. Transfer to other facility for continuous care 4. Go home for continuous care 5. Other (Specify ___________________________________________________)

6. Using Chanting box………..……………………………………….……………..______________ 1. No 2. Yes, once in a while (< 8 hours per day) 3. Yes, sometimes (>8 hours but < 16 hours per day) 4. Yes, usually (>16 hours but < 24 hours) 5. Yes, always (24 hours continuous listening)

149

7. Age (Day of birth: _______________yy/m/d)....…………..…..……..……….._____________

Obtained from the chart:

8. Gender ..………………………………………………..………….....…………….._____________ 1. Male 2. Female

9. Primary language used ……………………………………..............................._____________ 1. Chinese 2. Taiwanese 3. English

10. Primary religious belief ………………………………………………………….._____________ 1. None 2. Folklore cultural beliefs 3. Buddhism 4. Taoism 5. Christian 6. Catholic 7. Other (Specify ________________________________________________)

11. Years of education ……………………………………..…………………………_____________ 1. Self study (0 years) 2. Elementary (1-6 years) 3. Junior High School (7-9 years) 4. Senior High School/ Vocational High School (10-12 years) 5. College or University (2-year/3-year/4-year/5-year program) (13-16 years) 6. Masters degree (17-19 years) 7. Doctorate (≧ 20 years)

12. Marital status ………………………………………………................................._____________ 1. Never married 2. Married 3. Widowed 4. Divorced 5. Separated

13. Number of children ………………..……………………………………………._____________

14. Use of cigarettes …………………………………………………………………_____________ 1. No 2. Yes

i. Have used for __________years, but stopped for __________years ii. Have used for __________years, ______ Pack Per Day (PPD)

150

15. Use of alcohol …………………………………………………………………….______________ 1. No 2. Yes

i. Drink occasionally ii. Drink ________ Glass Per Day (GPD)

16. Type of cancer (Original) …………………………..…………………………..______________ 1. Unknown primary 2. Liver 3. Colon/Rectal 4. Lung 5. Breast 6. Digestive/Gastrointestinal 7. Ovarian 8. Cervical 9. Pancreas 10. Prostate 11. Laryngeal 12. Nasopharyngeal 13. Bone 14. Esophagus 15. Brain 16. Sarcoma 17. Hematological/Blood 18. Skin 19. Lymphoma 20. Kidney/Bladder 21. Other cancer (Specify __________________________________________)

17. Documented pain events in past 24 hours (times) ……………………....______________ 18. Documented highest pain score in past 24 hours ……………………...______________ 19. Documented lowest pain score in past 24 hours … ..……………..……..______________ 20. The most recent documented breakthrough pain event (yy/m/d)………..______________

Description ____________________________________________________________________________________________________________________________________________________

21. The most recent documented pain score ………………..…………………..______________ 22. Documented anxiety disorder ________________________________________________ 23. Documented anxiety events in past 24 hours (times)……………………..______________ 24. Documented highest anxiety score in past 24 hours ……………………..______________ 25. Documented lowest anxiety score in past 24 hours ………………………______________ 26. The most recent documented anxiety event (yy/m/d)…….………….........______________

Description ____________________________________________________________________________________________________________________________________________________

27. The most recent documented anxiety score …………..…………………..______________

151

Obtain from interview

28. Race /Ethnic background……………………………………………..............______________

:

1. Chinese 2. Taiwanese 3. Hakkanese 4. Aboriginal 5. Mainlander 6. Indonesian 7. Thai 8. Vietnamese 9. Philippine 10. Caucasian 11. Other (Specify ___________________________________________________)

29. Number of significant others………………………………………………….______________

(Circle all applied, but record the total number of significant others) 1. Spouse 2. Partner 3. Sibling (Specify _______________________________________________) 4. Friend (Specify _______________________________________________) 5. Spiritual mentor 6. Other (Specify ________________________________________________)

30. Monthly income ………………………………………………………………….._____________

1. No income at all 2. No stable income 3. <10,000 NT 4. 10,001 – 20,000 NT 5. 20,001 – 30,000 NT 6. 30,001 – 40,000 NT 7. 40,001 – 50,000 NT 8. 50,001 – 60,000 NT 9. >60,001 NT 10. Do not care to provide

152

* 777-NAA; 888-N/A; 999-Missing 31. Types of music liked(Ask every music type, do not leave blank)

Ask: Please tell me what types of music you like, do not like, or not sure.

Music types NO (0) Don’t Know (1) YES (2)

a. No preference

b. Classical

c. Jazz

d. Blues

e. New age

f. English popular music

g. Religious

h. Crystal music

i. Light music

j. Traditional Chinese orchestra

k. Chinese folk music

l. Chinese popular music

m. Taiwanese folk music

n. Taiwanese popular music

o. School folk music

p. Birds

q. Ocean waves

r. Frogs

s. Night life of nature

t. Forest

u. Wind

v. Stream

w. Other _________________

153

* 777-NAA; 888-N/A; 999-Missing

32. Experience with complementary and alternative therapy (Ask every therapy on the list, do not leave blank)

Complementary/Alternative Therapy No (0) Yes (1) Currently use No(0), Yes(1)

a. Acupuncture

b. Acupressure

c. Aromatherapy

d. Art therapy

e. Biofeedback

f. Chi Kung

g. Guided imagery

h. Healing touch / Therapeutic touch

i. Herbal remedy

j. Hypnosis

k. Massage

l. Music therapy

m. Chiropractic

n. Never used

o. Other _____________________________

p. Other _____________________________

q. Other _____________________________

r. Other _____________________________

154

VAS Example

Explain scales:

PAIN

The line is the pain scale. It is a line that goes from “no pain” to “the most pain imaginable.” If you are having a lot of pain right now, you will make your mark closer to the right end. If you are not having much pain, you will make your mark closer to the left end. I want you to mark how much pain you are having on the line of the scale. (show scale to the participant)

Bad examples

No Pain Most Pain Imaginable

Good example

No Pain Most Pain Imaginable

Please use one slash that cross the line at the point that shows how much pain you are having now. Make your mark like this: l . You may mark anywhere on this line now.

Pain Scale

Practice

No Pain Most Pain Imaginable

155

STUDY ID _________

Day 1 Time _____ Pretest

This line is a pain scale. It is a line that goes from “no pain” to “the most pain imaginable.” If you are having a lot of pain right now, you will make your mark closer to the left end. If you are not having much pain, you will make your mark closer to the right end. I want you to mark how much pain you are having right now on the line of the scale. (show scale to the participant)

33.

Please use one slash that cross the line at the point that shows how much pain you are having now. Make your mark like this: . You may mark anywhere on this line now.

PAIN Scale

Score _____

No Pain Most Pain Imaginable I want you to mark how much anxiety you are having on the line of the scale. This line is an anxiety scale. It is a line that goes from “no anxiety” to “the most anxiety imaginable.” If you are having a lot of anxiety right now, you will make your mark closer to the left end. If you are not having much anxiety, you will make your mark closer to the right end.

34.

Please use one slash that cross the line at the point that shows how much anxiety you are having now. Make your mark like this: . You may mark anywhere on this line now.

ANXIETY Scale

Score _____

No Anxiety Most Anxiety Imaginable

156

STUDY ID _________

Day 1 Time _____ Posttest

I want you to mark how much pain you are having on the line of the scale. (show scale to the participant) Think about how you really feel right now. Now, please mark the pain scale to show how much pain you have right now.

35.

Score _____

PAIN Scale

No Pain Most Pain Imaginable I want you to mark how much anxiety you are having on the line of the scale. (show scale to the participant) Think about how you really feel right now. Now, please mark the anxiety scale to show how much anxiety you have right now.

36.

Score _____

ANXIETY Scale

No Anxiety Most Anxiety Imaginable

Thank you for marking the scales.

157

STUDY ID _________

Day 2 Time _____ Pretest

This line is a pain scale. It is a line that goes from “no pain” to “the most pain imaginable.” If you are having a lot of pain right now, you will make your mark closer to the left end. If you are not having much pain, you will make your mark closer to the right end. I want you to mark how much pain you are having right now on the line of the scale. (show scale to the participant)

37.

Please use one slash that cross the line at the point that shows how much pain you are having now. Make your mark like this: . You may mark anywhere on this line now.

PAIN Scale

Score _____

No Pain Most Pain Imaginable I want you to mark how much anxiety you are having on the line of the scale. This line is an anxiety scale. It is a line that goes from “no anxiety” to “the most anxiety imaginable.” If you are having a lot of anxiety right now, you will make your mark closer to the left end. If you are not having much anxiety, you will make your mark closer to the right end.

38.

Please use one slash that cross the line at the point that shows how much anxiety you are having now. Make your mark like this: . You may mark anywhere on this line now.

ANXIETY Scale

Score _____

No Anxiety Most Anxiety Imaginable

158

STUDY ID _________

Day 2 Time _____ Posttest

I want you to mark how much pain you are having on the line of the scale. (show scale to the participant) Think about how you really feel right now. Now, please mark the pain scale to show how much pain you have right now.

39.

Score _____

PAIN Scale

No Pain Most Pain Imaginable I want you to mark how much anxiety you are having on the line of the scale. (show scale to the participant) Think about how you really feel right now. Now, please mark the anxiety scale to show how much anxiety you have right now.

40.

Score _____

ANXIETY Scale

No Anxiety Most Anxiety Imaginable

Thank you for marking the scales.

159

STUDY ID _________

Day 3 Time _____ Pretest

This line is a pain scale. It is a line that goes from “no pain” to “the most pain imaginable.” If you are having a lot of pain right now, you will make your mark closer to the left end. If you are not having much pain, you will make your mark closer to the right end. I want you to mark how much pain you are having right now on the line of the scale. (show scale to the participant)

41.

Please use one slash that cross the line at the point that shows how much pain you are having now. Make your mark like this: . You may mark anywhere on this line now.

PAIN Scale

Score _____

No Pain Most Pain Imaginable I want you to mark how much anxiety you are having on the line of the scale. This line is an anxiety scale. It is a line that goes from “no anxiety” to “the most anxiety imaginable.” If you are having a lot of anxiety right now, you will make your mark closer to the left end. If you are not having much anxiety, you will make your mark closer to the right end.

42.

Please use one slash that cross the line at the point that shows how much anxiety you are having now. Make your mark like this: . You may mark anywhere on this line now.

ANXIETY Scale

Score _____

No Anxiety Most Anxiety Imaginable

160

STUDY ID _________

Day 3 Time _____ Posttest

I want you to mark how much pain you are having on the line of the scale. (show scale to the participant) Think about how you really feel right now. Now, please mark the pain scale to show how much pain you have right now.

43.

Score _____

PAIN Scale

No Pain Most Pain Imaginable I want you to mark how much anxiety you are having on the line of the scale. (show scale to the participant) Think about how you really feel right now. Now, please mark the anxiety scale to show how much anxiety you have right now.

44.

Score _____

ANXIETY Scale

No Anxiety Most Anxiety Imaginable (Intervention group only) 45. How much did you like the assigned intervention? (circle the number)

1 2 3 4 5 Disliked Liked Very Much

46. Have you had any problem or comment being in the study?

_____________________________________________________________________

Thank you for marking the scales and being in the study.

161

47. Intervention used between testing times

Intervention (circle one) MU/ NS/ CB

Start song (a) Ending song (b) Total minutes used

(c) Reason for use (d)

1. Day 1 treatment Treatment 1

2. Day 1 to Day 2 Reason

3. Day 2 treatment Treatment 2

4. Day 2 to Day 3 Reason

5. Day 3 treatment Treatment 3

Reason for use

0. Regular treatment 1. Feel pain 2. Feel anxious 3. Want to relax 4. Like the intervention 5. _______________ 6. _______________ 7. _______________ 8. _______________

162

48. Current weak opioid pain medication “in effect” during Day 1 treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

49. Current strong opioid pain medication “in effect” during treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

50. Current non-opioid pain medication “in effect” during treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

Analgesics Non-opioid NSAIDs: Acetaminophen, Celecoxib, Etolodac, Fenbufen, Flurbiprofen, Ibuprofen, Ketorolac, Meclofenamic acid,

Meloxicam, Mepirizole, Nabumetone, Naproxen, Nefopam, Nimesulide, Piroxicam, Sulindac, Tiaprofenic acid Opioid Weak opioids: Codeine, Tramadol, Depain-X (Darvocet, Propoxyphene and Acetaminophen), Ultracet

(Tramadol and Acetaminophen) Strong opioids: Alfentanyl, Buprenorphine (Temgesic), Fentanyl (Durogesic), Levallorfan, Meperidine, Morphine

(MST Contin), Sulfentanil Frequency 1. QD; 2. BID; 3. TID; 4. QID; 5. Q4H; 6. Q6H; 7. Q3D; 8. Q8H; 9. Stat; 10. PRN

163

51. Current weak opioid pain medication “in effect” during Day 2 treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

52. Current strong opioid pain medication “in effect” during treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

53. Current non-opioid pain medication “in effect” during treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

Analgesics Non-opioid NSAIDs: Acetaminophen, Celecoxib, Etolodac, Fenbufen, Flurbiprofen, Ibuprofen, Ketorolac, Meclofenamic acid,

Meloxicam, Mepirizole, Nabumetone, Naproxen, Nefopam, Nimesulide, Piroxicam, Sulindac, Tiaprofenic acid Opioid Weak opioids: Codeine, Tramadol, Depain-X (Darvocet, Propoxyphene and Acetaminophen), Ultracet

(Tramadol and Acetaminophen) Strong opioids: Alfentanyl, Buprenorphine (Temgesic), Fentanyl (Durogesic), Levallorfan, Meperidine, Morphine

(MST Contin), Sulfentanil Frequency 1. QD; 2. BID; 3. TID; 4. QID; 5. Q4H; 6. Q6H; 7. Q3D; 8. Q8H; 9. Stat; 10. PRN

164

54. Current weak opioid pain medication “in effect” during Day 3 treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

55. Current strong opioid pain medication “in effect” during treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

56. Current non-opioid pain medication “in effect” during treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

Analgesics Non-opioid NSAIDs: Acetaminophen, Celecoxib, Etolodac, Fenbufen, Flurbiprofen, Ibuprofen, Ketorolac, Meclofenamic acid,

Meloxicam, Mepirizole, Nabumetone, Naproxen, Nefopam, Nimesulide, Piroxicam, Sulindac, Tiaprofenic acid Opioid Weak opioids: Codeine, Tramadol, Depain-X (Darvocet, Propoxyphene and Acetaminophen), Ultracet

(Tramadol and Acetaminophen) Strong opioids: Alfentanyl, Buprenorphine (Temgesic), Fentanyl (Durogesic), Levallorfan, Meperidine, Morphine

(MST Contin), Sulfentanil Frequency 1. QD; 2. BID; 3. TID; 4. QID; 5. Q4H; 6. Q6H; 7. Q3D; 8. Q8H; 9. Stat; 10. PRN

165

57. Current anxiolytics medication “in effect” during Day 1 treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

58. Current anxiolytics medication “in effect” during Day 2 treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

59. Current anxiolytics medication “in effect” during Day 3 treatment

Name (a) Route(b) Dose(c) Frequency(d) Time Given(e) On board(f) No=0, Yes=1

1.

2.

3.

4.

5.

1. Benzodiazepines: Alprazolam (Xanax), Diazepam (Valium), Chlordiazepoxide (Librium, Librax, Libritabs), Lorazepam

(Ativan), Clorazepate (Azene), Oxazepam (Serax) 2. Buspirone (BuSpar) 3. Tricyclics (TCAs): amitriptyline (Elavil), clomipramine (Anafranil), doxepin (Sinequan), imipramine, (Tofranil),

nortriptyline (Pamelor), protriptyline (Vivactil), trimipramine (Surmontil) 4. SSRIs: citalopram (Celexa), fluvoxamine (Luvox), paroxetine (Paxil), fluoxetine (Prozac), sertraline (Zoloft)

Frequency 1. QD; 2. BID; 3. TID; 4. QID; 5. Q4H; 6. Q6H; 7. Q3D; 8. Q8H; 9. Stat; 10. PRN

166

Appendix D

Comparison of Two Hospice Units

KMUH SJH

Variable n M (SD) n M (SD) t P

Admission (n/month) - 30.71 (4.39) - 16.5 (2.23) 7.61 < .001 Discharge (n/month) - 30.57 (5.50) - 16.86 (3.72) 5.46 < .001 Length of stay (days) - 13.18 (2.08) - 14.69 (4.18) - .85 .41 Occupancy rate (%/month) - 83.23 (4.91) - 70.37 (5.30) 4.71 .001 Age of RN (years) 18 34.89 (6.06) 12 31.67 (4.74) 1.55 .13 Experience in hospital (years) 18 10.89 (7.41) 12 6.67 (4.31) 1.97 .06 Experience in hospice (years) 18 6.33 (2.03) 12 6.67 (4.31) - .25 .81

Note. KMUH = Kaohsiung Medical University Hospital; SJH = St. Joseph Hospital; RN = Registered nurse. The variables were measured from October, 2010 to April 2011.

167

Appendix E

Frequency of Participants with Analgesics and Anxiolytics

Day 1 Day 2 Day 3 Medication n % n % n %

Weak opioids n = 39 n = 37 n = 37 Codeine 5 12.82 4 10.81 4 10.81 Darvocet 1 2.56 2 5.41 2 5.41 Tramadol 2 5.13 3 8.11 3 8.11 Ultracet 31 79.49 28 75.68 28 75.68 Strong opioids n = 116 n = 116 n = 115 Durogestic 33 28.45 36 31.03 36 31.30 Morphine 77 66.38 76 65.52 76 66.09 MST 3 2.59 3 2.59 3 2.61 Temgesic 3 2.59 1 0.86 0 - Non-opioids n = 136 n = 133 n = 129 Acetaminophen 23 16.91 21 15.79 19 14.73

Beclofen 2 1.47 2 1.50 2 1.55 Cataflam 3 2.20 4 3.01 3 2.33 Celecoxib 9 6.62 9 6.77 9 6.98

Chlorzoxzone 7 5.15 5 3.76 4 3.10 Clonazepam 2 1.47 2 1.50 2 1.55 Etoricoxib 1 0.74 1 0.75 2 1.55

Ibuprofen 1 0.74 1 0.75 1 0.78 Ketorolac 5 3.68 5 3.76 4 3.10 Mefenamic acid 1 0.74 1 0.75 1 0.78 Naproxen 1 0.74 2 1.50 1 0.78 Neurontin 6 4.41 6 4.51 6 4.65 Steroids 46 33.82 45 33.84 45 34.88 Tegretal 23 16.91 23 17.29 23 17.83 Tofranil 5 3.68 5 3.76 6 4.65 Urogen 1 0.74 1 0.75 1 0.78 Anxiolytics n = 35 n =30 n = 30 Alprazolam 16 45.71 14 46.67 14 46.67 Fluoxetine 5 14.29 1 3.33 1 3.33 Lorazepam 14 0.40 15 0.50 15 0.50

Note. MST = Morphine Sulfate ; the n represents the number of participants who received the drug and one participant could received more than one drug.

168

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