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The effect of soothing music on neonatal behavioural states in the hospital newborn nursery Kaminski, June L. 1993

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THE EFFECT OF SOOTHING MUSICON NEONATAL BEHAVIOURAL STATESIN THE HOSPITAL NEWBORN NURSERYbyJUNE LOUISE KAMINSKIB.Sc.N., The University of British Columbia, 1985A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTERS OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIESSchool of NursingWe accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIASeptember 1993© June Louise Kaminski, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature) Department of R.) ue.E.) 11.) GThe University of British ColumbiaVancouver, CanadaDate ^d^cs+ ) ‘ct DE-6 (2/88)ABSTRACTThis study was designed to test the effect of soothingmusic on the number of high arousal neonatal behaviouralstates and the frequency of behavioural state change withinthe hospital newborn nursery. The theoretical framework forthis study was drawn from theories related to newbornbehavioural states, environmental influences on newborns,psychophysiologic effects of music and music as a healthintervention. This study used a quasi-experimental, onesample, pretest, posttest design in which the subjectsserved as their own controls. The results were then analyzedusing a one-tailed, McNemar's test (alpha < .05) specificfor related small samples when nominal scale data aregathered.The sample consisted of twenty subjects observed in alarge tertiary care hospital in Western Canada. The subjectsranged in age from 24 to 57 hours old, were 36 to 42 weeksgestational age, weighed 2860 to 4160 grams at birth, andhad Apgar scores ranging from 9 to 10 at five minutespostbirth. There were 8 females and 12 males. All wereCaucasian and all were born vaginally without complications.All but two were breastfed.The subjects were observed for a total of four hourseach, two hours in the normal nursery environment andiiianother two hours with the addition of selected soothingmusic. All observations took place between 2400 and 0600hours.There was a significant difference at the alpha < .05level in the number of high arousal states (Nonalert Wakingand Crying) between the control and experimentalobservations. The control group exhibited significantly morehigh arousal states than the experimental group did. The zscore obtained from comparing the proportion of high arousalstates between the two observations was 2.36, p < .01,significantly higher than the score of 1.65 needed to besignificant at alpha < .05. There was also a statisticallysignificant difference in the number of state changes and inthe z score of 2.93, p < .001 for state lability. Thecontrol group demonstrated significantly more state changesthan the experimental group did.With a sample size of twenty, conclusions aretentative. The findings suggest that music may be useful tonewborns adapting to extrauterine existence within a nurserysetting. Interventions intended to reduce the frequency ofhigh arousal states in newborns while in the nursery are theresponsibility of nurses. Nursing and patient educationshould also address the possible use of music with babiesexhibiting high arousal behavioural states. The results ofthis study suggest areas for replication and further study.ivTable of ContentsPageABSTRACT^LIST OF TABLES^ viLIST OF FIGURES viiDEDICATION^ viiiACKNOWLEDGEMENTS^ ixCHAPTER ONE: INTRODUCTIONBackground to the Problem^ 1Problem Statement^ 7Purpose^ 8Theoretical Framework 8Hypotheses 12Definition of Terms^ 12Neonate^ 12Environment 13Behavioural State Continuum^ 14Music 15Significance^ 16Overview of the Thesis Content 17CHAPTER TWO: REVIEW OF THE LITERATUREIntroduction^ 19Neonatal Puerperal Adjustment^ 19Neonatal Behavioural States 20Environmental Effects on Neonatal States^ 23Physiological and Psychological Responsesto Music^ 24Music as a Health Intervention^ 29Summary 32CHAPTER THREE: METHODSIntroduction^ 33Study Design 33Sample Inclusion Criteria^ 34Data Collection 35Assumptions^ 39Limitations 40Data Analysis 42Reliability 44Instrument Reliability^ 44Interrater Reliability 46Study Reliability 46Validity^ 48Instrument Validity^ 48Study Validity 51Ethical Issues^ 54Summary^ 55CHAPTER FOUR: PRESENTATION AND DISCUSSION OFRESULTSIntroduction,^ 57Characteristics of the Sample^ 57Demographic and health - relatedCharacteristics of the Sample 57Findings^ 61Statistical Analysis of the Difference inFrequency of the High Arousal States betweenthe Two Groups^ 62State Lability (Frequency of State Changes)during the Control and ExperimentalObservations 63Statistical Analysis of State Lability^ 64Discussion of the Findings^ 64High Arousal State Frequencies in theControl and Experimental Observations 65High Arousal Behavioural States^ 65Nonalert Waking state^ 66Crying State^ 68Lability of the Behavioural States during theControl and Experimental Observations^ 73Summary of the Findings^ 76CHAPTER FIVE: SUMMARY, CONCLUSIONS, IMPLICATIONSAND RECOMMENDATIONSIntroduction^ 78Summary 78Conclusions 82Implications for Nursing Practice^ 83Recommendations for Further Nursing Research^ 86REFERENCES^ 88APPENDICESA. Parental Consent Form^ 95B. Music Selections 96C. Data Collection Tool 97D. Behavioural State Codes & Descriptions^ 99E. Physician's Information Letter^ 100viList of TablesPageTable 1. Demographic Characteristics of the NewbornSample compared with Thoman, Korner &Kraemer's 1975 Study Subjects^ 60Table 2. Number of High and Low Arousal BehaviouralStates and Number of State Changes (Lability)during the Control and the ExperimentalObservations (in 10 second epochs)^ 62viiList of FiguresPageFigure 1. Model of the Theoretical Framework^ 11Figure 2. One Group, Pretest, Postest Design^ 34Figure 3. Data Collection Schema^ 35viiiThis thesis is dedicated to my mate and my six children forgiving me their support and encouragement throughout thecompletion of this thesis.ixACKNOWLEDGEMENTSI would like to thank the members of my thesis committee,Wendy Hall (chairperson) and Donelda Ellis for sharing theirexpertise and providing guidance and support.I would like to thank Alison Rice for agreeing to serve asExternal Reader and for sharing her insights about thestudy.I would like to thank Professor Evelyn Thoman and herassociates for sharing their Taxonomy of Behavioural Statesand collection tool for use in this study.I would like to thank my friends and colleagues for theirsupport and encouragement throughout this endeavor.My appreciation is extended to the nursing staff andphysicians of the postpartum units of the hospital where thestudy was conducted.Finally, I would like to thank the patients who participatedin this study and their parents.CHAPTER ONEIntroductionBackground to the Problem"In the germ, where the first trace oflife begins to stir, music is the nurseof the Soul; it murmurs in the ear, andthe child sleeps; the tones arecompanions of his dreams - they are theworld in which he lives." (Lingerman,1983, p. 189).The birth of each human being begins with a complexprocess of adaptation to the outside world. The neonate mustmake many physiological and behavioural adjustments tosuccessfully adapt to the new environment. "The intrauterine- extrauterine adaptation of the transitional newborn isphysiologically demanding and is now known to take manyhours or several days. In addition, the infant is atconsiderable risk, more than is generally believed"(Anderson, 1989, p.197). Respiratory, cardiovascular,gastrointestinal, endocrinological and behaviouraladaptation is vital for a healthy adjustment to theextrauterine environment (Pratt, 1985). The newborn exertsan enormous amount of energy establishing biologicalhomeostasis.2Recently, professionals studying neonates have focusednot only on the newborns' physiological adjustments but alsoon their behavioural patterns (Brazelton, 1984). They foundthat neonates exhibit a continuum of behavioural states ofconsciousness. Lewis & Zarin-Ackerman (1970) describe thisstate continuum as a "major adaptive mechanism" which servesas a mediator of environmental input and a mode for theinfant to socially interact (p. 95). The relationshipbetween behavioural states and the environment and itsstimuli is supported in the literature (Ashton, 1971;Brazelton, 1973, 1984; Korner, 1972; Stratton, 1982; Thoman& Whitney, 1989). Thoman, Denenberg & Sievel (1981) wrotethat " A neonate's state behaviors reflect both its owninternal endogenous processes and exogenous influences fromthe environment" (p.47).Stability of state organization over time appears to bean important characteristic of clinically healthy newborns.In their 1981 study of newborn state organization, Thoman etal. observed that "... inconsistency in state organizationover the early weeks was the antecedent condition for laterdysfunction or death, occurring as early as 3.5 months andas late as 2.5 years (p.53). They observed that the newbornswho exhibited irregular or "poorly organized" state patternsall developed conditions ranging from delayed development,aplastic anemia, and hyperactivity to Sudden Infant DeathSyndrome. Since adaptation is so crucial for the transitoryneonate who is likely to spend a large percentage of thehospital stay in the nursery, it is imperative that nurses... create ways in which the nursery experience for infantscan be designed to optimize development" (Karraker, 1986,p.362).In the past few decades, hospitals have become theaccepted environment for childbirth and postpartumadjustment (Anderson, 1989). The majority of neonates bornin Western civilization spend the first one to three days oftheir lives in the hospital environment. Recently, "rooming-in" or accommodating the mother and her newborn in one roomhas become popular (Karraker, 1986). Despite this shift awayfrom nursery - focused care, many newborns still spend aconsiderable portion of their hospital stay in the normalnewborn nursery. Karraker (1986) explains that this occursdue to "...illness of either the mother or the infant, themother's need for rest, avoiding infections when the motherreceives visitors, and the mother's desire to be relieved ofcaretaking duties at times" (p. 362).The hospital newborn nursery is designed and operatedaccording to specific stipulations or standards (Jensen,Bobak & Zalar, 1989). These standards result inenvironmental conditions of bright, continuous light and ahigh level of noise. The American Academy of Pediatrics(1977) published guidelines which instruct that illuminationshould be 100 foot candles in brightness and that deluxecool-white fluorescent bulbs be used to keep the nurserywell-lit and shadow-free 24 hours per day.4In terms of noise, the nursery must contain an area toaccommodate 24 - 36 infants with 20 square feet each andthree feet of space between cots. Supply cupboards, washstations, utility and examination areas plus an adjacentclerical area should all be present within the nurserysetting. These requirements foster the generation of acontinuous, high level of noise since all caregiving androutine activities are performed in close proximity to thenewborns.Hilton (1985) referenced Kosten and Van Os (1962) asstating that the recommended noise level in the hospitalsetting should be no more than 35 decibels during sleepperiods and 40 decibels when the client is awake. Keefe(1987) described the nursery environment as having a noiselevel of over 80 decibels for an average of 146.8 minutesper four hour period of observation. Keefe warns that an 80decibel noise level is comparable to loud traffic noise. Shefound that the most striking and persistent noise was thesound of other infants crying. Anderson (1989) suggestedthat:"Newborn infants cared for in busy hospitalnurseries on a well intended demand -feeding schedule have generally begun tocry before they are taken to their mothers.Prevention of crying and startling duringthe intrauterine - extrauterine adaptationmay be very important to the infant's later5development" (p. 197).Prolonged crying can complicate the newborn'sadaptation since it obstructs venous return in the inferiorvena cava and reestablishes fetal circulation within theheart (Anderson, 1989). "Each time the strain phase of a cryis released, poorly oxygenated blood flows through theforamen ovale and back into the systemic circulation ratherthan into the lungs. Thus, some degree of hypoxia mustdevelop" (p. 197).The multiple adjustments that the neonate makes arechallenging even in a quiet, unobtrusive environment. Thenursery environment presents additional challenges since"... the profound physiological adjustments the infant isrequired to make in the transfer from intrauterine toextrauterine existence makes him (her) particularlyvulnerable to hazardous environmental conditions rarelynoxious to older individuals" (Jensen et al, 1989, p.10).One way to evaluate the neonate's vulnerability is toobserve behavioural state organization. "State organizationimproves with maturation and with well-being" (Brazelton,1984 p.60).One of the seven behavioural states (Thoman, 1990),Nonalert Waking, is considered a primitive state, common inpremature infants but usually limited in frequency inhealthy, fullterm newborns. A high frequency of this statehas been linked with poor central nervous system stabilityin newborns and potential longterm vulnerability (Thoman,61990). Nonalert Waking and Crying states are considered tobe high arousal states (Thoman, 1990).Obstetrical nurses assume a major responsibility formonitoring the puerperal adjustment in both the mother andher newborn (Jensen et al, 1989). Nursing interventionsdesigned to reduce or mask the impact of noxious stimuli inthe nursery environment are both desirable and ethical. Notonly must the environment be conducive to physiologicalhomeostasis but "...the pattern of infant state cycles mustbecome harmoniously integrated with the salient recurrentfeatures of the environment" (Keefe, 1987, p.141).Dossey, Keegan, Guzzetta & Holkmeier, (1988) outlinedways that music therapy can be used by nurses in theclinical setting. They said that soothing music can be usedfor the "...reduction of psychophysiologic stress, pain,anxiety, and isolation" (p. 267). Music can producephysiological relaxation by stimulating a hypometabolicresponse in the autonomic, immune, endocrine, andneuropeptide systems. Music can also affect thepsychological behaviours through the limbic system. Thispart of the brain is influenced by musical pitch and rhythmwhich in turn affects emotions and feelings.Adding soothing music to the nursery environment couldbe an inexpensive and feasible intervention for promoting anenvironment more conducive for newborn homeostasis. Soothingmusic has been used by health care professionals to reducestress-related behaviours and promote rest and feelings of7well-being in infants, children, and adults (Benenzon,1981). It would appear the use of lulling music could helpthe newborn cope with the noxious stimuli of the nurseryenvironment. Music researchers such as Clynes (1982) havefound that music can communicate specific emotional or moodstates, such as serenity or joy. The music seems tostimulate inherent emotional states via the limbic system inthe brain which signals the organism to "match" the mood ofthe music. They theorized that this would explain whysoothing music can lull a person into a state of relaxationor sleep.The newborn child can respond to sound and musicalmost immediately (Deutsch & Richards, 1979). He or she isquieted by one of the earliest and constant sounds he/shehears: the mother's heartbeat. Like the fetus, the neonatewill be jarred by loud and sudden sounds."Music will frequently quiet the child.., he/shereacts calmly to the lilting melody of a lullaby.He/she exhibits a more quieting and alertingbehavior to soft, high-pitched instruments andfemale voices than to low-pitched instrumentsand male voices" (Greenberg, 1979,p.48).Problem StatementNeonates cared for in a hospital nursery are exposedto bright, continuous light and a high noise level. Wolke8(1987) cautioned that "...high light and noise intensity...not only lead to the disturbance of the infant's rest butalso increase the time spent in rapid eye movement (REM)sleep" (p.988). This increase negatively affects the amountof deep, non - REM sleep (NREM) the neonate experiences.Since the newborn already spends approximately 52% ofhis/her sleep time in REM sleep, a further decrease of NREMsleep is significant for the newborn's well - being (Thoman,1990). Intense levels of light and noise can likewiseinterrupt the regulation of neonatal behavioural stateorganization (Keefe, 1987; Wolke, 1987). Neonates tend tocry, fuss and startle more and spend more time in transitoryand Nonalert Waking states. They also demonstrate anincrease in state change (lability). Health careprofessionals, including nurses have used music within thehospital setting to promote rest and sleep and to modulatestress-related behaviours in adults, children and infantsPenenzon, 1981; Dossey et al, 1988; Fagen, 1982).Purpose The purpose of this study is to relate the effect ofselected soothing music to the number of high arousal statesand number of state change observed in newborns cared for inthe hospital nursery.Theoretical FrameworkThe theoretical framework best suited to this study is9borrowed from physiology, developmental psychology, andmusic therapy. The framework is based primarily on Lewin's(1936) general systems theory. Lewin's (1936) main postulateis important in this study: behaviour evolves as a functionof the interplay between the person (system) and his/herenvironment(macrosystem).The neonatal period is one of immense biolologicalvulnerability and one in which a successful outcome dependslargely on appropriate neonatal adjustments to theextrauterine environment. The neonate is dependent on asupportive environment yet, "... most Western newborns maketheir first adaptations to the noise, smell, and fluorescentlighting" (Stratton, 1982, p.409) of a hospital nursery.Postpartum system balance in newborns is dependent onthe achievement of three tasks (Lewis & Zarin-Ackerman,1970). A newborn must establish homeostasis through self-regulation of arousal by making changes in state and sleeppatterns. He/she must process, store, and organize multiplestimuli. He/she must also establish a reciprocalrelationship with a primary caretaker and with theenvironment.Trevisan and Nowicki (1978) described the use of musicin systems theory terms. The input of soothing music canstimulate an alpha wave brain state - a state of relaxedawareness. In this state, messages of relaxation are sent bythe brain via efferent neural pathways to the body organs,muscles, and glands.10A relaxed alpha state also signals the limbic system inthe brain, the centre of psychological feelings andemotions. In the presence of emotional stress or limbictensions, the limbic cortex translates this stress to thehypothalamus resulting in high adrenalin production."These influences stimulate a sympathetic reactionwith such physical symptoms as increased heartrate,blood pressure, blood sugar, constriction of theblood vessels of the skin and viscera and a decreasein digestion. Also there is production of cortisolwhich acts in the catabolism (breakdown) of proteinin the system, lowering resistance and leaving theorganism more susceptible to illness" (Trevisan &Nowicki, 1978, p. xi).Slow instrumental music may initiate the "tuningsystem" naturally within the brain aiding the initialrelease of limbic emotions. The sensory stimulation of music(positive input) is received by the body and sent to theneocortex of the brain via the thalamus. This neocorticolinput interacts with internal limbic emotions and tension inthe thalamus. The combination of sensory stimulation and analpha wave state of relaxed awareness serve to initiate aparasympathetic relaxed response in the organism. In arelaxed state, infants are less likely to spend much timefussing, or in Crying or in Nonalert Waking states and moretime in NREM (Quiet) sleep (Thoman, 1990).Figure 11 1Model of the Theoretical Framework12Hypotheses 1. The control group will demonstrate a significantly highernumber of high arousal states than the experimental group.2. The control group will demonstrate a significantlygreater state lability or number of state changes than theexperimental group.Definition of TermsTo clarify the variables and assumptions implicit in thisstudy both theoretical and operational definitions of themajor concepts are warranted. The theoretical definitionsreflect concepts directly from the literature; theoperational definitions have been refined to pertainspecifically to the study. The concepts: neonate,environment, behavioural state continuum, and music havebeen defined both theoretically and operationally.NeonateTheoretical definition. Newborn human organism with ahigh level of cognitive functioning and a baseline ofbehaviours which predisposes the neonate to interact and tolearn. The newborn constantly seeks homeostasis, and isdependent on a supportive caregiving environment (Brazelton1973, 1984; Lewis & Zarin-Ackerman, 1970; Thoman, 1990;13Wolff, 1987).Operational definition. Full-term (greater or equal to 36weeks gestation), newborn (24 - 60 hours old), bornvaginally with no complications during pregnancy or birth.Apgar scores over or equal to 8 after 5 minutes of age,Occidental, either male or female with no postpartumcomplications or anomalies.EnvironmentTheoretical definition. The hospital newborn nursery, acare area designed for routine neonatal care for normal,fullterm (36 or more weeks gestation) infants weighing morethan 2000 grams. This area must meet the criteria for lightand equipment established by the American Academy ofPediatrics (1977).Operational definition. Tertiary care maternity hospitalin Vancouver, B.C., Canada. Approximately 300 square feetwith room for 16 regular cots, 2 bilirubin light cots, andone radiant warmer. Staffed by one LPN or RN for each 12hour shift. Lighting and equipment similiar tospecifications outlined by American Academy of Pediatrics(1977).14Behavioural State ContinuumTheoretical definition. A recurrent, intricatelyorganized pattern of behaviour that occurs spontaneously andis cyclic (Brazelton, 1973; Keefe, Kotzer, Reuss & Sander,1989; Thoman, 1990). Represents a major adaptive mechanismfor mediating environmental input and a mode for socialinteraction (Lewis & Zarin-Ackerman, 1970). The rhythmicpattern of states reflects the integrity of the newborn'scentral nervous system and is a sensitive measure of theneonate's response to the environment (Brazelton, 1973;Colombo, Moss & Horowitz, 1989).Operational definition. A continuum of seven distinctstates (Thoman, 1975; et al, 1981; 1985; & Whitney, 1989;1990) that recur cyclically in response to internal andexternal stimuli which can be coded in 10 second epochs. Thestates are listed along with their characteristicbehaviours:a) Ouiet S/eep: eyes closed, tonic muscle tone, no motoractivity except occasional startles, mouthing or sigh-sobs.b) Active Sleep: eyes closed, rapid eye movement (REM),phasic muscle tone, stretching, intermittent body movement,and sporadic startles.15c) Transitional: eyes closed or may be rapidly opening andclosing and there may be generalized motor activity.d) Drowse/Daze: Heavy - lidded eyes, eyelid flutters, smallbody movements (may have some larger ones).e) Crying: Intense, distressed vocalizations, distressedfacial expression, flailing, intense body movements.f) Quiet AXert: Eyes open, bright, and shining, oftenscanning, may have small body movements.g) Nonalert Waking: Open, dull eyes, high motor activity,facial grimaces, startles and periods of fussing.Music Theoretical definition. An auditory stimulus comprised ofsound arrangements with various combinations of melody,harmony, rhythm, and tone colour (Copland, 1967; Podolsky,1954). Reaches the body via the ear through neural pathwaysto the autonomic nervous system causing measureablephysiological responses (Haas, Distenfeld & Axen, 1986;Lundin, 1985).Operational definition. Soothing, dreamy arrangementswith a flowing, lyrical melody; a quiet, calm tone colour;simple and consonant harmony; and an easy, slow rhythm at16approximately the same rate as a regular heartbeat (65 - 80beats per minute) (Geden, Lower, Beattie & Beck, 1989; Haaset al., 1986; Lingerman, 1983; Lundin, 1985; Podolsky, 1954;Verdeau Pailles, 1985). Two examples are J. Brahm'sLullaby and Waltz of the F owers from the Nutcracker Suiteby P.I. Tchaikovsky (Guthiel, 1970).Significance Nursing is dedicated to holistic care of clients inall stages of development. Currently there is only a trendtowards continuous "rooming-in" during the postpartumhospital stay. This is the ideal caregiving arrangement forthe hospitalized healthy postpartum mother and newborn(Anderson, 1989; Keefe, 1987). Since patient advocacy is acentral nursing responsibility, nurses should support andencourage new mothers to take advantage of thisaccommodation. As long as newborns spend a significantamount of time in the nursery, nurses must assumeresponsibility for protecting them from noxious stimuli.Nurses and other health care team members must recognize thephysical as well as psychological vulnerability of thetransitional newborn. This recognition should lead toimplementation strategies to gently ease the newborn into aharmonious relationship with the external environment.The use of music as a therapeutic agent to soothe,relax, sedate, distract, and help cope with pain anddiscomfort is beginning to interest nurse scholars and17researchers (Davis-Rollans & Cunningham, 1987; Duxbury,Henley, Broz, Armstrong & Wachdork, 1984; Geden et al.,1989; Jacob, 1986; Karraker, 1986; Olds, 1985). Thisnursing study may add to the current nursing literature onthe use of music in disturbing environments. As long asnurses care for infants in the nursery setting, helping thenewborn by reducing the impact of noxious environmentalstimuli is a nursing responsibility. The use of soothingmusic in the nursery has the potential to be a viableintervention in achieving this goal.Overview of the Thesis ContentThis thesis is comprised of five chapters. In ChapterOne, the background to the problem, problem statement,purpose, theoretical framework, hypothesis, definitions andsignificance of the study are described. In Chapter Two, areview of selected literature representing relevant theoryabout the study variables is presented. Literature onneonatal puerperal adjustment, neonatal behavioural states,environmental effects on the neonate, psychophysiologicresponses to music, and the use of music as a healthintervention are reviewed. In Chapter Three, the researchmethods including a description of the research design,sampling procedures, assumptions and limitations of thestudy, reliability and validity, ethical considerations andstatistical procedures used in data analysis are presented.18In Chapter Four, the description of the sample, a report ofthe findings and a discussion of the results are given. Thesummary, conclusions, implications, and recommendations forfuture research are presented in Chapter Five.19CHAPTER TWOReview of the LiteratureIntroductionTheory from the disciplines of nursing, developmentalpsychology, physiology, and music therapy influenced thedevelopment of this study. Relevant theory is presentedwithin six distinct categories: neonatal puerperaladjustment, neonatal behavioural states, environmentaleffects on the neonate, psychophysiologic responses tomusic, and the use of music as a health intervention.Neonatal Puerperal AdjustmentAdjustment to extrauterine existence imposes amultitude of physiological and psychological tasks on thenewborn (Anderson, 1989; Ashton, 1971; Brazelton, 1973;Gorski, Lekowitz & Huntington, 1987; Lawson, Turkewitz,Platt & McCarton, 1985; Lerner, 1984; Prechtl, 1974;Stratton, 1982; Thoman, 1990). During this time, importantphysiological regulators have been triggered by birth andare set in place. Many persist across the life span(Anderson, 1989). Jensen et al. (1989) list thephysiological tasks as a) establishing and maintainingrespirations and oxygen consumption, b) ingesting, retainingand digesting nutrients, a transition from maternalparenteral to infant enteral nutrition, c) elimination of20wastes, d) regulation of temperature and e) regulation ofweight (p.586). The neonate must also regulate periods ofrest with periods of wakeful activity (Keefe, 1987).At birth, the normal human can respond to auditory,visual, tactile, gustatory and olfactory stimulation(Verney, 1981; Whaley & Wong, 1989). Horowitz (1975)describes the neonate as "...an exquisitely evolutionallyadapted organism who arrives with a baseline of behaviourthat predisposes the organism to interact and to learn yetis "....entirely dependent (emphasis added by author) forultimate physical survival" (p.29).Neonatal Behavioural States The concept of infant states originates in generalsystems theory (Lerner, 1984). The states are recurrent,intricately organized patterns of behaviours observed in thehuman neonate (Keefe, 1987). The cyclic pattern of thebehavioural states reflects the neonate's internal statusand indicates the integrity of the infant's central nervoussystem (Colombo et al., 1989).Each healthy, full-term infant displays a uniqueyet organized series of distinct states over time. Thepredominant state of consciousness may be the bestreflection of where the infant is during an attempt tomaintain controls over his or her immature autonomic nervous21system (Brazelton, 1984). Brazelton (1984) further informsthat there are several published versions of state matrices.State scales have been presented in the literature by:Brazelton (1973) and (1984), Brown (1964), Dittrichova(1962) and (1966), Korner (1972), Lewis and Zarin-Ackerman(1970), Parmalee (1974), Prechtl (1974), Thoman et al.(1981), Thoman and Whitney (1989), Wolff (1966) and (1987).All of these state taxonomies are remarkably similar, allare based on sleep - awake patterns. Most focus on one tothree distinct sleep states, a few include an intermediatedrowsy state as well as one to three awake states. However,according to Thoman (1990), "Our studies and those of Wolffare the only ones which have involved lengthy andlongitudinal behavioural recordings of the full range ofinfants' sleeping and waking states in the home" (p.94).Thoman (1990) described seven states includinga) Quiet Alert b) Nonalert Waking c) Crying d) Transitionale) Drowse/Daze f) Active or REM Sleep and g) Quiet or NREMSleep. Thoman (1990) deliberately chose names for the statesto indicate the qualitative nature of the behaviouralpatterns one can observe in infants. Each state is distinctfrom the other six states and is distinguished by particularobservable behaviours, e.g. REM eye movements in ActiveSleep.Descriptions of the cyclic frequency and duration ofthese behavioural states exist in the literature. Thoman(1990) summarized the average mean percent of time spent in22each state over a seven hour observation period (n = 28):Quiet Alert: 6.7%, Nonalert Waking: 2.8%, Crying: 3.4%,Drowse/ Daze: 5.4%, Transition: 1.3%, Active Sleep (REM):52.3%, and Quiet Sleep: 28.1% (p. 98).Since each newborn is a dynamic individual, each mustlearn to organize his/her behavioural states in a uniquepattern. Although similarities in behavioural stateorganizational patterns exist, no two infants will displayexactly the same sequence. The state behaviour pattern oforganization is an important indicator of the newborn'sgeneral level of well-being and is a sensitive measure ofthe neonate's response to external events e.g. a high noiselevel or bright lights (Keefe, 1987).Thoman (1975) distinguishes newborns as having either"well-organized" states or "poorly-organized" ones. Shedescribed babies as "well-organized" if they were "easy toread" or if they gave clear cues as to whether they wereawake, asleep, or uncomfortable. These infants spent moretime in "states of greater equilibrium", e.g. Quiet Sleep orQuiet Alert. Clear characteristics appropriate to eachbehavioural state were demonstrated. Relatively little timewas spent in transitory states by these newborns. "Well-organized" infants demonstrated cycling of states,especially the sleep states."Poorly-organized" infants spent significantly lesstime in Quiet Sleep or Quiet Alert states. They spent moretime in Transitional, Crying, Drowsy and Nonalert Waking23states. The behavioural states were demonstrated in a highlylabile fashion both in duration and in changing from onestate to another. Behaviours exhibited did not "match" theapparent state, e.g. eyes might be open when asleep.Environmental Effects On Neonatal StatesTo Lewis & Zarin-Ackerman (1970), state represents aninfant and environmental interaction in which state ismodified by the environment. The human newborn ismarvelously equipped to adapt to the extrauterineenvironment. Still, "...the caregiving environment seemsgreatly responsible for enriching, stagnating, or disturbingoriginal neonatal behaviour" (Gorski et al., 1987, p. 40).Young infants have no verbal language besides crying,and learn through sensorimotor experiences and by makingassociations with stimuli. Sensorimotor experiences areexposures to tactile, kinaesthetic, auditory, visual, motor,gustatory and vestibular information (Wolke, 1987). Whilecared for in the newborn nursery, the neonate mustsynchronize his or her behavioural states and physiologicaladjustments with an environment where there is no clear,pronounced diurnal rhythm in noise and light intensity or incaregiving activities. This is significant since for theneonate, one of the primary biorhythmic elements is thedistribution and flow of sleep-awake states over a 24 hourperiod (Keefe, 1987). The achievement of synchronous24interaction or coordinated exchange between the caregivingenvironment and the newborn represents an initial level ofadaptation which is crucial to the functioning of thenewborn living system (Thoman & Whitney, 1989).High light and noise intensity not only lead to thedisturbance of the infant's rest but also increase the timethe baby spends in Active (REM) Sleep. Lower tissueoxygenation, increased chest wall instability and periodicbreathing, with the occurrence of five to 14 times moreapneic episodes during REM sleep in comparison with Quiet(NREM) sleep, have been reported (Wolke, 1987). These eventshave implications for brain oxygenation and intact centralnervous system functioning (Anderson, 1989).Noise pollution in the newborn nursery is mainlycaused by caregiving activities (Wolke, 1987) and by otherinfants crying (Keefe, 1987). "Sudden loud sounds often leadto adverse physiological effects in the newborn. Theseinclude sleep disturbances, motor arousal and crying,hypoxemia, tachycardia, and increased intracranial pressure"(Wolke, 1987, p. 987). With less time spent in NREM sleep,the newborn's eyes are likely to be at least partially open,increasing the exposure to disturbing fluorescent lights.Physiolpgical and Psychological Responses to Music Music has been a major thread in the historicalliterature on healing and health (Podolsky, 1954). The25ancient primitives as well as civilized societies (Greek,Roman, Oriental, Hebrew, etc.) lauded music as "... one ofthe greatest of all healing forces" (Podolsky, 1954, p.1).Scholars have theorized on how music affects the listener."Deep within us, music strikes a resonance so that werespond first on a rhythmic, sensorimotor level and later inan associative, perceptual or intellectual way" (p. 256).Other investigators have found that soothing music aidsdigestion (Podolsky, 1954), relaxes muscles and calmsrestless minds (Jacobs, 1986), decreases physiologicalresponses to stress (Standley, 1986), regulates respiratoryrates (Haas et al., 1986), and skin temperature, (McFarland,1985) calms patients during radiation therapy (Buckingham,1983) and helps to reduce pain perception (Geden et al.,1989; Standley, 1986). Verdeau Pailles (1985) theorizedthat musical rhythms affect humans because "... they are intune with our own internal rhythms" (p. 40) and that musiccan have a positive influence on both neural and hormonalfunction thus facilitating healthy immune and growthprocesses.Music affects the actual brain-wave state via theneuro-endrocrine system through electrical and chemicalcircuits which transmit neural messages to the brain(Trevisan & Nowicki, 1978). Music can actually affect theemotional or feeling state of the listener through directstimulation of the limbic system. "Music seems to berecognized by our brain as the representation of integral,26holistic auditory images (the harmonic structure) whoselong-term succession in time bears in itself a distinctGestalt value" (Roederer, 1982, p.45).Although music is obviously composed of various sounds,it "...is distinguished from most other sounds - much of thetime - in that it uses steady frequencies. The amplitude ofmusical sound varies continuously as for natural sounds butdiscrete frequency steps are used to allow relationshipsbetween tones to develop" (Clynes, 1982, p.48).Music is considered cultural in that it may serve thesame function (as stimulus and in the response by thelistener) for more than one person. The fact that musicalresponses are shared is also illustrated in people's tastesor preferences for music. For instance, " Occidental peoplelove simple rhythms, careful tuning, fixed tonal steps andharmonies" (Lundin, 1985, p.6). Schoen (1968) pointed outthat no two people will be affected exactly the same by anystimulus. He said "However, a given musical selection willarouse a certain definite reaction and will arouse the samereaction on different occasions in a large proportion ofthose who listen" (p.151).Musical phenomena are felt as sonorous vibrationsinside the body, as a source of energy and "release", and assemantic content (Verdeau - Pailles, 1985). Podolsky (1954)described how musical rhythm regulates inner body rhythmswhich help the person to feel more integrated and organized.Rhythm must be considered both as a stimulus object and as a27response of the organism. On the response side, rhythm isboth motor and perceptual. Lundin (1985) explained thatmusical stimuli can cause a physiological rhythm to appearin the central nervous system pathways. Periodic increasesand decreases in the intensity of the neural sensationsbecome coordinated with the series of objective stimulationsfrom the musical rhythm.The perceptual organization of distinct rhythmicstimuli involves some discrimination of stimuli. Humans tendto perceive musical stimuli in groups or phrases: instead ofhearing a series as "click - click -click", we may groupthem as "CLICK - click-click". This organization is labelled"subjective rhythm". The capacity for subjective rhythm isinherent in the organism and occurs without training.Lundin (1985) also wrote "... the fundamentalconditions of a rhythmic experience are to be found in thelaws of periodicity of functioning in the nervous system"(p.122). Tame (1984) found that most people find musicplayed at about the same pace as the normal heartbeatsoothing ( 65 - 80 beats per minute). This is similiar toSalk's findings (1981) that infants seemed to find rhythmsof about 72 beats per minute (similiar to the mother'sheartbeat heard in utero) soothing as they slept longer whenexposed to this stimulus.Although music is mostly an auditory stimulus, theeffects of the sound vibrations are processed through andresponded to by much of the human body (Harvey, 1985). The28sound vibrations are channeled through the ear, the skin,and through bone conduction, then processed in the brainstem (the reticular activating system), the limbic system(thalamus) and the cerebral cortex, particularly thetemporal lobes. Neural impulses then trigger autonomicnervous system reactions affecting the listener'srespirations, pulse rate, blood pressure, muscle tone, brainwave frequency, galvanic skin response, pilomotor reflexes,pupillary reflexes and gastric motility (Harvey, 1985).Goldstein (1985) found music can evoke "natural highs"through inducing the release of endorphins, the brain's ownendogenous neurotransmitter opiates. Pleasing musicincreases the production of the neurochemicalphenylthyamine, the "chemical of love" which produces aneuphoric "falling in love" type of feeling in the listener(Harvey, 1985; Rosenbaum, 1984). Harvey (1985) also notedthat music can cause a decrease in the blood levels ofadrenocorticotrophic hormone, (ACTH), one of the majorstress hormones found in the human body.Although, as Tame (1984) stressed, "... there isscarcely a single function of the body which cannot beaffected by musical tones" (p. 136) due to its seemingintangibility, " ... music is not considered by amaterialistic age to be capable of producing significanthealing effects" (p. 157).29Music as a Health InterventionMusic used for healing is both an ancient art and acurrent form of scientific therapy. Research on the effectsand usefulness of music as an intervention is still in itsinfancy. Studies focusing on the use of music in therapy arebecoming more frequent in the literature: all support theancient postulate that music is a viable intervention inhealing (Lundin, 1985; Trevisan & Nowicki, 1978).The most common use of music in healing is as anaudioanalgesic (MacClelland, 1979). As early as 1914, Kaneused music to calm surgery patients prior to applyinganesthesia (Podolsky, 1954). Several studies in dentalsurgery and practice have documented the use of music forpain control (Bonny, 1983; Clifton, 1983; Clynes, 1982;Foutz, 1970; Hanser, 1987). Standley (1986) pointed out thatff^auditory stimuli may directly suppress painneurologically and may mask the sound of the dental drill,removing a source of conditioned anxiety" (p. 59). Geden etal. (1989), Livingston (1979) and Sammons (1984) assertedthat music can be successfully used as an audioanalgesicduring childbirth. They found music reduced the mother'sperception of pain, shortened the length of labour time, andincreased feelings of euphoria during the birth. Standley(1986) described how the audioanalgesic properties of musichelped terminally ill cancer patients reduce anxiety anddiscomfort during radiotherapy regimes.30Music has also been lauded as an anxiolytic agent.Reder, Floyd & Kirkpatrick (1985) tested music for thisproperty with orthopedic, gynecologic, and urologic surgerypatients. The patients who listened to selected meditative,soothing music showed decreased serum stress hormone (i.e.cortisol levels) postoperatively.Music can serve as a focus of attention or as adistractor from uncomfortable or invasive stimuli. Lingerman(1983) described how Romantic "tonic-like" music was usedwith severly burned patients. Music distracted the clientsfrom the pain associated with dressing changes andtreatments, elicited movement for maintenance of jointmobility, augmented respiratory exercises and helpedalleviate the psychological trauma of permanent disabilityand scarring. Livinggood, Kesic & Paige (1984) found thatmusic distracted and reduced anxiety in family memberswaiting for relatives to undergo emergency surgery. A studycarried out at St. Joseph Hospital in New York described howClassical and soothing Popular music was used in a six bedIntensive Care Unit. The incidence of myocardial infarctiondropped and the mortality rate decreased by 8 - 12% belowthe "national average" on this ward when music was playedcontinuously (Verdeau - Pailles, 1985).Melodic music has been used quite extensively inpsychiatric settings as a means of gaining contact with thepatient, especially schizophrenics and in occupationaltherapy (Lundin, 1985). Bright, stimulating music has been31used to treat depressive disorders and to evoke groupparticipation (Standley, 1986).Another intervention has been the use of Baroquemusic to reinforce or structure learning. Standley (1986)described how severly handicapped, nonresponsive infantsshowed physiologic responses such as overt sucking movementswhen exposed to lullaby-like music.The sedative effects of music have been aptly describedin the literature. Olds (1985) studied the fetal response tomusic and found that dreamy, lyrical music seemed to calmthe fetus, while loud, complex music stimulated hyperactivefetal movement. Schoen (1968) found that music with a slowtempo, less decided accent, and an easy, flowing melodyresulted in slower physiologic responses in his adultsubjects. Chetta (1981), Fagen (1982), Marley (1984) andOwens (1979) credited soothing music for decreasing fear,distress and anxiety in hospitalized infants, toddlers, andtheir families. Fagen (1982) described music as anintervention ideally suited to "...promote creative wellnessattributes in the very ill child" (p.61). Verdeau-Pailles(1985) postulated that lullabies used in a newborn IntensiveCare Unit setting resulted in 16% less time needed forpremature infants to reach the weight criterion fordischarge. She also described the soothing effects of musicon neonates:32"Newborn children have been calmed by: a) themother's heartbeat recorded through a liquidenvironment, b) the rhythm of a lullaby thatrecalls the pendular motion of the pregnantmother's heavy gait or c) a particular musicalwork or works of the same composer that werelistened to frequently by the pregnant mother"(p. 48).SummgryIn summary, newborns enter the world equipped with asophisticated repertoire of adaptive physiological andpsychological behaviours. They demonstrate a cyclic patternof organized behavioural states. These behavioural statesare distinctly affected by the surrounding environment andmay be "well" or "poorly" organized.Music has distinct effects on the human organism.Soothing music can be used to achieve an alpha wave brainstate which initiates a state of relaxed awareness. Thisstate of relaxation may facilitiate the newborn's ability toregulate his/her behavioural state organization despite thenoxious environmental stimuli in the hospital nursery.33CHAPTER THREEMethodsIntroduction This chapter includes an outline of the methods used tocompare newborns' behavioural state patterns exhibitedduring exposure to selected music with those displayed whenthe newborns had no music exposure. Content includes adiscussion of the research design, sample selection andinclusion criteria, the data collection instrument andprocedures, the assumptions and limitations inherent in thestudy, data analysis, reliability, validity and proceduresused for protection of human rights.Study Design A pre-experimental, one group, pretest, posttestdesign was used. This is a "... quasi-experimental design inwhich the investigator pretests the sample, introduces theexperimental manipulation to everyone in the study and thenobtains posttest measures" (Woods & Catanzaro, 1988, p.179).This design enabled the determination of the influence ofthe treatment variable (soothing music) on the independentvariable (behavioural state) by using ipsative controls:each participant served as his or her own control.Each subject (n = 20) was directly observed on twoseparate occasions for two hours for each observationperiod. During the control observation the newborn's34behavioural state organization was documented without anymusic present. The experimental observation includedexposure to continuous selected music.All observations and coding were done in 10 secondepochs. The same observer documented the subjects'behaviours during both the control and experimentalobservations.Figure 2:One Group, Pretest, Posttest Design01^X^02Sample Inclusion Criteria The sample subjects (n = 20) were selected byconvenience sampling from a population of neonates in atertiary hospital who met the following criteria:1) Greater than 24 hours but less than 60 hours of age.2) Equal to or greater than 36 weeks gestational age.3) Apgar scores greater or equal to 8 after 5 minutes ofage.4) No gestational complications.Experimental ObservationControl ObservationNmAmmin CWJ7CassetteTape 1PlayerPillowSpeakerOWmnmrNewbornin ColObserver 0 000.11■011,355) Normal spontaneous delivery.6) No postpartum complications or anomalies.7) Occidental descent.8) Equal as possible numbers of males and females.Data CollectionFigure 3:Data Collection Model The investigator visited the two postpartum units of theagency where the study was conducted to explain the study tothe nursing staff and to answer questions regarding thestudy. The investigator requested that the charge nurse onthe postpartum unit(s) of the selected agency identifypatients that met the inclusion criteria. The investigatorthen consulted with the assigned registered nurse on36occasions when the potential participant's mother had voicedan intent to use the nursery for newborn care and when shewas interested in hearing about the study.The investigator then talked to potential participants'mothers, and sometimes fathers about the study, reviewed thepatient informed consent form (Appendix A) and requested theparent(s)' signature on the form. When the subject'sparent(s) gave written consent, the investigator arranged apreferred time for observations (all mothers preferred latenight hours, after bedtime and between infant feedings).Twenty newborn subjects who met the sample selectioncriteria were individually observed for a total of fourhours. During the first two hour observation (control) eachsubject was observed without exposure to continuous selectedmusic. During the second observation (experimental) theselected music (see Appendix B) was played via a three inchcircular "Pillow" speaker placed in the cot, connected to adual cassette tape playing system, (Model: Samsung PD-790C)set at 50 decibels of sound. The tape system was set oncontinuous play mode. Music was played during theexperimental observation to provide data for comparison ofbehavioural states exhibited and number of state changeswhen the subjects were exposed to the music in the nurseryand when they were not. Observations were made in one of twonurseries in a tertiary hospital in Vancouver, B.C.Each subject was breast or bottle fed within a halfhour before both the control and experimental observations37began. Each subject also had his/her diaper changed by themother or nursery nurse prior to both the control andexperimental observations. The subjects were all positionedin a lateral position and bundled uniformly.All subjects were dressed in a diaper, a hospitalinfant gown (extended to baby's hips) and wrapped loosely ina flannel blanket with hands and forearms free. The newbornswere bundled by the nursery nurse with the blanket wrappedmore loosely than usual to allow easier viewing of foot andknee movement for the investigator. The cot was situatedamongst the other infants in the nursery. The observer satwithin a five foot radius of the cot in direct line ofvision to the infant. All subjects were continuouslyobserved for frequency of the dependent variable,behavioural state and for behavioural state changes(lability) in 10 second epochs. The control observation wasdone first for two hours unless the subject becamedistressed and required caregiving. Once the infant wascalm, he/she was repositioned in the cot by the nurserynurse and the observation continued for a total of twohours. The investigator began the experimental observationafter the subject had been fed, the diaper had been changedand the newborn was repositioned in the cot as describedabove. If possible, the experimental observation was donecontinuously for two hours. Some subjects did requirecaregiving during this second observation. If so, the38experimental observation was resumed once the newborn wasreturned to the nursery in his/her cot.The average amount of time from the beginning of thecontrol observation and the ending of the experimentalobservation was approximately six hours. The longesttimespan for one subject was ten and a half hours from startto finish.The observer recorded the observed state behaviours andlability using a collection tool designed by E. Thoman(1990) (see Appendix C). "A frequency coding system allowsthe investigator to determine ... how the observation timeis divided into specific, mutually exclusive states" (Woods& Catanzaro, 1988, p. 280). The observer initiallydesignated the first four subjects' data as pilot study datato discover potential problems while learning to use thedata collection tool. The observation of the behavioursincluded in the tool and the recognition of the behaviouralstates described by Thoman (1990) was not a problem for anyof the four initial subjects. The investigator chose toinclude the data for the four initial subjects with thestudy data. The direct observation approach was chosenbecause "... hypotheses require data that can best beproduced during observation" especially with groups orindividuals "... who are not able to answer questionnairesor interviews.., such as infants or young children" (Woods &Catanzaro, 1988, p.278).The data were coded in time-samples of 10 second39epochs: the newborns' state behaviours were observed andrecorded every 10 seconds. Behaviours typifying each statewere observed (Thoman, 1990). The frequency of eachsubject's state occurrence was tallied for both two hourobservation periods. The frequencies of selected newbornbehaviours (see Appendix D) were tallied from the codingtool sheets (see Appendix C) for each subject. All subjects(n = 20) were observed for two distinct periods: once withno music exposure (control observation) and once withexposure to the independent variable, the selected music(experimental observation).Assump ionsThere are several assumptions evident in this study.1) The potential problems of subject reactivity,novelty, and response selection were not significantin this study since the neonate is unlikely to be awareof the observations or become interactive with theobserver.2) Maturation was not an issue because all subjects were24-60 hours old and both observations were done within 12hours of each other.403) Caregiving received by the subjects in the nurserywas uniform across the subjects and did not interferewith the study observations.4) The neonatal behaviours observed reflected thecategories of states outlined by Thoman (1990). Theunique individual characteristics of each neonate wouldnot significantly alter the flow of behaviours or thespecificity of states.5) The method of feeding (breast or bottle) would notaffect the neonate's behavioural state patterns.6) The effects of the music would be observedimmediately following the introduction of the stimulus.LimitationsSome limitations evident in the study included:1) The data collected can only tentatively be considered forhealthy, full-term infants in the immediate puerperalperiod because behavioural states are dynamic andpatterns change as the neonate matures.412) The study did not control for variance in caregivereffects. The quality of care given by the assignednursery nurse may have a significant difference in therhythmical change of each neonate's behavioural states.3) Direct observation limited the data available to thebehaviours that are visible. No data on innatephysiological or biochemical responses were gathered.4) The data gathered were limited by the observationalperception of the observer and the presence of infant'sclothing.5) The study did not control for variance in maternal-infant interaction, maternal quality of care, orreciprocity of behaviours.6) There was no interrater reliability established becauseonly one investigator conducted the study.7) Data gathered during pilot testing were included in thedata analysis and may have affected the findings.8) The sample was not randomly selected but a sample ofconvenience which limits generalizability.429) The small sample size may have affected the robustnessof the statistical testing.10) The investigator was aware of the timing of the controland the experimental conditions and that may have biasedthe investigator's observations.11) The presence of the investigator may have affected thenurses' usual behaviours in the nursery setting.Data AnalysisThe nominal data collected from the frequencies ofbehavioural states were tabulated as molar units(behavioural state categories) and as molecular units(actual observed behaviours). The data for this study meetthe conditions for a nominal scale of measurement. Nominaldata are categorical data that do not have an implied order(Roberts & Ogden-Burke, 1989). Nominal data are separatedinto clear categories. In this study, the behavioural stateswere categorized into high arousal states (Nonalert Wakingand Crying) or low arousal states (Quiet Sleep, ActiveSleep, Drowse/Daze, Transitional, and Quiet Alert).Combinations of the observed behaviours were clusteredaccording to Thoman's descriptions (see Appendix D) toaccurately describe the seven categories of behaviouralstates. The tallied frequency score for each subject was43compared for differences in demonstration of the behaviouralstates between the control and the experimentalobservations. The demographic data of the sample weresummarized using descriptive statistics (mean, standarddeviation and range) to indicate the homogeneity of thesample.The number of high arousal states observed during thecontrol and experimental periods was compared using theMcNemar's test as directed by Roberts and Ogden-Burke(1989). This test is suitable to test differences when thedata are nominal and two variables are studied. TheMcNemar's test "... tests the significance of the differencebetween two proportions based on the same sample ofindividuals. The data consists of pairs of observations"(Ferguson, 1981, p.187).A normal deviate z score was obtained by dividing thedifference between the two proportions of high arousalstates and low arousal states for both the control andexperimental observations. A z score was also calculated forthe proportions of state changes between the twoobservations. Related group design tests are preferred whengroups are identical because they are more sensitive to theeffects of the independent variable (Miller, 1974). A one-tailed z score was obtained since it was predicted that thecontrol group would have a higher number of high arousalstates than the experimental group.44ReliabilityReliability refers to the consistency and accuracy of ameasurement instrument (Miller, 1974), it gives a similiarresult no matter who is doing the measuring (Woods &Catanzaro, 1988). If the measurement is used more than onceto measure the same object or behaviour under similiarcircumstances it will yield virtually the same value.The measurement tool used in this study was developedby Evelyn Thoman and colleagues at the University ofConnecticut. Thoman has presented reliability values inrelation to stability and consistency of measurementincluding test-retest reliability and interraterreliability.Instrument ReliabilityIn their 1975 study Thoman, Korner & Kraemer used atest-retest correlation coefficient to test the individualconsistency of infants in the seven behavioural statecategories over time. They achieved a reliabilitycoefficient of r = .75, a high level of reliability. Thisstatistic suggests consistency of behavioural states overtime in each subject. States were exhibited in similiarpatterns of occurrence and change (lability) for most of thesubjects over time.Thoman et al., (1981) observed infants on threeoccasions in the hospital, at home for seven hours duringweeks one, two, three, four, and five and again at three45months, six months and one year of age for a total of tenobservations per subject. Thoman et al., (1981) used alower-bounds reliability coefficient for twenty molecularbehaviours for the observations done on weeks one throughfive. They achieved a reliability coefficient of r = .70 ormore (median r = .785) for the twenty behaviours, reflectingstability in measurement across the repeated observations.Thoman et al. (1981) also incorporated a F ratio byusing an analysis of variance (ANOVA) test to indicate therelative degree of profile consistency across time. Herintent was to describe in a single number how parallel theprofile curves were for each infant. Babies who demonstrateda low profile consistency statistic (F), e.g. F = 3.09later developed health or behavioural problems such asaplastic anemia and sudden infant death syndrome (SIDS).Those who showed a high F value, e.g. F = 304.86 developedwithout any major problems.In their 1989 study, Thoman & Whitney calculated test-retest correlation coefficients which ranged from r = .70 to.87 for all seven states, again suggesting measurementreliability. Thoman also demonstrated measurementreliability in her 1990 study in the seven behavioural statecategories. She again tested using an ANOVA format to obtainan F value for individual differences. She obtained ameasure of reliability once more indicating stability overtime in the state measures for individual infants.Developmental changes in states were also manifested in a46reliable pattern for most subjects. Thoman found the infantsshowed a significant linear increase in waking during thedaytime as they matured (r = .97, p < .01), while wakingduring the night remained stable across the early weeks.Interrater Reliabil.tyThoman and her collegues have consistently maintaineda high level of interrater reliability over fifteen years ofstudy. Thoman (1975) quotes a mean interrater agreement of91.9% in behavioural state category identification equatingwith an interobserver reliability coefficient of r = .82.In their 1989 study, Thoman & Whitney compared thedata from direct observations with data gathered throughcomputer-aided scoring. They calculated a mean agreement of86% (range was 76 - 98% agreement) on behavioural stateidentification between the two data collection methods.Again in her 1990 study Thoman cites > 90% exactagreement between observers on each 10 second epoch codingof behavioural state observed.Study Reliability The investigator attempted to ensure internalreliability by following Thoman's specific guidelines forusing her instrument. Since Thoman (1975) recordedobservational data in ten second epochs, this study alsoused this ten second unit of measurement. Thoman's codes,coding tool and behavioural state categories and behaviourswere all used as she directed. Considerable time was taken47(six months) by the observer to memorize the codes andbehavioural parameters of each state. Practice identifyingmolecular behaviours was afforded while teaching in asimiliar obstetrical clinical area prior to the study.A pilot study was carried out with four newbornswithin the selected nursery environment, adhering to theexact protocol of the intended study. No apparent problemsarose during the data collection during the pilot studyperiod. The investigator chose to include these four initialsubjects in the final sample. The investigator concedes thatthis choice may have affected the reliability of the data.An attempt to closely mirror the demographiccharacteristics of the infants studied by Thoman during thepuerperal observations was made. Like the 41 subjects inThoman et al.'s (1975) study, the subjects were allCaucasian, included males and females (Thoman et al. did notquantify gender) and none showed signs of any complications.All infants' diapers had been changed and they had been fedwithin one hour of the beginning of an observation.The infants in this study were placed in their cots ontheir right side like the infants in Thoman et al.'s (1975)study. However, Thoman et al. placed the cots under aradiant warmer in a separate room adjacent to the nursery.They were dressed in only a diaper and were observed once inthe morning and once in the afternoon. A radiant warmer wasnot used in this study. The infants in this study weredressed in a diaper and nightshirt and loosely bundled in a48cotton blanket to prevent hypothermia. Their cots weresituated in the main nursery amidst the cots of othernewborns. All observations were done after midnight in thisstudy.ValidityValidity "..• describes the degree to which a testor instrument measures what it purports to measure" (Woods &Catanzaro, 1988, p. 251). It suggests that an instrumentactually measures the constructs or concept it is supposedto measure. The instrument used to code the behaviouralstates was developed by Professor E. Thoman (University ofConnecticut) in 1975. Thoman has replicated her studiesusing this particular instrument several times between 1975and 1990.Instrument ValidityThoman's behavioural state taxonomy instrumentappears to meet the criteria for construct validity, contentvalidity, predictive validity, and ecological validity.Construct validity is the judgement of the validity ofa measurement instrument on the basis of many interrelatedexperimental findings (Miller, 1974). It represents a cyclicprocess that requires extensive psychometric studiescombined with theory development (Woods & Catanzaro, 1988).Thoman (1990) asserts that her taxonomy of behaviouralstates has been assessed psychometrically more than anyother state classification scheme. Thoman and her collegues49(1975, 1981, 1990) have used an intensive, mini-longitudinalapproach to achieve repeated results in studies to observethe occurrence of the seven behavioural states and how theyare organized over the first five weeks of life and beyond.Content validity is concerned with whether themeasurement tool and the items contained in it really arerepresentative of the domain being studied (Woods &Catanzaro, 1988). Five steps are common to achieving contentvalidity:a) Literature review- Thoman has embellished the backgroundtheory throughout her published work over the past fifteenyears culminating in an extensive review of currentbehavioural state theory in 1990. She has applied conceptsfrom theory to qualitatively describe behavioural states,assign molecular behaviour identifiers and design themeasurement tool.b) Personal reflection- This seems evident in Thoman's 1990publication. She painstakingly explores the validity of hercumulative work, identifying every possible interpretationof her longitudinal study findings.C) Identification of components of a concept-  is the thirdstep toward content validity. Thoman and her colleagues havegiven clear descriptions of seven categories of behaviouralstates (1975, 1981, 1989, 1990). The behavioural states havebeen labeled according to their qualitative components, e.g.Nonalert Waking, Quiet Alert, Drowse/Daze, Transitional,Quiet Sleep, Active REM Sleep.50d) identification of items- the fourth step has also beendemonstrated both in Thoman's published work and in hercoding tool guidelines. Specific behaviours, e.g. eyesopen/closed, Rapid eye movement (REM), large and small bodymovements, startles, mouthings, and so on have beenidentified as the molecular behaviours that combine toproduce the seven molar behavioural states.e) Empirical analysis of items- the fifth step towardcontent validity is demonstrated through Thoman'ssubstantitive study results from observing infantsrepeatedly from twelve hours old up to 30 months old. Carehas been taken by Thoman (1990) to interrelate the repeatedfindings to provide a consistency profile of states overtime for each subject.Thoman claims that she has achieved predictive validityin her work. Predictive validity refers to the amount ofcorrelation between a measurement of a concept and a futuremeasure of the same concept. It demonstrates the extent thatan instrument's predictions of future behaviours are judgedto be accurate (Treece & Treece, 1986).Thoman described in her 1975, et al., 1981, & Whitney,1989, and 1990 publications how predictive validity wasachieved in her studies. In one longitudinal study (1975) of22 infants observed between two to five weeks of age, sheoutlined how she used a Friedman analysis of variance(ANOVA) calculation to yield a single state stability scorefrom the four weekly state profiles accumulated over the51observation period. Thoman (1990) calculated state stabilityscores ranging from F = 3.09 to 304.86 (p < .001).The infants with the four lowest profile consistencyindices were judged by the observers to be "poorlyorganized" and had major developmental delays or problemsbetween 3.5 to 30 months of age. One infant developedaplastic anemia, one had seizures and hypoarrhythmia withsevere retardation, another died of sudden infant deathsyndrome (SIDS), and the fourth became hyperactive. None ofthe babies at the upper end of the consistency continuumshowed any evidence of developmental delay or disability bythirty months of age.Study ValidityThere are two important criteria for evaluating thecredibility and dependability of a study's results: internaland external validity (LoBiondo-Wood & Haber, 1986).Internal validity. Internal validity "...asks if theindependent variable really made the difference" (LoBiondo-Wood & Haber, 1986, p.108) in the study findings. Sixthreats to internal validity have been identified. These arehistory, maturation, testing, instrumentation, mortality andselection bias. The investigator has attempted to controlthe effects of these six threats in this particular study.a) History- refers to prior exposure to the independentvariable. This threat does not appear to be a problem inthis study since the subjects are only 24 to 67 hours old.They are unlikely to have acquired a history of exposure to52music postnatally, although they may have had exposure tomusic while in utero (Olds, 1985). It is unlikely thoughthat the subjects were exposed to the exact eighteen piecesof music selected as the independent variable (see AppendixB).b) Maturation- was not an issue in this study. Bothobservations (group and experimental) occurred within a fewhours of each other.c) Testing- was not a concern. All infants were observedinitially as the control group thus there was not a pretestto sensitize the subjects to the independent variable.d) Instrumentation- was a viable threat to the internalvalidity of this study. The investigator attempted controlof this threat by utilizing the instrument exactly the sameduring each observation of the twenty subjects. However, thesame investigator performed both observations with priorknowledge of whether it was a control or experimentalobservation. This could threaten the internal validity ofthe study findings.e) Mortality- could have also been a significant threat tothis study's internal validity. Fortunately, none of thesubjects was lost. All twenty participated in both two hourobservations.f) Selection bias- was a potential threat to this study. Thesample was one of convenience, chosen according to theselection criteria. Lack of randomization may have affectedthe degree of internal validity attained in the study.53External validity. External validity deals withpossible problems of generalizability of the investigator'sfindings to additional populations and to otherenvironmental conditions (LoBiondo-Wood & Haber, 1986).External validity is subclassified into population validityand ecological validity.Population validity refers to the generalization ofresults to other populations. The measurement instrument hasbeen used by Thoman and her colleagues (1975, 1981, 1989,1990) to observe infants with a variety of characteristics,e.g. premature infants, and infants of various racial andsocioeconomic status. The subjects in this study, however,were selected according to specific selection criteria e.g.gender, racial origin, and mode of delivery. This may havediminished the generalizability of the findings to othernewborn populations.Ecological validity refers to the generalization ofresults to other settings or environmental conditions. Theauthor has attemped to ensure ecological validity bydescribing the method and procedures used in the study tofacilitate potential replication of the findings.54Ethical Issues The study proposal was reviewed by the University ofBritish Columbia Behavioural Sciences Screening Committeefor Research and other Studies involving Human Subjects aswell as by the Research Coordinating Committee at theselected Lower Mainland hospital.Written consent was solicited (see Appendix A) from theparent(s) of the neonatal subject by the investigator withpermission by the unit managers and the approval of theResearch Coordinating Committee of the agency.A letter of information was distributed to eachpotential subject's parent(s) outlining the study. Thepurpose and procedures for the study were explained to eachparent. Reassurance that participation or refusal would inno way interfere with the usual care of the infant wasgiven. A consent form was used to petition the parent(s)'written informed consent. Written and/or verbal consent wassought from at least one parent. Under no circumstances didthe parents receive the impression that participation wasanything but voluntary. Parents had the uncontested right torefuse to participate or terminate participation at any timeduring the study. A letter of information for the attendingPhysician(s) was also placed on the subject's chart (seeAppendix E).The investigator served as observer only - caregivingof the subjects continued to be the responsibility of theassigned nursery nurse. The observer applied only the55independent variable, the selected music to the group duringthe experimental observations. Care to limit the effect ofthe observer on the routine operation of the hospitalnursery was diligently taken. Confidentiality was assured:codes were used - no recording of the infant's identity wasused.aliMMALYThis chapter outlined the methods used to compare thedifferences in behavioural state frequencies between thecontrol observations (no music exposure) and theexperimental observations (exposure to selected music) oftwenty newborns. The research design used to study theproposed hypothesis was "One group, pretest, posttest". Thesample consisted of twenty newborns who met the inclusioncriteria. The newborns were observed for two hours on twooccasions (one a control observation, the other anexperimental observation). The behavioural states exhibitedwere recorded in ten second epochs for both observations.All subjects were exposed to exactly the same music duringthe experimental observation. One observer collected thedata for all observations.A pilot study was conducted which identified nodifficulties regarding procedures, musical equipment or thedata collection sheet. The hypotheses were summarized usingdescriptive statistics and analyzed using a one-tailed,56McNemar's test. The significance level was set at alpha=.05. The reliability and validity of the measurementinstrument developed by Thoman & colleagues was described(1975, 1990). In addition, study validity and reliabilitywere discuseed.The proposal was approved by the University of BritishColumbia's Behavioural Science Screening Committee forResearch and Other Studies involving Human Subjects and bythe Research Coordinating Committee of the agency where thestudy was conducted. Written consent was obtained by aparent of each of the twenty newborns that participated inthe study. Procedures for protection of subject privacy wereimplemented.57CHAPTER FOURPresentation and Discussion of ResultsIntroductionThis chapter is divided into three sections. The firstsection describes the demographic and health - relatedcharacteristics of the subjects in the sample. The secondsection presents the results for the investigated studyhypotheses. The third section discusses the findings of thestudy.Characteristics of the Sample During the period from November 1992 through January1993, twenty newborns who met the inclusion criteria of thestudy were recruited. Each participated in both a controland experimental observation in one of two newborn nurserieswithin a tertiary hospital in Vancouver, B.C. The samplewill be described in terms of demographic and health relatedcharacteristics.Demographic and Health related Characteristics of the SampleDemographic and health related data collected about thesubjects concerned gestational age, Apgar score at fiveminutes postbirth, age, in hours at the beginning of thefirst observation, birth weight, maternal age, number ofsiblings, gender, method of feeding, race, and mode of58delivery. The subjects varied in gestational age, Apgarscores, age at time of the observations and birth weight.Maternal age also varied as did the number of newborns'siblings (see Table 1).Eight (40%) of the infants were female, twelve (60%)were male. According to 1992 population statistics, out of46,300 live births in British Columbia, 22,600 or 49% werefemale, 23,700 or 51% were male (Statistics Canada, Ministryof Industry, Science and Technology, 1992). This fact lowersthe gender representativeness of the study subjects comparedto the target population.All but two were breastfed. All twenty subjects wereborn by spontaneous vaginal delivery without any apparentintrapartum complications. There was no record of majorantenatal or postpartum problems or any congenitalanomalies. All subjects were of Caucasian race.Gender distribution, a non-random sample, and singleracial origin of the subjects obviously limit therepresentativeness of this sample in relation to the targetpopulation in the Lower Mainland of British Columbia. Therewas no representation from the large Oriental or Indo-Canadian population or other minority cultural groups commonto Vancouver. Caucasians were selected due to the evidencein the literature that cultural music preferences andconditioning vary (Lundin, 1985). Lundin (1985) asserts thatthe "...Occidental love for simple rhythms, careful tuning,fixed tonal steps, harmonies, the tonic effect, and the59diatonic scale is not shared the world over" (p. 179).Common musical instruments used in soothing Western musicinclude the piano, violin, flute, harp and oboe.Roederer (1982) points out that musical familiarity ispsycho-physiological, imprinted in the neural circuitry ofthe auditory system. Benenzon (1981) elaborates byattributing cultural preference of certain forms of music tothe "...mnemonic engram of the being in gestation" (p.19).This mnemonic engram contains an inherited genetic patterncomprised of experiences of the developing child's folkloriclegacy, corresponding to the life of his or her ancestors,race, and cultural milieu.Oriental, particularly Chinese music is written using apentatonic, five-note scale in contrast to the Westerndiatonic major/minor scales (Geoffrey, 1971). Oriental musicis composed primarily of melody and timbre with no harmonyand a nature that seems "mistuned" to Occidental listeners.Common Oriental instruments include stone chimes (piench'ing), silk-stringed zithers, panpipes, sheng mouthorgans, and simple clay flutes. These instruments produce amuch different sound compared to Western instruments.East Indian music is written using 22 shrutis or notes.The traditional Indian music has no sense of key as we knowit in Western music (e.g. C major) and also has no harmony.Indian rhythm is much more complex than the rhythms used intraditional Western music (Geoffry, 1971). Common Indianinstruments include the vina and sitar, both enormous60stringed instruments and the vansha or transverse flute.These instruments produce a distinct sound compared toWestern or Oriental instruments.It seemed prudent to select subjects who were mostlikely to be favorably disposed to the decidedly Westernmusic selections (listed in Appendix B) thus racial originwas limited to Caucasian infants for this study.Table 1Demog aphic Characteristics of the Newlwrn Sample comparedwith Thoman. Korner & Kraemer's 1975 Study Subjects 1975 Study^Current Studyn = 41 n = 20Total Time:^2 hours^ 4 hoursVariable^Range^Mean^SD^RangeGest. Age:wks 38-42 39.3 1.5 36-42Apgar (5 min.) 9-10 9.1 0.3 9-10Hours old 12-67 37.8 12.5 24-57Birth wt:gms 2500 3527.0 383.6 2860-4000 -4160Maternal Age 18-29 27.7 5.9 20-38Siblings 0-2 0.4 0.7 0-2NOTE: Sample consisted of 8 female and 12 male Caucasianinfants. All but 2 were breastfed. All born vaginally,without complications.61Findings The findings of the study will be presented in relationto the two study hypotheses. A description of the datarelated to the dependent variable, the number of higharousal states (Nonalert Waking and Crying) will bepresented first. Data describing the lability or frequencyof state changes over time will follow.Hypothesis 1: The control group will demonstrate asignificantly higher number of high arousal states than theexperimental group.The comparison of the high arousal behavioural states(Nonalert Waking and Crying) between the two groups beginswith an analysis of the number of times these two stateswere manifested during the control and experimentalobservations. This is followed by a calculation of thedifferences in proportions between each subjects' two scores(control and experimental) for high arousal states using aone-tailed, McNemar's test (alpha < .05). The difference inproportion of lability or frequency of state changes wasalso analyzed using the one-tailed, McNemar's test (alpha< .05).62Table 2Number of High and law Arousal Behavioural States and Numberof State Changes (Lqbility) during the Control and the Experimental Observations (in 10 second epochs). Observation^High Arousal Low Arousal^Lability:States^States^StateChangesCQUEQLNumber ofepochs 2404 11996 596EXPERIMENTALNumber ofepochs872 13528 463Statistical analysis qf the difference in frequency of the high arousal behavioural states between the twogroups. A one-tailed, McNemar's test was calculated forthe data for the high arousal behavioural states (NonalertWaking and Crying). This statistic tested the differences inproportion of the number of high arousal behavioural statesdemonstrated within the two hour control and experimentalobservations. The significance level was set at alpha < .05indicating that the z scores would be different from astandard z score of 1.65 due to chance only one out of63twenty times (Ferguson, 1981). Because the first hypothesissuggested a directional difference (control group wouldscore higher in high arousal states) the one-tailed z score(Miller, 1974) was used.The subjects demonstrated a score of 2404 epochs higharousal states during the two hour control observationcompared to 872 epochs of high arousal states during theexperimental period. The one-tailed, z score for the higharousal behavioural states (Nonalert Waking and Cryingcombined) was 2.32 (p < .01) which is considerably higherthan the z score of 1.65 needed to be significant at alpha <.05 level. The newborns demonstrated significantly more higharousal states during the control condition.nate _Lability (Frequency of State Changes) during theControl and Experimental Observations Hypothesis 2: The control group will demonstratesignificantly greater state lability or number of statechanges than the experimental group.State lability or frequency of state changes wasmeasured to test the second hypothesis. A measure of statelability (Colombo, 1989 and Thoman, 1990) was derived bycounting the number of state changes that occurred duringthe two observation periods. The newborns exhibited acombined frequency score of 596 state changes during the two64hour control observation. They demonstrated a combinedfrequency score of 463 state changes during the two hourexperimental observation.Statistical analysis of state laPility. A one - tailed,McNemar's test to test the second hypothesis was calculatedto measure the differences in proportions between thecontrol and experimental scores for state lability. The one-directional z score used for comparison was 1.65 (alpha <.05). A directional difference (control group woulddemonstrate more state changes) was hypothesized making aone-tailed test suitable.The z score obtained for state lability was 2.93 whichis considerably higher than the z score of 1.65 needed to besignificant at the alpha < .05 level. This suggests thatthere was a significant difference in the number of statechange in the newborns between the control and experimentalobservations.Discussion of the FindingsThe findings presented in the first half of thischapter will be discussed in two parts. The discussionbegins with an interpretation of the differences in higharousal behavioural states exhibited by the twenty newbornsduring the two observations. The lability or number of statechanges will be further defined with a discussion of the65differences in lability or fluctuations of the sevenbehavioural states over time in both observations.High Arousal State Frequencies in the Control andExperimental Observations The high arousal behavioural state frequenciesexhibited by the twenty newborn subjects within the controlobservation provided an interesting contrast to thefrequencies displayed during the experimental period. Thefrequencies can be viewed in terms of supporting/rejectingthe first hypothesis of this study. This hypothesistheorized that during the control observation the newbornswould exhibit a higher number of high arousal state(Nonalert Waking and Crying) behaviours.To adequately discuss the significance of the findings,an examination of the high arousal behavioural states isappropriate. The first part of the discussion will includetheory from the literature to support the study results forthese high arousal behavioural states.High arousal behavioural states. Two of the sevenbehavioural states described by Thoman (1990) are consideredhigh arousal states, Nonalert Waking and Crying (Anderson,1989; Brazelton, 1984; Keefe, 1987; Thoman, 1990). Bothstates occur while the infant is awake and exhibiting66responsive behaviours to some form of disturbing internal orexternal stimulus.Brazelton (1984) described signs of stress and fatiguein newborns. He correlated specific behaviours andbehavioural states with a newborn's common reaction tostressful stimuli. These behaviours included:a) Signs of autonomic nervous system stress such asacrocyanosis, rapid respirations, and tachycardia,correlated with the crying state.b) A movement to a higher arousal state to attempt self-regulation and to shut out disturbing environmental stimuli.This change of state is most likely to become Crying orfussing states (e.g. Nonalert Waking).c) Behavioural changes, e.g. unfocused eyes (common inNonalert Waking state); uncoordinated, active arm and legmovement (typical in Crying state); hiccoughs; sneezes;yawns and crying.The two states, Nonalert Waking and Crying (Thoman,1990) reflect several of the behaviours described byBrazelton (1984). It seems likely that these two statesrepresent an infant's attempts to cope with perceivedstressors. Although both states share a similiar function,distinct behaviours differentiate them.Nonalert waking state. The Nonalert Waking state(called the Active Alert state by Brazelton, 1984 and byThoman in her early work e.g. 1975) is a "primitive" wakingstate which occurs frequently in premature infants but67usually diminishes quickly in the postterm period. Thoman &Whitney (1989, 1990) observed that fullterm infants whodemonstrated persistently high levels of the Nonalert Wakingstate during the first week or two of life also showederratic, unstable state patterns over successive weeks ofage. Thoman (1990) stated that high levels of NonalertWaking indicated a baby was at risk for future health ordevelopmental problems as this was "...indicative of pooreroverall state-integrity" (p.100). She claimed that no otherwaking state was inversely related to state stability andthat high frequencies of Nonalert Waking reflected amalfunctioning in the developing central nervous system thatcould affect later developmental status.Behaviours exhibited by newborns when in the NonalertWaking state include (Brazelton, 1984; Thoman, 1990):a) open, but dull, inattentive, unfocused eyes.b) motor activity that varies but is typically high.c) isolated fussy vocalizations.d) periodic distressed facial expressions.e) irregular, increased respirations.f) increasing sensitivity to disturbing stimuli (e.g.hunger, fatigue, noise, excessive handling). If thestimuli becomes intolerable newborn is most likely tochange to the Crying state.Newborns in this study, exposed to soothing music, spentsignificantly less time in the Nonalert Waking state.Perhaps the music played a role in facilitating adaptation68in the listening subjects to the nursery environmentalstimuli. The music may have also stimulated the limbicsystem and temporal lobes of the cerebral cortex to assistthe newborns to generally maintain lower arousal states inthe presence of any environmental stimuli (Harvey, 1985).Crying state. Crying behaviour represents the infant'smost effective means of expressing needs. Crying is areflexive vocalization in response to a given disturbingstimulus (e.g. hunger, pain, loud noise). Infants use cryingto indicate a need for a decrease or increase of a stimulus,for instance, a decrease in pain, an increase in tactilestimulation (Shaw-Schuster & Smith-Ashburn, 1986).Needs expressed through crying may reflect hunger,thirst, discomfort, feelings of insecurity, loneliness,boredom, fear, overstimulation, fatigue, and disturbingemotional tension. The pattern, tone, and rhythm of cryingbecomes uniquely distinguishable in response to each ofthese sensations, e.g. a hunger cry will come to sounddifferent from a painful cry (Thoman, 1990).When infants experience mild anxiety, the sensationacts as an incentive or powerful motive for action(Brazelton, 1984). They begin to fuss and cry softly toelicit caregiving behaviours. If the feeling of need is notresponded to, infants will likely begin to cry excessively,signaling a more acute state of anxiety which will only stopif the infants' need are satiated. If their needs are met,69e.g. feeding given or they are cuddled, they usually stopcrying as tension is decreased.Although crying is a necessary and very adaptivebehavioural state, it can be detrimental if prolonged orfrequent. Intense crying in the infant resembles the adultValsalva maneuver which can obstruct venous return in theinferior vena cava. This can potentially reestablish fetalcirculation in the heart in sporadic bursts during thecrying episode (Anderson, 1989).With every strain phase of a cry, poorly oxygenatedblood flows through the foramen ovale (which connects theright and left atrium in the fetus), returning to thesystemic circulation rather than to the pulmonary vesselsconnected to the lungs. This circulating blood does notbecome oxygenated while the infant is crying putting theinfant at risk for hypoxemia. The shunted blood moves as alarge bolus through the foramen ovale increasing thepotential for emboli to form and for insufficientoxygenation of the brain (Anderson, 1989; Shaw-Schuster &Smith-Ashburn, 1986).The venous return is also obstructed in the superiorvena cava which promotes increased cerebral blood volume butdecreased cerebral oxygenation. This predisposes newborns tointracranial hemmorrage which can lead to future learningdisabilities and has even been linked to cerebral palsy(Anderson, 1989). Anderson (1989) described a lifespanperspective by warning that a patent foramen ovale has been70found in apparently healthy adults. Lechat, Mas, Lascault,Loron, Theard, Kilimczac, Drobinski, Thomas, & Grosgogeat(1988) found that patent foramen ovales were present in 40%of "ischemic stroke" patients less than 55 years old whosuffered paradoxical emboli through what appeared to be anormal adult heart. Anderson speculated that this findingcould be related to neonatal episodes of distress yearsbefore.While in the Crying state, newborns exhibit a very highlevel of arousal (Thoman, 1975). This can magnify the energyexpenditure of an infant by as much as 200% (Owens, 1979).This may stimulate an infant's delicate basal metabolicrate, increasing the need for energy to maintain their lifeprocesses and normal development.In a newborn, the Crying state demonstrates the closestobvious behaviours common to a general stress response(Brazelton, 1984). The normal newborn has a heart rate of120 to 150 beats per minute. When crying the neonate's pulsecan increase to 170 to 180 beats per minute (Shaw-Schuster &Smith-Ashburn, 1986). During a stress response, respirationsincrease, blood pressure rises and gastrointestinal functionis disrupted, often demonstrated by emesis or "spitting up".A "flight or fight" endrocrine response is initiated,stimulating secretion of catecholamines (epinephrine,norepinephrine), cortisol and adrenocorticotrophic hormone(ACTH) which all function to ready the body to challenge orescape from the perceived stressor. Cardiac output71increases, and blood vessels constrict to concentrate theblood flow toward the heart, brain, and skeletal muscles. Inthe newborn this is complicated by the shunting ofdeoxygenated blood to the systemic circulation instead ofrichly oxygenated blood being pumped to the major organsduring the stress response (Anderson, 1989).During stress, increased cortisol secretion stimulatescatabolism of tissue proteins to facilitate glyconeogenesis,stimulating blood glucose levels which can potentially leadto hyperglycemia (Shaw-Shuster & Smith-Ashburn, 1986).Catabolism of fats and carbohydrates is also stimulated inthe liver which increases the risk of stored brown fat beingused in the newborn to elevate the blood glucose level.During the perception of stress, the limbic system inthe brain is also stimulated increasing the emotionalsensation of tension and anxiety. If crying is prolonged,all of these effects can seriously impede the newborn'sdelicate adaptation to the extrauterine environment. If oneinfant is upset, the potential for others to be upset ishigh since infectious crying may also be observed in babies.When one baby starts crying, others often follow suit (Shaw-Schuster & Smith-Ashburn, 1986).The newborns exposed to soothing music in this studydemonstrated significantly less crying behaviour than theydid when in the hospital newborn nursery without musicexposure. The relaxation response represents the opposite ofthe stress response demonstrated by newborns when in the72high arousal states (Nonalert Waking and Crying). Therelaxation response is triggered by the parasympatheticnervous system contrasted with the sympathetic predominancein the stress response (Shaw-Shuster & Smith-Ashburn, 1986).The relaxation response is manifested by decreased heartrate and blood pressure, slower and deeper respirations,blood flow is redistributed to include the peripheral body,digestion and peristalsis resume, oxygen consumptiondecreases, the immune system is reactivated and emotionaltensions drain leaving a sense of wellbeing (Ader, 1981).Soothing music with a lyrical melody, simple harmony,soft tone colour, and easy rhythm (About 60 to 80 beats perminute) can help to stimulate the relaxation response(Benenzon, 1981). Music can stimulate the release ofendorphins from the brain, reduce blood levels of ACTH andincrease phenylethylamine secretion. Neural impulsestriggered by soothing music can trigger autonomic nervoussystem reactions to produce relaxation in muscle tone, brainwave frequency, galvanic skin response, pilomotor reflexesand pupillary reflexes (Verdeau-Pailles, 1985) Music alsofacilitates emotional homeostasis (Livingston, 1979).It is possible that the exposure to the selectedsoothing music in this study somehow helped facilitate therelaxation response in the subjects, decreasing the amountof time spent in high arousal states during the experimentalobservation.73Lability of the Behaviourial States during the Control andExperimental Observatigps The findings suggest a significant difference in themean number of state changes or lability within the controland experimental observations. The infants changed state anaverage of 29.8 times during the control period and 23.1times during the experimental one. The one-tailed z score of2.93 (alpha < .05, p < .001) indicates that the differencein lability between the control and experimental periods issignificant.Lability or changes in state can be observed over timeto reveal patterns of infant organization and stateregulation (Keefe, 1987). This variability of state is anearly indicator of an infant's capacity for self-organization. It is also an indicator of an infant's abilityand effort to adapt to perceived disturbing internal orexternal stimuli (Brazelton, 1984).Erratic or frequent state changes may imply that aninfant is having difficulty achieving a rhythmic flow to thestates. Keefe (1987) explains that the infant's ability torhythmically organize state behaviour is indicative ofcentral nervous system maturation and can be predictive oflater development. Thoman (1990) described newborns whoexhibited frequent state changes, labelling them as "poorlyorganized". Over time these apparently clinically normalnewborns developed serious conditions, e.g. aplastic anemia,74hyperactivity, mental retardation, and one died of SuddenInfant Death Syndrome. Other babies observed by Thoman(1990) who did demonstrate regular patterns of state changesin the newborn period exhibited no major developmentalproblems by the age of 30 months.During the control period, the infants studieddemonstrated a higher frequency of state changes, often to astate of high arousal (Nonalert or Crying). These sameinfants demonstrated fewer state changes coupled with lesstime spent in high arousal states when exposed to soothingmusic. These findings suggest that music may have served insome capacity to help the newborns regulate theirbehavioural state changes, so that they were not moving sofrequently to high arousal states.Lability of states is regulated by the infant's centralnervous system in response to internal and external stimuli(Keefe, 1987). State is a behavioural mode which functionsas a filter, both for internal and environmental input andfor modulating behavioural response (Thoman, 1990). Statesfunction as a process for maintaining equilibrium. Infantsattempt to regulate stimulation impinging on them bychanging state. The inability of an infant to change stateappropriately is potentially maladaptive (Thoman, 1990).Soothing music may be of benefit to newborns attemptingto regulate their behavioural state through the innatequalities of gentle rhythm, tone colour, melody and harmony.A steady rhythm of 60 to 80 beats per minute is in tempo75with the average maternal heartbeat. This particular rhythmand sound has been used in studies showing significantresults in relaxing infants and children while in hospitalsettings (Salk, 1981).Rhythm is the sequence and proportion of durations ofnotes in music, representing musical "movement" (Verdeau-Pailles, 1985). The human body operates through an ensembleof rhythmical functions, e.g. circulation of blood,respiration patterns, and walking gait. Soothing musicalrhythm and its organization stimulates a similiar relaxedrhythm within the physical systems. Through the limbicsystem it also stimulates a more relaxed emotional affect(Lundin, 1985) and promotes an alpha brain wave pattern.Melody, harmony, and tone colour enrich the effect ofmusical rhythm. When all four musical characteristics arepurposefully subdued, lyrical and "dreamy" they can prompt aparasympathetic relaxation response in the listener(Benenzon, 1981). The behavioural states and their frequencyof change are strongly involved in maintaining thehomeostatic rhythm of the newborn's physical andpsychological being. The use of soothing music seems to be apotential way to help facilitate an organized rhythm ofbehavioural state manifestation with less movement betweenstates.76Summary of the findings In this chapter a description of the sample in terms ofthe subjects' ages (hours postbirth), gestational age, birthweight, 5 minute Apgar scores, gender, method of feeding,number of siblings, maternal age, mode of delivery and racewas presented. All subjects were Caucasian which did notgive a true representation of the racial demography of thetarget population (which included a fairly large number ofOriental and Indo - Canadian newborns). The sample consistedof 8 females and 12 males with an average age of 37.8 hourspostbirth.The findings and a discussion of the findings inrelation to the research hypotheses were presented. Adiscussion of the number of high arousal behavioural statesand the number of lability or state changes was included.There was a significant difference between the controland the experimental conditions in the number of higharousal states (Nonalert Waking and Crying) exhibited. Thecontrol group exhibited significantly more high arousalstates than the experimental group did. Descriptivestatistics of the results were presented along with the one-tailed, McNemar's test values (alpha < .05,p < .01). A lower number of Nonalert Waking and Cryingstates occurred during the experimental observation. It77would appear that the newborns exhibited fewer high arousalbehavioural states when exposed to soothing music.There was a significant difference between the controland experimental conditions in the lability or fluctuationbetween states. This finding supports the second hypothesissince the newborns demonstrated fewer changes in stateduring the experimental observation. It appears thatsoothing music could benefit newborns attempting to adapt toextrauterine life while cared for in the hospital newbornnursery. This adaptation would include a demonstration offew high arousal states and fewer behavioural state changes(lability) (Brazelton, 1984; Colombo et al., 1989; Thoman,1990).78CHAPTER FIVESummary, Conclusion, Implicationsand RecommendationsIntroductionThis study was designed to determine the difference inthe number of high arousal behavioural states and of statechanges when the subjects were exposed to soothing music inthe normal newborn nursery. This chapter presents anoverview of the study, followed by conclusions, implicationsfor nursing practice and education and recommendations fornursing research.Summar" Staff at various Lower Mainland hospitals shared withthe author a concern that newborns cared for in the normalnewborn nursery did not seem to sleep well and exhibitedbehaviours associated with stress. The author had readseveral studies describing how infants, children, and adultshad slept longer, exhibited less pain and stress relatedbehaviours while in the hospital when soothing music wasplayed. This study was designed to compare the number ofhigh arousal behavioural states and the number of statechange in newborns cared for in the nursery under normalcircumstances and when exposed to selected soothing music.The theoretical framework for this study was drawn from79theories on behavioural state patterns, puerperal newbornadjustment, environmental effects on newborns, psycho-physiologic responses to music, and the use of music as ahealth intervention. Review of the literature on these fivetheoretical topics provided information about the factors toconsider when observing newborns and using music as astimulus. This literature provided various behavioural statetaxonomies to choose from, environmental qualities ofnewborn nurseries to consider, and gave examples of soothingmusic that have been used in hospital settings.The literature suggested that the nursery environmentcould be a disturbing milieu for the newborn adapting to theextrauterine transition (Anders & Chalemian, 1974; Anderson,1986; Anderson, 1989; Chard & Richards, 1977; Karraker,1986; Keefe, 1987). Theorists postulated that noxiousenvironmental stimuli could stimulate an increase in higharousal states, e.g. Nonalert Waking and Crying in newborns(Anderson, 1986; Anderson, 1989; Brackbill, 1971; Brazelton,1984; Moreau, Birch & Turkewitz, 1970; Parmalee & Stern,1974; Thoman, 1990). They also suggested that prolonged timespent in these states could be detrimental to theirimmediate and longterm health.As well, the literature indicated that infants maydemonstrate erratic and frequent behavioural state changeswhen exposed to disturbing stimuli (Colombo et al., 1989;Dement, 1972; Harper, Leake, Miyahara, Mason,Hoppenbrouwers, Sterman & Hodgman, 1981; Thoman, 1990) e.g.80hearing other babies crying, sudden loud noises, and brightfluorescent lights (Anderson, 1989; Karraker, 1986; Keefe,1987; Shaw-Shuster & Smith-Ashburn, 1986). Reference to thecalming results observed in patients when soft, lyrical,flowing music was used in hospital wards, operating rooms,intensive care units, and special care nurseries supportedthe hypothesis that music could be of benefit to newbornscared for in the normal nursery (Bonny, 1983; Buckingham,1983; Chetta, 1981; Clynes, 1982; Cohen, Thorpe & Trehab,1987; Davis-Rollans & Cunningham, 1987; Dossey et al., 1988;Fagen, 1982; Hammer, 1984; Hanser, 1987; Hanslick, 1986;Jacob, 1986; Lingerman, 1983; Livingston, 1979; MacClelland,1979; McFarland, 1985; Marley, 1984; Owens, 1979; Podolsky,1954; Pratt, 1985; Roederer, 1982; Sammons, 1984; Schoen,1968, Standley, 1986; Verdeau-Pailles, 1985). The literaturealso suggested that behavioural states were the best indexto use when assessing newborn behaviours and stability.Therefore, this study was designed to determine if there wasa difference in the number of high arousal behaviouralstates exhibited by newborns in the nursery when the infantswere exposed to selected soothing music. The study was alsodesigned to see if there was a difference in the number ofstate changes (lability) in newborns when soothing music wasplayed.The study used a quasi-experimental, one group,pretest, posttest design in which the subjects served astheir own controls. The study was conducted in a large81tertiary care hospital in Western Canada. The authorobserved each infant for a total of four hours within one oftwo normal newborn nurseries. The infants were observed forbehavioural state changes and categories for two hours inthe usual nursery environment, and again for two hours withselected music exposure isolated to the subject beingobserved. Only the subject was exposed to the music via athree inch diameter, circular "Pillow Speaker" placed in theinfant's cot.The sample was composed of twenty newborns. They werebetween 36 and 42 weeks gestational age, 24 to 57 hours old,weighed 2860 to 4160 grams at birth, had 5 minute Apgarscores of 9 to 10, had 0 to 2 siblings, and their mothers'ages ranged from 20 to 38 years. There were 8 females and 12males in the study. All subjects were born by spontaneousvaginal delivery without complications. All were Caucasian,all but two were breastfed.The two research hypotheses were tested using an one-tailed, McNemar's test (alpha ‹.05) statistic. There was asignificant difference between the control and theexperimental conditions at the alpha < .05 level, in thefrequency of high arousal behavioural states, (NonalertWaking and Crying). There was also a significant differenceat the alpha < .05 level for the number of state changes orstate lability.The findings reflected support for the two hypothesessince the mean differences between the number of high82arousal states and number of state changes demonstratedduring the control and experimental observations weresignificant. The infants demonstrated significantly fewerhigh arousal states and fewer behavioural state changesduring the experimental observation. These findings suggestthat the dependent variable, the selected music, was relatedto the exhibition of fewer high arousal states and the fewerchanges of behavioural state.Conclusions Although the sample size was small (n = 20) it waslarge enough to provide worthwhile data for a preliminaryresearch study. This study was exploratory in nature andcovered a wide range of subject behaviours.The trends identified in this study contribute towardthe refinement of the concepts related to the effects ofsoothing music on neonatal behavioural states andbehavioural state lability within the normal newbornnursery. Based on the findings the following tentativeconclusions or trends are suggested:1. That soothing music may be a beneficial stimulus to usewith newborns being cared for in a hospital nursery setting.2. That soothing music may be useful to newborns learning toregulate their behavioural state changes within the hospitalnursery environment.83Implications for Nursing PracticeThe incidence of high arousal states and frequency ofstate change in newborns cared for in the hospital nurseryhave been examined. The results of this study haveimplications for nurses. Implications are identified inrelation to practice and to nursing education. Nurses areresponsible for providing care for neonates within thenormal newborn nursery. The findings suggest thatinterventions may facilitate fewer high arousal states(Nonalert Waking and Crying). The findings also suggest thatexposing the newborns to soothing music would be a cost-effective, feasible intervention for nurses to provide.However, in order to utilize music as an interventionnurses would need to:a) learn to recognize behavioural states (Brazelton, 1984;Keefe, 1987; Thoman, 1990).b) understand the physiological implications for anewborn when frequent high arousal behavioural states areexhibited (Anderson, 1989).C) know an alternative to using music in the nurseryenvironment could be to encourage "rooming-in" as much aspossible. There is, however limited data available todemonstrate that the mother's hospital room is lessnoxious than the nursery environment. Anderson (1989),Karraker (1986) and Keefe (1987) present study results84which suggest that lighting and noise is significantlylower at nighttime in the mother's postpartum room.d) recognize the potential of noxious stimuli (such as loudnoises, bright lights) to disrupt normal state patternswithin the nursery setting.The implications of this study have relevance also toeducation. There are implications for staff inservice,patient education, specialized education of professionalsand in the general education of nursing students. Nursesshould become aware of the usefulness of music as a healthintervention to provide more holistic care for theirclients. Nurses should also become proficient in assessingbehavioural states in newborns and providing appropriatestimulation to correlate with the apparent state ofconsciousness.Nurses are the primary educators of patients, which inthis case would be the newborns' parents. Many parents donot understand that newborns demonstrate behavioural statesnor how best to care for them when in a particular state.Many do not understand a baby's need for stimulation or theeffects of noxious stimuli, e.g. intense light, noise ortemperature fluctuations. Teaching parents the necessity ofstimulation and how to use music as a way to stimulate orsoothe can facilitate newborn wellbeing.Implications for nursing students also arise from thisstudy. The curriculum content of nursing programs shouldinclude theory, promotion of valuing and practice for85students in a few areas. First, in order to appreciate theeffects of music on neonates, nursing students need to learnto recognize behavioural states, to understand theirsignificance in the newborn and learn the potentialphysiological and psychological harm associated withfrequent exhibition of high arousal states in newborns(Anderson, 1989, Keefe, 1987, Thoman. 1990). Nursingstudents must also learn the significance of frequentbehavioural state changes and need to learn to value andteach parents to adopt the practice of "rooming-in" (Anders& Chalemian, 1979; Anderson, 1989; Keefe, 1987). To considermusic as an intervention, they could learn about and valuethe positive effects of creating a relaxation response innewborns to facilitate adaptation to the extrauterineenvironment. Nursing students should develop a repertoireof "alternative" therapeutic techniques including the use ofmusic in the clinical setting. This would relate to nursingstudents' understanding of the value and practice ofinterventions to create a nursery environment more conduciveto adaptation.Recommendations for Further Nursing ResearchFindings from this study suggest avenues for furthernursing research. Replications of this particular studycould validate the representability of the findings.Variations in study demography, e.g. attempts to match the86target population more closely, especially for gender andrace could also support (or negate) this study'srepresentability. Other studies, using various culturaltypes of music could also be done to examine the variable ofethnic predisposition in relation to musical familiarity andpreference. Perhaps studies with subjects of a particularcultural heritage, e.g. Oriental or Indian could beconducted using Western music or music from their particularnative culture.The usefulness of music for newborns in alternateenvironments could also be tested, for example, in themother's hospital room when "rooming - in" or at home.More research needs to be done on the patterns ofbehavioural states exhibited within the nursery environment.(Anders & Chalemian, 1974; Ashton, 1971; Brazelton, 1984;Lawson, Turkowitz, Platt & McCarton, 1985; Lerner, 1984).Research is needed to determine if there are significantdifferences in state patterns between different demographicgroups based on gender, length and mode of labour anddelivery, method of feeding and pattern of caregiving in thehospital. Further research in special care nurseries couldalso be valuable to examine the relationship of high arousalstates and music in premature and high risk newborns(Duxbury et al, 1984; Marley, 1984; Owens, 1979; Scanlon,Nelson, Grvlackl & Smith, 1979).In summary, the findings of this study suggest thathigh arousal states and state lability in newborns may be87influenced by exposure to soothing music. Further testingcould support the hypotheses that soothing music helpsreduce the frequency of high arousal states and frequency ofstate change when newborns are in the nursery. The methodsand findings of this study offer some direction for furthertesting of the potential usefulness of music for neonatesexperiencing extrauterine adjustment within the hospitalsetting. Further testing of the study hypotheses issuggested.88ReferencesAder, R. (1981). Psychoneuroimmunoloay. New York: Academic.American Academy of Pediatrics (1977). 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Mosby.95APPENDIX ACONSENT FORMI agree / do not agree (please circle correctstatement) to allow my newborn to participate in the study" The effect of soothing music on behavioural stateorganization in the hospital newborn nursery", designed byJune Kaminski (telephone #: 984 - 0813) a graduate studentfrom the University of British Columbia's School of Nursing.I understand that the purpose of the study is toobserve the way infants organize their newborn behaviourswhile cared for in the hospital nursery. I know that twoobservations will be necessary for the study, one withoutmusic exposure, and one with exposure to selected soothingmusic. I understand that both observations will be two hourslong, therefore, the total time required will be four hours.I understand that confidentiality will be strictlyrespected and that the written reports will contain nopersonally identifiable information. I understand that thedata collection and analysis forms will be destroyed aftercompletion of the study. Only the graduate studentconducting the observations will be aware of the identity ofthe participants. I understand that the investigator willrespond to any questions I may have about the study.I understand that my baby's participation in thisstudy in purely voluntary. I may withdraw my infant at anytime without jeopardy to the conduct of my care (or mybaby's care) by health professionals. I acknowledge that Ihave received a copy of this consent form.My faculty advisor is Wendy Hall, Assistant Professor,UBC School of Nursing. She can be reached at 822-7447.I consent to my child's participation in this study.( Parent(s) Signature(s)).I do not consent to my child's participation in this study.( Parent(s) Signature(s)).Date:^Investigator's Signature:^96Appendix B: Music Selections1. Beethoven: Piano Sonata, Opus 27, No. 2, 1st movement(Moonlight)2. Beethoven: Symphony No. 6, Opus 68, 2nd movement (By theBrook)3. Brahms: Three Intermezzi, Opus 1174. Drahms: Symphony Number 2, 2nd movement5. Brahms: Lullaby6. Debussy: Claire de lune7. Debussy: L'apres midi d'une faune8. Dvorak; Silent Woods; Cello Concerto9. Grkeg: Peer Gynt, Suite 1: Morning: Ase's Death10. Mendelssohn: A Midsummer Night's Dream: Incidental Music11. Mendeissohn: Violin Concerto in E minor, Opus 64, 2ndmovement12. Mqzart: Piano Concerto Number 21 (slow movement)13. Ravel: Pavane pour une enfante defunte14. Respighi: Pines of Rome15. Saint Saens: Carnival of the Animals: The SwanThe Aquarium16. chubert: Quintet in A for Piano & Strings, Opus 114,3rd & 4th movements17. Tchaikovsky: Waltz of the Flowers (Nutcracker Suite)18. Vaughan Williams: Fantasia on "Greensleeves"(Cass-Beggs, 1978, p. 132; Lundin, 1985, p.159;Guthiel, 1970, p. 74 - 81; McFarland, 1985, p. 257).NEWBORNMOVEMENTBEHAVIOURSTATENEWBORNBEHAVIOURSDATA COLLECTION TOOL:TOTAL 15 MINUTESS#.^CODE NAME:^DATE:^TIME:4.^5.NEWBORNMOVEMENT.N.s•7. 8. r 10.98APPENDIX DBehavioural State Codes and DescriptionsCode Symbol^State^State Description Quiet Sleep Eyes: Closed, no REM.Muscle Tone: tonic.Motor Activity: Virtuallynone, with the exception ofoccasional startles,twitches, sighsobs, orrhythmic mouthing.A^Active REM Sleep Eyes: usually closed, mayopen and close duringREM.Muscle Tone: Phasic.Motor Activity: May rangefrom minor twitches towrithing and stretching.Vocalization: Brief highpitched cry episodes mayoccur.Colour: Variable orflushed.Crying^eyes: May be open ortightly squeezed shut.Muscle Tone: Rigid.Motor Activity: Flailingof limbs, may arch back,intense facial tighteningVocalization: Intense,distressed wailing.99Drowse/Daze^Byes: either half closedor opening and closingslowly. Eyelids heavy.guscle Tone: semi- phasicMotor Activity; May havesmall and large bodymovements.Transitional^Eyes; May be closed, orclosing and opening.Muscle Tone: phasicMotor Activity: may havegeneralized motormovements, may be large.Quiet Alert^Eyes: Open, bright andshining, often scanning.Muscle Tong: RelaxedMotor Activity: Smallmovements only.ee^Nonalert Waking^Byes: Open but does notseek out visual stimuli.Vague, glassy.Muscle Tone: Phasic.Motor Activity: alertwith large movements.Periods of fussing,grimaces and jerks.100Appendix EInformation Letter for Physicians of Recruited Subjectsfor Proposed Nursing Research Study:" The effects of soothing music on Neonatal BehaviouralStatesin the Hospital Newborn Nursery"Dear Dr. ^Your patient, Newborn ^  hasbeen given parental consent to participate in this study.This project is being done as a partial requirement for theco - investigator's Master's degree in Nursing Education atthe University of British Columbia's School of Nursing.The study requires that Baby ^  beobserved for a total of four hours while being care for inthe hospital nursery. This observation will be done in twotwo - hour periods. During the "control" observation thechild will have no music exposure. During the "experimental"period the child will receive exposure to selected,continuous soothing music. Normal caregiving activities bythe nursery staff will not be interrupted during these twoobservation periods.Participation in this study is purely voluntary. If atany time the parents wish to withdraw the newborn from thestudy, they are certainly free to do so. If you have anyreservations about your patient participating in this study,your wishes about the newborn's continued participation willbe promptly adhered to. If you have questions or wish todiscuss the study please phone us at the following numbers.Sincerely,Wendy Hall, Assistant Professor, UBC School of NursingPhone: 822 - 7447June Kaminski, MSN Candidate, UBC School of NursingPhone: 984 - 0813 Home. 599-2266 Work.


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