1. Running head: RESEARCH CRITIQUE
Critique of the Effect of Complementary Music Therapy
On the Patient’s Postoperative State Anxiety, Pain Control,
and Environmental Noise Satisfaction
Chelsea Zabala
Southwestern Adventist University
NURS 421 Nursing Research
Lenora D. Follett, PhD, RN
7/21/2014

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Information about the Author
Tressa Comeaux, APRN, FNP-C, CEN, is a CICU staff nurse at the Our Lady of the Lake
Regional Medical Center in Patient Care Services in Baton Rouge, LA. Susan Steele-Moses, DNS,
APRN-CNS, AOCN is a research director at the Our Lady of the Lake Regional Medical Center in
Academic Affairs in Baton Rouge, LA.
Brief Summary of the Article
This is a study of the effect of complementary music therapy on patients’ postoperative
state anxiety, pain control, and environmental noise satisfaction. Researchers conducted the
study at the Our Lady of the Lake Regional Medical Center (OLOLRMC) in Baton Rouge,
Louisiana. The sample participants consisted of postoperative patients. The participants were
asked to use non-lyrical music for 30 minutes after prescribed analgesia. Then patients’ filled
out questionnaires to measure their anxiety state, pain control, and environmental noise
satisfaction. Data collection was done twice (a third time if participant was not discharged—
though Time 3 was not used in the findings because of certain limitations).
The researchers then analyzed the data and presented the results of the study in the
article. They found that anxiety state was not significantly affected—increase or decrease—by
the complementary music therapy, but pain control and environmental noise satisfaction was
increased with use of the therapy. Though limitations were found in the study, researchers
concluded that complementary music therapy “is recommended for use in improving
postoperative outcomes in other facilities” (Comeaux & Steele-Moses, 2013, p. 318) and gave
suggestions for future research.

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Critique of the Effect of Complementary Music Therapy on the Patient’s Postoperative State
Anxiety, Pain Control, and Environmental Noise Satisfaction
Although I did not necessarily choose to critique this research article, I found it very
interesting and applicable to my experience as a nursing student and informative to be able to
use in my future clinical practices. I also have an interest in music, so I thought this article
particular would be interesting to read and critique. Pain is a common feeling in human beings
and anyway to lessen the experience I believe is worthy of investigative research.
Research Problem
The problem statement is clear and persuasive supported by findings on the subject
stating that “unrelieved postoperative pain remains a common problem despite advances in
pain management” (Comeaux & Steele-Moses, 2013, p. 313). It was easy to locate—first
sentence of the research article—and suggests reasonable evidence to further research the
effects of complementary music therapy in “increasing patient satisfaction with the
postoperative experience” (Comeaux & Steele-Moses, 2013, p. 313). A positivist paradigm is
implied for use in this quantitative article, further evidenced by the use of deductive reasoning
to tests the hypothesis and the researchers’ intent to seek generalizability in nursing practice.
The purpose of the study is to “determine the effect of music therapy on state anxiety,
postoperative pain, and environmental noise perception” (Comeaux & Steele-Moses, 2013, p.
315). The purpose statement and research hypothesis clearly identified the variables and
specified population for the research study. Both purpose and hypothesis were properly stated
suggesting the nature of inquiry of the research. Several earlier studies were found to support

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the suggested research hypothesis. This is not a null hypothesis, though the null hypothesis is
implied though not stated.
Theoretical or ConceptualFramework and Definitions and Design
This is a quantitative study that explicitly stated the use of the Relationship-Based Care
(RBC) delivery model to support the study. The article explained the “three crucial relationships
in RBC include care of self, care of colleagues, and care of patients and families” (Comeaux &
Steele-Moses, 2013, p. 313) thereby explaining the model to the readers briefly. The model
appears to be appropriate for the research problem as complementary music therapy falls in
the category of care of patients and families in the RBC model. The hypothesis and RBC model
are not closely related. The concepts used in the study are consistent with the category of care
of patients and families only. In this quantitative article, operational definitions were consistent
with the conceptual definition of caring. The researchers did not refer back to the RBC model
later in the study, though the findings imply interpretation in regards to care of the patients.
The RBC model seems to only be a means to support the research and does not seemto guide
the research process.
Review of the Literature
For this research article, the literature review mentioned the databases used in
search for other relevant articles (e.g. CINAHL, The Cochrane Library) and gave a period from
2007-2012 article search criteria (Comeaux & Steele-Moses, 2013, p. 313), therefore literature
reviewed for this topic is considered up-to-date. Some of the sources used in the study included
some primary sources, but mostly referenced what seemed like secondary sources and opinion
articles and included some referenced testing tools used for the testing procedures used in the

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article. The study was not an introduction to a newfound study, but the literature review did
not support the need for this particular study—instead demonstrating that no gap existed in
the literature.
Design
In the body of the article, the research design was not stated, but upon further review
the research design was found in the abstract of the article stating that they used “a quasi-
experimental non-equivalent control group design” (Comeaux & Steele-Moses, 2013, p. 314).
The research question was therapy question, but the highest, most rigorous design was not
used—which are randomized controlled trials. The researchers had one control group and one
intervention group. Though it was not randomized, the comparison strategy was effective in
highlighting key relationships between complementary music therapy (intervention) and
patients’ outcomes in the pilot study.
The intervention was stated clearly and accurately in the article. Use of blinding was not
explicitly stated, but it was implied that the data collectors were blinded because “daily, clinical
support staff rounded…and collected completed packets” (Comeaux & Steele-Moses, 2013, p.
316). Intervention fidelity appeared to be kept as the research procedure was explained to the
patient the first postoperative day by “a member of the clinical support team, which consisted
of a clinical nurse, specialist, clinical educator, program director for nursing research, and
direct-care nurse” (Comeaux & Steele-Moses, 2013, pp. 315-316) and as stated earlier, a clinical
support staff rounded daily to collect the questionnaires.
The research was done as a longitudinal study. The number and timing of the data
collection was appropriate—Time 1 is day of enrollment (1st postoperative day); Time 2 is next

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postoperative day; Time 3 is the next day after with no inclusion of Time 3 if patient was
transferred or discharged—as it was found “pain in the postoperative patient is often
unrelieved” (Comeaux & Steele-Moses, 2013, p. 313). In terms of enhancing the statistical
conclusion validity, the researchers used a small sample of 41 participants as a pilot study. Two
statistical tests were used to grade the dependent variables including the State-Trait Anxiety
Inventory (STAI) for anxiety and the Likert scale (scale of 1-4) to measure the patients’ pain and
noise level satisfaction. Overall, these steps were adequate enough to protect the statistical
conclusion validity of the study.
The research design was not able to control when the patient was going to be
transferred or discharge, therefore a rival explanation—such as the cause preceding the
effect—may contribute towards the patients’ outcomes. But given the length of time of the
study per participant (about 2-3 days) internal validity problems could arise in relation to
concurrent events (history effect) and early discharge or partial completion of the
questionnaires on discharge day (mortality/attrition). Also the fact that the study was not
randomized, can pose a problem. What type of pain medications the patient received and other
pain distractions used by patients were external factors not considered that could interfere
with the study’s external validity. The design was able to draw causal inferences about the
relationship between the independent and dependent variables, despite little attention to the
external factors to the study.
The article stated the study limitations which included “patients were not assigned
randomly to the intervention”, “personal distraction may have confounded findings”, “patients
in control group also reported listening to music”, “no manipulation to usual care” may have

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caused a crossover effect, “data collected at Time Three were limited due to the unit’s average
length of stay or participants’ failure to complete the questionnaire” related to the “tedious,
somewhat repetitive, and upsetting for some” STAI Questionnaire (Comeaux & Steele-Moses,
2013, pp. 317-318). These limitations are liable to affect the patients’ outcomes and affect the
external validity of the study, though the study does acknowledge the limitations, but claims
the support of an earlier larger study (Comeaux & Steele-Moses, 2013, p. 318).
Sampling Plan and Data Collection
The participants in the study were postoperative patients admitted to the inpatient
surgical unit at the Our Lady of the Lake Regional Medical Center (OLOLRMC). Eligibility criteria
was clearly stated and included: “anticipated 3-day hospital length of stay, alert and oriented,
age 18 or older, able to read and write English, and hematology-oncology diagnosis (Comeaux &
Steele-Moses, 2013, p. 315)”. The study stated that the participants “were not assigned
randomly to the intervention but rather placed into groups based on the hallway assignment”
(Comeaux & Steele-Moses, 2013, p. 315).
The article did not explicitly state what type of sampling design was used, but it suggests
a consecutive sampling. It is a better choice of sampling than convenience when randomization
is not possible. The sample was collected from a “larger study, which is still ongoing” reasoning
the need to “test the efficacy and feasibility of the study methods” (Comeaux & Steele-Moses,
2013, p. 315). The smaller sample size taken from the larger study may not be large enough to
support the statistical conclusion validity. The suggestion was made in the article that “the
study should be replicated with a larger sample size and with different patient populations to
validate these findings” (Comeaux & Steele-Moses, 2013, p. 318).

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The article did include limitations that could result in sample bias and weaknesses. Data
collected on Time Three limited the representative sample “due to the unit’s average length of
stay or participants’ failure to compete the questionnaire on the day of discharge”; also the
“STAI Questionnaire was tedious, somewhat repetitive, and upsetting for some” (Comeaux &
Steele-Moses, 2013, p. 318). Gender and race were key characteristics identified in the study,
along with the dependent variables—pain management satisfaction, environmental noise
satisfaction, and anxiety states. The sample supports inferences for postoperative patients, but
are limited only to those who fulfilled the inclusion criteria, therefore, generalizability would be
supported if the study was replicated with a different population and larger sample size.
The study used self-reports to collect data in the form of State-Trait Anxiety Inventory
Questionnaires which used a 4-point Likert scale and was split into two forms. The 4-point
Likert scale was also used in two other standardized tests to measure the patient’s pain
management satisfaction and environmental noise satisfaction level. This was the best method
to measure the dependent variables given observation could affect the participant’s behavior
and biophysiologic measures are not possible in this study. The researchers’ self-report
methods were adequate providing appropriate scales and approved forms to collect relevant
data from the participants.
Two forms of the STAI Questionnaires—STAI Form Y-1 and STAI Form Y-2—were used to
ensure no patient biases were taken into account. STAI Form Y-1 was used to measure state
anxiety, while STAI Form Y-2 was used to measure “participants’ usual emotional feelings”
(Comeaux & Steele-Moses, 2013, p. 315). Also a member of the clinical support team explained
the purpose of the study and procedures before obtaining verbal consent and enrolling the

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patient into the study. No mention was made that the staff of the clinical support team was
trained and specifically chosen. Data was collected three times during the study—Time One
being first postoperative day, following 24 hours later consecutively for Time Two and Three.
The staff would then round and collect the questionnaires that were placed in manila envelopes
daily from the participants’ room. Participants were able to fill out the questionnaires’ in their
rooms, but only at the allotted times.
Measurement and Data Quality
Participants completed State Anxiety Inventory questionnaires and two other
standardized tests using the Likert scale to measure pain satisfaction and environmental noise.
Evidence of the reliability of the measurement tools used in this study came from other studies
and were used because they were “developed and used extensively by a national vendor”
(Comeaux & Steele-Moses, The effect of complementary music therapy on the patient's
postoperative state anxiety, pain control, and environmental noise satisfaction, 2013, p. 315).
The reliability scores for the Likert scales used for the participant’s satisfaction with pain
management and environmental noise were both adequate, rating above a 0.7 mark. Reliability
of the STAI questionnaires used for the participant’s anxiety states were cited from another
article.
Internal consistency was only adequate on the STAI Form Y-2 questionnaire, but STAI
Form Y-1 questionnaire was under the adequate 0.7 mark for adequate internal consistency. No
methods or measures were stated to have been taken for the various tests on validity in the
article. Hypothesis may not be supported because of failure to support data quality with low
reliability, internal consistency, and no measures of validity to support the measurement tools.

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Many tests for the measurement tools for this study were either not stated in the article or not
used at all.
Data Analysis and Results
The sample demographic characteristics were summarized by use of descriptive
statistics. The descriptive statistics included number and percentage of males and females
(gender) and the race—which consisted of Caucasians and African-Americans with one not
disclosed. A paired t-test was used to test the mean differences within the groups, while an
independent t-test was completed for the analysis between groups (Comeaux & Steele-Moses,
2013, p. 316). The major key variables were described and the statistics were appropriate for
use in this study.
The t-test was used as an inferential statistic for the study. The article provided
information about hypothesis testing, but a confidence interval was not stated which supports
the use of no parameter estimation. Effect sizes or risk indexes were not included in the article
either. The articles missing statistical information does not support the hypotheses—instead
yielding support to the null hypothesis. Overall, the report yielded minimal information to the
readers about the evidence reported in the study. The danger of a Type II error is plausible in
this study in light of the minimal use of statistical information to validate statistical information.
No multivariate statistical analysis tests were stated to be used for the study. The use of
ANCOVA, for example, would have strengthened the study’s internal validity since
randomization was not used, therefore use of multivariate statistical tools would have been
preferred. The given statistical tests used in the study were appropriate, but statistical
significance was not obtained for all of the key variables. Therefore, the study results only

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“partially supported the hypothesis that music therapy is effective as a non-pharmacological
adjunct to analgesia in increasing pain management and environmental noise satisfaction;
however state anxiety remained unchanged” (Comeaux & Steele-Moses, 2013, p. 317).
Findings were organized to an extent though not fully explained for the reader to
understand the statistical significance. Tables had appropriate headings and summarized large
amounts of statistical data, but a legend was not provided to enable the reader to understand
the statistical symbols significance to the study results. The tables were hard to interpret,
unless one knows the symbols significance. The article partially explained the statistical
significance, but did provide enough information to support their conclusion for the partial
support of the research hypothesis.
Discussion
As a result, findings from the study seem to support their hypothesis partially as
evidenced by “During the Time One measurement, all participants reported being only
somewhat satisfied with pain management over the previous 24 hours….suggesting participants
were not satisfied with the standard of care alone.”; also “At Time One, environmental noise
satisfaction was slightly higher in the control group than with the music group”; and the
“difference between groups at Time Two revealed no significant change in state anxiety”
(Comeaux & Steele-Moses, 2013, p. 317). Complementary music therapy only had an effect on
the participant’s pain and environmental noise satisfaction, while state anxiety remained
unchanged. The study included nursing implications, limitations of the study, and
recommendations for future research. Implications included practical and effective ways to
implement their study findings. Limitations covered bias and other factors that may have

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affected the results of the study. Recommendations for future research included suggestions
for researchers who want to undertake a similar experiment.
Conclusion of the Student
This study stimulated my thinking about the value of music therapy as a complementary
treatment for postoperative patients in general. The study was clear and explained their work
to the reader well. The relevance of this study was not clearly established by the researchers,
since no gap in the research was presented, though the importance of this experiment was
supported by the findings of the research. The strengths of the study included that it is was an
easy-read while presenting important information that may have clinical implications in future
healthcare. Some of the weaknesses of the study included not having a proper literature
review, not establishing a gap for the relevance of the study, a wrong choice in the model—
hypothesis was supported by the model, instead of the other way around, and there was
evidence of attrition in the study. The strengths of the study were that the research was
presented clearly and concisely, it is understandable to the readers, and the findings did
support the hypothesis—albeit partially. Overall, the study was a good-read and useful for use
in my future clinical practice, but planning of the study needed to be more solid, in order, for
other healthcare providers to be able to trust the validity and relevance of the study.

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References
Comeaux, T., & Steele-Moses, S. (2013). The effect of complementary music therapy on the
patient's postoperative state anxiety, pain control, and environmental noise satisfaction.
MEDSURG Nursing, 22(5), 313-318. Retrieved from
http://proxy.swau.edu:2055/login.aspx?direct=true&db=c8h&AN=2012361512&site=eh
ost-live