64 Journal of Nursing and Health Sciences Vol. 9 (Special Issue) January-April 2015 Research Article Effect of Music Therapy And Environment Modification On Pain Reduction During Intravenous insertion on Preschool Children With Leukemia In Surabaya Iqlima Dwi Kurnia* Nuzul Qur aniati ** Kristiawati*** Erna Supatmini**** Suparmiasih***** Abstract Background Pain is an unpleasant experience associated with psychological factors. Hospitalized preschool children with leukemia may experience pain caused by invasive procedures. Music therapy and environment modification are a non-pharmacological analgesic. Purpose This study was to investigate the effect of music therapy and environment modification on pain reduction during intravenous insertion of preschool children with leukemia in Surabaya. Methods This research was pre experimental with one shot case study design. Purposive sampling was used to recruit fifteen preschool children with leukemia at a pediatric ward at Soetomo General Hospital Surabaya. Data was collected through observation of pain states at the 0 minute (starting the insertion of IV catheter), * Faculty of Nursing Universitas Airlangga, Surabaya, Indonesia ** Faculty of Nursing Universitas Airlangga, Surabaya, Indonesia *** Faculty of Nursing Universitas Airlangga, Surabaya, Indonesia ****Soetomo General Hospital, Surabaya, Indonesia *****Soetomo General Hospital, Surabaya, Indonesia Corresponding author: Kristiawati, E-mail: tia.woespinto@gmail.com
Journal of Nursing and Health Sciences Vol. 9 (Special Issue) January-April 2015 65 and at the first and fifth minutes after insertion. Face, Leg, Activity, Cry and Consolability (FLACC) was used for pain measurement and has been tested for validity and reliability. Music therapy (popular children s songs with 60 beat per minute) was given simultaneously during the placement of IV line. Modification of the environment was achieved by painting the walls and ceiling of the examination room. Data was analyzed using the Friedman test with level of significance α <.05. Results The results of this study showed that when given music therapy and environmental modification pain during the placement of IV line was decreased overtime from the 0 minute, the first and fifth minutes after the insertion (p =.00). Conclusion The study results support the effect of music therapy and environment modification on pain reduction during the placement of IV line on preschool children. Further research should be conducted using RCT with larger sample size. Keyword: Environment modification, leukemia, music therapy, pain response Introduction Pain is an unpleasant experience; the definition states that pain experience is subjective. Pain (can be?) associated with psychological factors, but pain can be seen from the signs or symptoms of the patient shown (Carpenito, 2000). Visible reaction of pain will vary in person in accordance with development, for example, among children and adults. Fear and anxiety due to illness and hospitalization is a major stressor that is often experienced by children. Stress that occurs in children due to the child not knowing the reason why hospitalized, a new environment away from family, the presence of painful procedures and physical change of condition from healthy to sick. Children may find it difficult to understand the pain and assume that a procedure done by a nurse can cause pain. This is because children find it difficult to describe and express pain verbally to parents or caregivers (Hockenberry & Wilson, 2009). An Intra Venous Line (IV line) procedure is an invasive procedure that is often conducted in the children s hospital. The presence of deep venous puncture procedures can cause anxiety, fear, and pain in children (Wang, Sun & Chen, 2008). Pain reduction techniques are basically classified into two techniques, pharmacology and non pharmacology. Pharmacology includes drugs that can reduce pain, while non pharmacology includes distraction, relaxation, cutaneous stimulation and guided imagination (guided imagery). Invasive procedures that usually occurred with children in hospitals, such as venous blood collection, IV line procedure and other procedures that involved venous access that can cause pain (Zempsky, 2008), procedures involving venous access, IV line, is the most perceived source of pain in children when hospitalized.
66 Journal of Nursing and Health Sciences Vol. 9 (Special Issue) January-April 2015 Observing the children s reaction to the invasive procedure, it was found that their physical and verbal aggression were equally excessive when seeing a doctor or nurse in white clothing from a distance, causing the child to become agitated, crying, avoiding, trying to secure the equipment, or trying to find a safe place. Pain perception in preschool children saw pain as a scary thing, and as a result the child responded with more aggression to the person causing the pain by hitting and kicking as a defensive reaction. (Supartini, 2004). Pain management during medical procedures needs to be handled, because, basically, the first experience a child has to invasive procedures could lead to a deterrent effect and a refusal when performing a similar procedure in the future. Pain management also allows health professionals to provide a wide range of diagnostic procedures to the client. If the pain is decreased when doing an invasive procedure, the nurse will able to shorten the time in caring for the client, accelerate healing, keep the client from traumatic hospitalization, reduce the length of hospital stay and also decrease cost. Daily blood transfusion application in hospital can be a substitute for therapy or treatment in hospital. Pain relief methods that can be done in preschool children can be grouped into two categories, namely pharmacologic and non pharmacologic or complementary therapy. Two of the complementary therapies are music therapy and environmental modifications. Music therapy is music using musical elements to increase and care for physical health, along with improving mental, emotional, and spiritual health of the client. Music therapy consists of two main elements, therapy elements and music elements. The therapy elements include musical skills for the therapist, developing relationships between therapist and clients, structured activities and recommendations by the caring team for the client to achieve specific goals and objectives. Music affects the autonomic nervous system, a part of the nervous system that is responsible for controlling blood pressure, heart rate and brain function, which also controls moods and emotions. When we feel pain, we become fearful, frustrated and angry which produces tense muscles in the body, making the pain to become more severe. Listening to music regularly can help to relax the body physically and mentally, and help to relieve and prevent pain. Research Questions The purpose of this study was to analyze the effect of music therapy and environmental modification for pain reduction in preschool children with leukemia during intravenous line insertion. Methods This study used a quantitative approach. Study design is all the processes required in the planning and conducting the study. Based on the study objectives, this study used a pre-experimental research design with one shot case study. The sampling method used in this study was purposive sampling. Participants Population includes population target and achievable population (Sastroasmoro & Ismail, 2010). Population in this study was all children with leukemia who would be administered the IV line procedure. Sample is part of the number and characteristics of the population (Sugiyono, 2009). In this study, sample criteria included inclusion criteria and exclusion criteria were as follows: 1. Criteria for inclusion in this study were: children with leukemia aged 3-6 years of age who would do the IV line. Children who agreed to be observed.
Journal of Nursing and Health Sciences Vol. 9 (Special Issue) January-April 2015 67 2. Exclusion criteria: children who have hearing and vision disturbance. Sampling is selection process of the population to represent the population (Nursalam, 2009). The sampling technique used was a purposive sampling, which is a sample determination technique by selecting a sample among the population according to the researchers desire, so that the samples can represent the population characteristic that has been known previously (Nursalam, 2009). Ethical consideration This study has been approved by the Ethical Committee (EC) of Soetomo General Hospital Surabaya No. 271/panke.KK/X/2013. Data collection and data analysis The data collection tool used in this study was an observation sheet for respondents aged 3 to 5 years, using FLACC (Face, Legs, Activity, Cry and Consolability Scale). Pain observation tools FLACC is an interval scale that includes five categories of behavior: facial expression, leg movement, activity, cry and comforted capabilities. This tool measured the pain to see the behavior response of infant pain. Scores of this instrument ranged from 0-2, and after totaled, total score between 0 (no pain) to 10 (worst pain). FLACC pain assessment tool originally was a behavioral scale to assess postoperative pain in young children. The observation sheet contains data of respondents including initials name, age, sex and pain scale FLACC. Data was analyzed using SPSS. The data tested used the Friedman test with decision hypothesis, if the value of p <.05 then Ho is rejected. Results Implementation of Music Therapy and Environmental Modification Demographic data collection was done after approval from the respondents. Then researchers conducted anxiety observations among respondents before IV line procedure. Respondent was brought to the procedure room where the environment had been modified by painting the walls and ceiling sections with images of flowers, grass, birds and clouds, fifteen minutes before the start of procedure in order that the respondent would feel relaxed and not afraid, and also the researcher would play music in the procedure room based on popular children s songs with 60 beat per minute for 10-15 minutes. The results are presented in Table 1-3 as follows:
68 Journal of Nursing and Health Sciences Vol. 9 (Special Issue) January-April 2015 Table 1: Respondents distribution by parental characteristics in pediatric ward Soetomo Hospital, Surabaya, October- November 2013 No. Parents Characteristic F (%) 1. Mother Education level a. Primary Schoolb. 2 13.33% b.junior High School 11 86.67% c. Senior High school 12 13.33% 2. Father Education level a. Primary School 1 6.67% b. Junior High School 11 73.33% c. Senior High school 3 20% 3. Mother s job a. Housewife 12 80% b. Private 3 20% 4. Father s Job a. Civil Official 0 0% b. Private 13 86.67% c. Farmer 2 13.33% Table 2: Preschool children s anxiety in Pediatric Ward Soetomo Hospital, Surabaya, October - November 2013 No. Respondents Anxiety Yes No 1. An. F + - 2. An. Ft - + 3. An. S - + 4. An. A + _ 5. An. Sr - + 6. An. R + - 7. An. D - + 8 An. G + - 9. An. M + - 10. An. An + - 11. An. D - + 12. An. Bg - + 13. An. Mf - + 14. An. Sy + - 15 An Fd - + Total 7 8
Journal of Nursing and Health Sciences Vol. 9 (Special Issue) January-April 2015 69 Table 3: Pain Response Preschool Children with Leukemia when administered IV Line Procedure in Pediatric Ward Soetomo Hospital, Surabaya. No. Respondent Age Sex Day of hospitalize Response 0 minute 1 minute 5 minute 1. An. F 6 M 1 severe moderate mild 2. An. Ft 6 M 2 mild no pain no pain 3. An. S 6 F 2 moderate moderate moderate 4. An. A 5 M 1 moderate moderate mild 5. An. Sr 5 F 2 moderate moderate moderate 6. An. R 5 F 3 severe moderate moderate 7. An. D 6 F 3 moderate mild no pain 8. An. G 4 M 1 severe moderate mild 9. An. M 6 F 1 moderate mild no pain 10. An. An 5 F 1 moderate moderate moderate 11. An. D 6 F 3 moderate mild no pain 12. An. Bg 6 F 1 severe severe moderate 13. An. Mf 5 F 2 mild mild no pain 14. An. Sy 6 F 1 moderate no pain no pain 15. An Fd 6 M 4 severe severe moderate Discussion Pain responses in 0 minute Data results from 15 respondents showed a response to pain at the 0 minute time of administration of IV line puncture procedure with music therapy and environmental modifications. Five respondents stated severe pain, eight respondents stated moderate pain and two respondents mild pain. Pain is a subjective response of a person, because it is influenced by many factors. One is anxiety, if a child feels anxious, they will give a different response to pain than children who are not anxious. This is similar with the data result in five respondents that stated severe pain in the first 0 minutes, all children felt anxious and feared the procedure that would be performed. Perry & Potter (2005) stated that the relationship between anxiety and pain is complex. Anxiety often increases response to pain, but pain may also increase, causing pain. Pain response at minute after IV line procedure The result of the study obtained from 15 respondents showed a pain response at 1 minute after intra venous line puncture procedure with music therapy and environmental modifications, seven respondents expressed moderate pain, six respondents expressed mild pain and two respondents did not express pain. Pain response showed by each respondent varied in accordance with past experiences. Of the seven respondents who experienced moderate pain, three respondents were hospitalized more than once. Four respondents experienced moderate pain, and were
70 Journal of Nursing and Health Sciences Vol. 9 (Special Issue) January-April 2015 hospitalized for the first time. Mild pain with first time hospitalization was experienced by two respondents, and two respondents were hospitalized more than one time. Two respondents did not feel pain. Pain response shown by respondents was in accordance with Perry & Potter (2005) stated that everyone will learn from their past pain experience. However, past pain experience not does not ensure someone will cope easier with the pain in the future. When a person suffered from pain repeatedly without any reduction effort in pain than before or had severe pain, anxiety, and fear will happen. In addition, pain is also influenced by age. Nine respondents aged 6 years and five respondents aged 5 years, and one respondent was 4 years old. Preschool age children found it difficult to understand the pain and assumed that nursing procedure can cause pain. This is because children find it difficult to describe and express pain verbally to parents or nurses (Hockenberry & Wilson, 2009). Pain response that respondents perceived ranging from 0 minutes to 1 minute after the puncture was decreased when music therapy and environmental modification was given. When intra venous line procedure was done, respondents distracted by listening to the music they desired and also seeing the pictures of animals, flowers and clouds on the wall was consistent with the theory according to Candace Pert that neuropeptide and biochemical receptors released by hypotalamus closely associated with emotional events, pleased emotions or relaxed conditions was able to reduce the levels of cortisol, epinephrine-nor epinephrine, dopa, and growth hormone in serum (Nicholas & Humenick, 2002). In addition, through the modification of physical environment can increase the child s happiness, safety feeling and comfortable environment for the child, so the child is always evolving and feel comfortable in their environment. Pain response at 5 minutes after IV line procedure The result of the study obtained that from 15 respondents showed pain response 5 minutes after intra venous line puncture procedure with music therapy and environmental modification of the environment with three respondents expressed mild pain. Moderate pain was expressed by 6 respondents, and they expressed no pain. Pain response in the first 5 minutes after the puncture procedure showed decrease in pain response of 0 minutes, 1 minute to 5 minutes after the procedure, the study found increase in the number of respondents who expressed no pain, from 1 to 4 respondents. 5 respondents were male respondents and 10 were female. Age factor is an important variable that affects the pain response. Children will find it difficult to understand the pain and nursing procedures that cause pain. Children will have difficulty expressing verbally their pain response to other people and their parents. Therefore, nurses should use simple communication techniques to help children understand and describe their pain. Nurses can use the images that show the children how to describe the pain response. The effect of music therapy and environmental modification as effort to decrease pain at first 0 minute, 1 minute and 5 minutes after intra venous line procedure. From the results of statistical tests by SPSS 16 using Friedman test showed there was decrease in pain response at the time of the action or at first 0 minutes, 1 minute and 5 minutes after intravenous line procedure. Statistic test obtained p value.000, which means the value of p <.05 then Ho was rejected, means there were effects of music therapy and environmental modifications to the pain response at 0 minute, 1 minute and 5 minute after intravenous line procedure in preschool age children with leukemia.
Journal of Nursing and Health Sciences Vol. 9 (Special Issue) January-April 2015 71 Wilcoxon test results showed p value <.05. This indicates that there are differences in the provision of music therapy and modification of the environment by the procedure of IV line as a way of reducing pain in children of preschool age with leukemia in each minute. The longer therapy decreases the level of pain in children Conclusion 1. Pain response in preschool age children with leukemia who undergo IV line procedure at first 0 minutes (when action), indicating most respondents experienced moderate pain. 2. Pain response in preschool age children with leukemia who undergo IV line procedure at first 1 minute after action showed, most respondents experienced moderate pain. 3. Pain response in preschool age children with leukemia who undergo IV line procedure at 5 minutes after procedure showed nearly half respondents expressed no pain. 4. There was a decrease in pain response at first 0 minute, 1 minute and 5 minute at pre-school age children with leukemia after music therapy and environmental modifications to IV line procedure. Suggestions 1. For parents of children with leukemia they are expected to always assist and play an active role in every action/ procedure administered to the child. 2. The Pediatric nurse is expected to create a standard of music therapy and environmental modifications, particularly in preschool children with leukemia. 3. Hospital is expected to provide music therapy and environmental modifications facility to support children s services, especially treatment of preschoolers with leukemia. Acknowledgements This study was funded by Faculty of Nursing Universitas Airlangga. Refferences Carpenito, L.J. (2000). Rencana asuhandan dokumentasi keperawatan. Jakarta: EGC Hockenberry, M.J.,& Wilson, D. (2009). Essentials of pediatric nursing. (8 th ed). St Louis: Mosby Nicholas, F.H., & Humenick, S.S. (2002). Childbirth education: practice, research and theory. Philadelphia: WB Saunders Nursalam, M (2009). Konsep dan penerapan metodologi penelitian ilmu keperawatan: pedoman skripsi, tesis dan instrumen penelitian keperawatan. Jakarta: Salemba Medika Perry, A.G., & Potter, P.A. (2005). Fundamental of nursing: concepts, process and practice. (6th ed). St Louis: Mosby Sastroasmoro, S., & Ismail, S. (2010). Dasar-dasar metodologi penelitian klinis. Jakarta: Sagung Seto Sugiyono. (2009). Metode penelitian klinis. Bandung: Alfabeta Supartini, Y. (2004). Konsep dasar keperawatan anak. Jakarta: EGC Wang, Z.X., Sun, L.H., & Chen, A.P. (2008). The efficacy of non- pharmacological methods of pain management in school age children receiving venepuncture in a pediatric departemen: A randomized controlled trial of audio visual distraction and routine psychological intervention. Swiss Med Wkly, 138 (39-40), 579-89. Retrieved August 10, 2013, from http://www.ncbi.nlm.nih.gov/ pubmed/18853287
72 Journal of Nursing and Health Sciences Vol. 9 (Special Issue) January-April 2015 Zempsky, W.T., (2008). Pharmacologic approaches for reducing venous access pain in children. Pediatrics 122, 140-153. Retrieved August 9, 2012, from http://www.pediatrics.org/cgi/ content/full/122/ Supplement_3/S140.