Introduction

The following assignment is in two sections. The first section is a review of the literature I have selected, which will be discussing relevant information and research into music therapy. The second section is the research proposal; outlining ethical considerations and research methods, which may be used to conduct the study.

Alzheimer’s disease is the most common cause of dementia and includes a set of symptoms that can include memory loss and difficulties with thinking, language or problem solving (Alzheimer’s Society, 2018). Alzheimer’s is a progressive disease, meaning over time, more parts of the brain are damaged. As this happens, more symptoms develop and become more severe (Alzheimer’s Society, 2018).

Literature Review

The literature research was commenced in May 2018 using CINAHL, Medline, Cochrane and Google Scholar. CINAHL was used which initially found 107 articles. After limiting the search (Appendix 2) the number of articles found came down to 22. The titles and abstracts of these were read and a final three were chosen.

Medline was used, and 63 articles were found, this was after limiting the search results (Appendix 2). 18 titles were excluded due to not being appropriate, leaving 45 articles left. The abstracts were read, and papers were excluded when they did not appear suitable to this study, this then left two papers out of the search.

Cochrane was used, and the search gave 35 articles which matched the search criteria. Two papers were left after limiting the search (Appendix 2). From reading both full papers, these were discarded.

Google Scholar was used to gain articles. After viewing 100 titles and 50 abstracts, one full paper was used from this search engine; which was found after using specific keywords and limiting the search to papers, which have been published from 2014 to 2018.

Critical Appraisal Skills Programme ([CASP] 2018), will be used to critically analyse the literature chosen.

Sung, Chnag & Lee (2010) shown clearly what the aims of this study was and why it was important to conduct it and gain results. Sung et al (2010) have shown that their study was relevant due to finding out that nursing staff can learn how to implement preferred music intervention to provide appropriate care tailored to the individual needs for the older adults with dementia in long-term care settings.

This study adopted a quantitative research method, specifically using a quasi-experimental research design. Two groups of participants took part and were randomly allocated to an experimental group and a control group. The Rating Anxiety in Dementia (RAID) tool was used, to measure the participant’s level of anxiety throughout the study (Shankar, Walker, Frost & Orrell, 1999). It was not stated clearly as to why they used this type of data collection design.

It was explained within the study as to why some participants did not engage within or complete the research, this was due to hospitalisation of one of the participants and some participants not meeting the inclusion criteria. The researchers did not justify why they randomly allocated participants into two groups, however, it was justified why they needed a certain number of participants and that they all met the inclusion criteria (appendix 3) and completed the study.

Sung et al (2010) discussed their analysis having used the statistical package SPPS, an analysis of covariance (ANCOVA) to determine the effectiveness of the preferred music intervention on anxiety in older adults with dementia in nursing homes. This study found that preferred music intervention reduced anxiety in older adults with dementia in nursing homes, adding to the existing knowledge we have on the effects of music therapy with dementia.

One section of the paper encloses the study’s limitations, it is not shown that the research was explained to the participants, therefore the reader would not know if ethical standards were maintained throughout the study.  It is also discussed what factors would provide stronger data in study’s in the future with a similar hypothesis.

Ho, Lai, Jeng, Tang, Sung & Chen (2011) does not show a clear statement of the aims of their research but they do provide the reader a small introduction as to what the design of the study was all about. Their results found that listening to researcher-composed music improved agitated behaviour in nursing home residents with dementia during meal times. However, it did not discuss how the findings could help other populations within society or how this research could be used in other ways other than agitation at meal times for persons with dementia.

A quantitative research design was used and the Cohen-Mansfield Agitation Inventory ([CMAI] Cohen-Mansfield, 1996) was used to measure the level of agitation in the dementia residents. Ho et al (2011) did not justify why it was appropriate to use a quantitative research design or did not explain why they would be using the CMAI. It was also not discussed in the paper how the researchers gained the agitation scores from the dementia residents.

Participants were selected if they met the criteria set out (appendix 3). A total of 31 elderly persons with dementia were invited to participate; 9 people withdrew from the study due to receiving more information and unforeseen medical reasons; leaving 22 participants taking part. The researchers did not evaluate their own role within the study and did not comment on any potential bias and influence during the data collection, recruitment or data analysis.

Data was analysed using statistical package SPSS and Fisher’s skewness coefficient was used to check the normality of the data. The Friedman test was used to examine treatment effects across time, and multiple tests with the Bonferroni’s correction were used to determine group differences in CMAI scores at each weekly post-test (Ho et al, 2011). However, it was not justified why these were used to analyse the data collected.

Limitations of the study were discussed and found that a small sample size was used to gain the results, so it is hard to comment on generalisability; another limitation shown is that the researcher composed the music so there is a chance of bias which was not stated within the paper.

Sung, Lee, Chang & Smith (2011) study had a clear statement for the aim of the study. They explained that it is important to understand the attitudes towards music therapy among nursing home staff because it can provide baseline data to further develop educational programmes to train nursing staff about the implementation of music therapy for older adults with dementia.

Sung et al’s (2011) study used a qualitative research design, which was appropriate for this study due to collecting the thoughts and opinions that nursing staff have on music therapy, and not collecting numerical data.

A convenience sample was used to get participants for the study from 16 nursing homes. A 23-item questionnaire was then sent out to 285 nursing staff participants, with 214 responses, giving them a response rate of 75%. The questionnaire was pilot tested before going out and required no amendments. It was not justified as to why a questionnaire was used to collect the data. It was not enclosed what questions were asked within the questionnaire. This may include some bias within the way the questions were written, showing the researchers did not critically examine their own role, potential bias and influence with the study.

The researchers included the study limitations within the paper discussing that sampling bias may have occurred as nursing staff with positive attitudes towards the music therapy may have self-selected into the study. Another limitation was explained and was shown that the sample size was too small for the results to be high in generalisability. Advice and recommendations were given to improve the study if it was to be done again. The findings were discussed which were that nursing staff gave strong positive attitudes towards the use of music therapy; these findings were also discussed thoroughly in relation to implications to clinical practice and existing knowledge we already have and explained that the treatment of music therapy can improve mental health of older people who are living in long-term care facilities.

Ridder, Stige, Qvale, & Gold (2013) set out the aim of this study very clearly for the reader, however it was not discussed why it was important to conduct a study in this nature. This is a quantitative study, using the Cohen-Mansfield Agitation Inventory (CMAI) to measure agitation (Cohen-Mansfield, 1996) and using the Quality of Life in Alzheimer’s Disease (QOL-AD) measuring quality of life using a scale (Logsdon, Gibbons, McCurry & Teri, 1999). The data for these scales were collected by proxy interviews. These were carried out via phone, with a researcher, asking the proxy respondent to rate the outcome measures (CMAI and QOL-AD).

It was enclosed that the researcher holding the interviews over the phone was blind as to whom had treatment; this lowers the risk of researcher bias taking place within the results. However, the questions asked to the participants to gain the data from the CMAI and QOL-AD scales have not been enclosed; therefore, there may be a potential risk for bias to arise.

The study was designed as a crossover randomized controlled study and participants were randomly selected into different groups with different conditions. Participants also had to meet the criteria set out by the researchers to take part (appendix 3). It was not discussed why the researchers used this type of design or recruitment within the study and did not discuss the saturation of the data.

The researchers have included a discussion of the findings which confirmed that music therapy decreased the amount of agitation within the dementia residents. A section on the limitations of the study with reference of the disadvantages of using the proxy interviews as a form of data collection were discussed. It was not stated within the paper whether the research was explained to the participants, so it is hard for the reader to assess whether ethical standards were maintained throughout the study. It is stated that statistical analysis was done by the researchers themselves and does not state whether the researcher critically examined their own role, potential bias and influence during analysis and selection of data for presentation.

The researchers have discussed the contribution this study has made to existing knowledge and understanding and discusses that individual music therapy is not successful unless the therapist, staff and relatives are aware of their roles in bringing the positive results from the music therapy process and there being a change in the participant’s daily life. However, the researchers have not shown the reader whether the findings could be transferred to other populations or other ways the research could be used.

McDermott, Orrell & Ridder (2014) showed the aim of this study very clearly and showed the reader why it was important and relevant to conduct this study. McDermott et al (2014) shows there was a gap within knowledge to do with music therapy and the importance of it, and explains that their study covers this gap of knowledge found.

This study used a qualitative study approach and the researchers justified why they chose this approach. This study used focus groups and interviews with separate groups of people; and were all conducted by the lead researcher, and this was stated very clearly. However, it was not disclosed within the paper about potential bias the researcher may have caused. The use of focus groups and interviews were justified given the advantages that they hold and how this would help the data that is being collected. Discussion of what questions were being asked within the focus groups and interviews were included within the paper (appendix 3). Due to this information being enclosed, this gives the reader the assumption that there was a lowered risk of researcher bias.

Two care homes were involved within the study. The researchers explained the study to every resident and their families and the staff within these homes, and continued to invite the participants by sending a letter to them. 44 families were contacted, but only 19 replied. It was explained that four families could not participate due to work/family commitments.

Focus groups and interviews were audio recorded when possible with consent from the participants. If this was declined, the researcher took notes. The paper stated that the audio recordings were clear and concise and were played back several times for researchers to understand the common themes and key comments.

Data analysis was conducted by categorisation of key themes for scale development and further revision of these resulted in six key themes being identified and the findings were discussed greatly in relation to the research question. It was stated that the letter of invitation for participation also contained research information sheets, which included everything the participants needed to know about the study; which suggests to the reader that ethical standards were maintained, which is shown to be a strength within the research.

Ray & Mittelman (2017) study aim was discussed but it is not clear to the reader. It does state that the importance and relevance of the study when implementing music therapy. The researchers used a quantitative research design due to using different numerical measuring scales; there was no justification for this.

Participants had to consent to screening prior to the study by using Reisberg’s Functional Assessment Screening Test ([FAST] Auer & Reisberg, 1997). Only participants who scored five or above on the FAST (which indicated moderate to serve dementia) were considered eligible for the inclusion in the study.

A convenience sample was used for the study recruitment and participation from three nursing homes, but it was not justified why this design was used. Out of 150 participants who were initially invited to the project, 18 participants did not take part, this was due to several reasons such as; discharges prior to the study, health issues, and not meeting the baseline assessment to participate; leaving 132 participants to take part.

Three instruments of measuring depression, agitation and wandering were used. The Cornell Scale for Depression (CDS) by Kurlowicz, Evans, Strumpf & Maislin, (2002). The Cohen-Mansfield Agitation Inventory (CMAI) by Cohen-Mansfield (1996). The Algase Wandering Scale (AWS) by Algase, Beattie, Bogue & Yao (2001). It was not stated clearly how the researchers gained the information from these measuring scales.

The findings were discussed, and it was found that music therapy intervention reduces symptoms of depression and agitation but not wandering behaviours for the 2-week duration of the study. These changes were also shown 2 weeks post-treatment.

Strengths and limitations were discussed in relation to the study and it is stated clearly in the paper that to protect the validity of the study, the researcher did not take part in the intervention nor was there any proper relationship with the participants. A disadvantage that was discussed is that the study was not done with a good distribution of people with different socioeconomic status and racial groups.

The common themes and evidence found throughout these 6 articles shows that music therapy on people with dementia provides a person-centred approach to decrease the level of agitation and depression, however Ray & Mittelman (2017) found that music therapy had no impact on the effects of wandering within dementia patients. Five of the six articles are not in the United Kingdom, which shows that there needs to be more research done on the effects of music therapy within the UK. Most of the articles used a quantitative research design approach to study the effects of music therapy rather than the opinions and thoughts that surround using this type of treatment and if this treatment had an effect on family life.

Therefore, there are gaps in the UK research. There is not much research on the opinions of music therapy from the family/carers perspective who know the people suffering from dementia the most. Therefore, the research question for this study is: what are the views of the family/carers of dementia patients receiving care in a nursing home environment regarding the effect of music therapy?

Aim– To gather personal thoughts from family members/carers of people with dementia that have received music therapy and the effects of using this.

Objectives

• To hold focus groups for family members and carers of dementia service users that have received music therapy and to find their feelings and attitudes towards its effectiveness.
• To analyse findings and to explore if music therapy has an impact on an individual; and to promote more use of music therapy within the care environment.

Methodology

A Qualitative research design will be used for this study to explore the thoughts and feelings of the participants involved to answer the research question/hypotheses. Nind (2017) explained that quantitative research is research ‘with’ rather than ‘for’ people which generates research knowledge that is relevant, meaningful and practical. An advantage for using qualitative research is that it is more employed to achieve deeper insights into issues related to the topic area being researched (Chalhoub-Deville & Deville, 2008). Sallee and Flood (2012) explored the disadvantages to this and found that policy-makers may give low credibility to results from qualitative research.

Kroeze (2012) explored the thoughts of a Quantitative researcher and found that they believe the social world consists of concrete and unchangeable reality, which can be quantified objectively. This research method investigates answers to the questions in a numerical way by looking at: how many, how much and to what extent (Rasinger, 2013). The advantages of this quantitative research method is that the findings are likely to be generalised to a whole population due to it involving a larger sample which is randomly selected (Carr, 1994). However, quantitative research fails to explain deeper underlying meanings and explanations (Bouwer, Béguin, Sanders and van den Bergh, 2015)

According to Balls (2009), a phenomenology is a methodology, which acknowledges and values the meaning that people ascribe to their own experiences. This would be the most appropriate for this study due to looking into the experiences family/carers may have come across and their opinions.

Study Design

A qualitative research design has been chosen to explore the thoughts and feelings of the participants involved to answer the question/hypotheses given. It is shown that qualitative research is the best way of finding this information out, due to it looking at the participants in a holistic way, focusing on their previous experiences and their feelings towards those, but also considering their individual personal backgrounds that they bring into the group (Polik & Beck, 2012). The target population is the families and/or carers of people with dementia who have received/receiving music therapy as a treatment and to hear their opinions, thoughts and feelings on the effects that music therapy has on that individual through the method of a focus group.

Study Methods

Theoretical sampling will be used to achieve the number of participants needed. These participants will be sampled from a dementia support group, which is held in a community hospital. Given (2008) found that theoretical sampling strengthens the consistency of the study, and it can provide structure to data collection and the data analysis processes. This addresses one of the disadvantages of qualitative methods that relate to lack of structure (Given, 2008). However, Saunders, Lewis & Thornhill (2012) found that there is no clear process to follow relating to the application of this sampling.

Interviews are a common way of gaining information from members of society. Scourfield (2001) describes interviews as ‘human’, face to face interaction that enables you to communicate with your participants in depth and gives you opportunity to follow up on some responses given. Berg (2007) confirms that using interviews to collect data, provide in-depth answers. However, Brown (2001) shows that interviews can be very time-consuming, and there is a potential for subconscious bias and potential inconsistencies.

Questionnaires are normally filtered with open-ended, qualitative questions throughout. Bryman (2012) shows that to make sure responses from the questionnaire are data rich, the best thing to do is to keep the number of open-ended questions to an absolute minimum. Sarantakos (2005) found that questionnaires are relatively inexpensive and quick to administer which is a big advantage to using these. Bryman (2012) found that there is a low response rate for questionnaires.

Focus groups are generally used to gather in-depth knowledge about perceptions, beliefs and opinions of individual regarding a particular topic (Ndumele, Ableman, Russell, Gurrola & Hicks, 2011). The focus is the participants in the group, how they interact, to allow them to develop their ideas and questions using their own words within the context of the event they have experienced (Liamputtong, 2011). Doody (2013) said that it is very cost effective, and it is a less intense setting, leaving the participants feeling relaxed which may create more reliability within their answers. However, there is a lack of control with focus groups, this may lead to irrelevant topics being discussed within the group (Liamputtong, 2011). The difficulty to assemble a focus group due to location and time constraints is also a disadvantage that they hold, which Vaughn (2012) discovered.

Focus groups will be used because they are very cost effective and gain in-depth data. To overcome the disadvantages of using a focus group, the researcher will have to take control of the group and make sure that irrelevant topics are not discussed, however the researcher must make sure there is not a potential risk of researcher bias within the data collected. Questions will be asked in the focus group to create a conversation between the participants (Appendix 6).

While engaging participants through theoretical sampling, the sample size needs to be taken into consideration throughout the process. The suggested size for a focus group should be between four and twelve participants (Dilorio, Hockenberry-Eaton, Maiback, & Rivero, 1994). However, Bloor, Frankland, Thomas, and Robson (2001) suggests between six and ten within one group. They stress that a large group of participants often prevents individuals sharing their experiences. Due to this, the families/carers of ten people with dementia will be selected through theoretical sampling.

Data Analysis

Data analysis for this qualitative study will be conducted by using a Narrative analysis. This method involves the reformulation of stories presented by respondents considering the context of each case and different experiences of each respondent. In other words, narrative analysis is the revision of primary qualitative data by the researcher (Sutton & Austin, 2015).

It is understood that it is very important that in a study researcher bias is not involved to create validity to the results gained which will increase generalisability. To make sure this study is more scientifically robust, the researcher would go back to participants and ask if they have interpreted the discussion in a correct manner. This is a chance for participants to correct the researcher if any mistakes are made, ensuring there is no subjectivity from the researcher and again ensuring validity of the results.

Confidentiality, Data Protection & Ethical Considerations

Obtaining consent is vital within research and it involves informing the participant about their rights, the purpose of the study, the procedures to be undertaken, the potential risks and/or benefits of participation and alternative treatments available if any (Berry, 2005).

The Data Protection Act (1998) is designed to protect personal data stored in an organised paper filing system or on a computer. To protect participants under this act, when storing the data collected from the study, the participants will be labelled by numbers instead of names, which will enhance confidentiality (International Committee of Medical Journal Editors, 2017). Following the University’s guidelines, data needs to be retained securely for the next 10 years due to it being subject to sections of the Data Protection Act (1998). After this period, the documents withheld will be destroyed in an appropriate manner.

Notes and transcripts will be taken from the focus group; these would be stored in a secured locked filing container where the researcher only has the key for them. The focus group will also be audio-recorded to ensure the researcher does not miss anything in the notes, this will be destroyed at the end of the project and the transcript will be archived.

Ethical approval will be sort form the universities’ ethics board. Long & Johnson (2007) confirmed that research undertaken within nursing homes must be approved by an ethics committee and meet the legal requirements outlined in the Mental Capacity Act (2005).

Participant recruitment will be conducted through theoretical sampling within a dementia support group within a community hospital. Families and carers of ten people with dementia will be selected through this sampling and will be sent an invitation letter for the study (appendix 4). Only ten families/carers will be used due to not wanting the focus group to be too large. Informed consent will be sought from all participants through signing a form (appendix 5) after explaining the study to each person thoroughly, ensuring the participant understand all stages of the study and making them understand that they are free to withdraw their consent at any time.

Project Timeframe

This study will approximately take 6 months. Ethical approval will be applied for which takes 60 calendar days (Health Research Authority, 2018). Once this has been approved, the recruitment of the participants may take up to 1 month using the method of theoretical sampling. A focus group will then be arranged, with an appropriate time and location given to all participants, which will be within the next 1-2 months after the recruitment (depending on availability of the participants). In months 3 and 4 the data collected from the focus group will be analysed. Within the final 2 months of the process, a report and dissemination will take place to finalise the whole study. With no delays and everything staying on track within the timeframes, the study from start to finish should take 6 months.

To share the information and knowledge which has been gathered from this study, it will be presented within a written article. This means that people interested within the topic area will be able to find this article by using common key words.

Study Limitations

This study does hold some limitations, one being that it is a small sample size that was used. Due to this, the results gained could not be generalisable to other studies. Another limitation is that the family/carers who are in the focus group may not have medical knowledge so may not wish to comment. The results gathered from this may not be reliable or accurate because of this knowledge gap.

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Appendix 1