Research

Study Protocol


Study title:
Exploring the connection between emerging parental identity and parent
musicality across the Neonatal Unit (NU) journey

Short Title:
Parental Identity and Musicality in the Neonatal Unit

Principal Investigator (PI):
Elizabeth McLean, Registered Music Therapist (RMT), Monash Childrens,
Monash Health
PhD Candidate, The University of Melbourne

Supervisors:
Prof. Katrina Skewes McFerran
Dr. Grace Thompson

Site Information:
Monash Childrens Hospital
Monash Medical Centre
246 Clayton Rd, Clayton
VIC 3168

Casey Hospital
Special Care Nursery
62 70 Kangan Drive
Berwick
VIC 3806

Version: Draft 2 (June 2015)




Elizabeth McLean
Study Protocol
Monash Health & The University of Melbourne
Draft Two

Research Aim:
The primary research aim for this study is to examine:

How does fostering parent musicality contribute to emerging parental
identity across the NU journey?

Research Methodology:

Constructivist Grounded Theory
To generate theoretical understandings of this research topic, a Constructivist
Grounded Theory (CGT) methodology will be employed. (Charmaz, 2014). CGT is
a method of analysis focused on theory building with the aim to develop a
detailed understanding of the underlying social or psychological processes
within a certain context by exploring in more detail social interactions and social
structures (Charmaz, 2006). CGT emphasises the coconstruction of a theory that
is both the participants and the researchers stories and views through an
interactive process of data and analysis to construct a shared reality (Charmaz,
2014).

Participants and Recruitment
This will be a multisite study, recruiting participants from within both a level
two and level three NU at Clayton and Casey sites of Monash Health (See site
information above). To examine this research topic, mothers and fathers of
preterm infants admitted to a NU will initially be purposefully recruited. The
inclusion criteria for participants will include:
Mothers and fathers with a preterm infant in the NU at time of
recruitment (Preterm infant will be defined as an infant born at < 35
weeks GA)
Both mothers and fathers who have received music therapy services from
the PI and those who have not received music therapy services at time of
recruitment
Both first and second time parents in the NU at time of recruitment

Recruitment at both sites will involve an independent contractor/s to complete
informed consent procedures.

Data Collection
Data collection will involve individual indepth interviews and focus groups with
eligible participants. This study will apply theoretical sampling which is a central
tenet of classic grounded theory and is a process of data collection for generating
theory whereby the researcher jointly collects, codes and analyses data and then
decides what data to collect next, to develop the emerging theory (Glaser, 1967,
p. 45).

Elizabeth McLean
Study Protocol
Monash Health & The University of Melbourne
Draft Two


Background, Relevance and Justification of the Project:
This proposed grounded theory study will build upon the results of a previous
qualitative study conducted within Monash Health by the PI (HREC #14173L),
exploring parents experiences and perceptions of singing and using their voice
with their baby in a NU. A frequently recurring theme emerged from these
results, highlighting singing and voice as one of the only ways to identify as the
parent to their baby within the NU environment. Furthermore, parents with a
stronger preexisting relationship to music both personally and as an existing
parent, were more inclined to seek musical engagement with their baby to
support their own identity as a parent in the NU. Specifically, results illuminated
singing and voice interactions leading to the validation of a parents identity
through their babys perceived recognition of their unique voice (McLean, 2015).
Parental identity and its potential association or connection with music,
particularly through singing and voice, is currently underrepresented both
within neonatal music therapy research and practice and further afield. This
warrants further exploration to gain a richer theoretical understanding of the
musical conditions and circumstances that may contribute to emerging parental
identity in a NU. Furthermore, results highlighted the early period of a parents
journey through the NU as a critical time for seeking connection with their baby
through singing and voice interactions, while also feeling threatened as the
parent to their baby. These findings argue for future studies that examine the
role of supportive interventions at differing time points for parents in a NU to
ensure quality practice and care.

A seminal body of research exists across multiple theoretical fields of infant
psychotherapy, psychoanalysis and developmental psychology documenting the
musical predispositions of infancy (Papouek, 1996; Trehub, 2001) and the
inherent musicality of parent infant interactions to support a healthy parent
infant relationship (S. N. Malloch, 2000). The intrinsically communicative nature
of musicality has been constructed though extensive theoretical development,
culminating in a theory of communicative musicality which explains adult
infant companionship as mutual musical interactions (S. Malloch & Trevarthen,
2010; Trevarthen & Malloch, 2002). Malloch & Trevarthen (2010) describe
musicality as an innate human ability that makes music production and
appreciation possible. Communicative Musicality provides a theoretical
framework underpinning Malloch et als (2012) study that measured the effect of
live, improvisational contingent singing delivered by a music therapist with full
term and late preterm hospitalized infants in a NICU. While results reported
infants receiving the music therapy intervention were more able to self regulate
during social interactions with adults compared to the control group, this study
did not examine parents role in delivering contingent musical interactions with
their baby which appears central to the theory of communicative musicality. This
raises the question of where the parent sits within this theory of musicality that
Elizabeth McLean
Study Protocol
Monash Health & The University of Melbourne
Draft Two

describes crucial musical mutuality between parent and infant. Further research
is needed to examine the musicality of parents in order to more deeply
understand how to support and foster this musical companionship and
interaction between parent and infant, particularly in the context of premature
birth and neonatology.

While neonatal medicine maximizes an infants chance of survival, this is often to
the severe compromise of the psychological, emotional and social wellbeing of
both the infant and their parent. The parent within a NU is documented as
experiencing an altered transition into parenthood with a lack of emotional and
physical preparation for a NU admission and fears for their newborns safety,
comfort and life (McKechnie, Pridham, & Tluczek, 2014; Vazquez & Cong, 2014;
Whittingham, 2014). Moreover, a wealth of research documents the effects of a
preterm birth and NU admission on a parents ability to create a sympathetic,
contingent and emotionally rich relationship with their baby (S. Malloch et al.,
2012), leading to potential longlasting impact on preterm and atterm infants
development and functioning (Brecht, Shaw, St. John, & Horwitz, 2012; Sikorova
& Kucova, 2012).

Due to the wealth of literature highlighting the detrimental consequences of a
preterm birth and NU experience on both parent and infant wellbeing and
functioning, exploring the experience of parenthood within neonatology is
gaining momentum. In particular, numerous studies exploring a parents sense of
identity and role in a NU have emerged. Early studies have documented delays
and disruptions in maternal identity for mothers of preterm infants related to a
lack of tactile connection with baby (Reid, 2000), denied maternal role
experiences (Zabielski, 1994) and illness related distress associated with babys
fragile medical state (Miles, HolditchDavis, Burchinal, & Nelson, 1999).
Furthermore, Fenwick et als (2008) grounded theory study revealed women
seeking connection with their baby to try and find a place for themselves in
their infants life, as they worked to establish and/or strengthen their tenuous
identity as a mother (p. 74). While significantly less scholarship exists on
fathers within this setting, several studies have documented contributing factors
in supporting fathers in their paternal role in a NU including opportunities for
physical contact with their baby (Crathern, 2009; Helth & Jarden, 2013; Johnson,
2008), positive feedback from their baby during interactions (Feeley, Waitzer,
Sherrard, Boisvert, & Zelkowitz, 2013) and peer support from other parents
(Swartz, 2005; Vazquez & Cong, 2014). What remains missing within neonatal
music therapy scholarship is the way in which a music therapist may foster
emerging parental identity for parents of a preterm infant in a NU through the
appropriation of music and what conditions may support or hinder this.



Elizabeth McLean
Study Protocol
Monash Health & The University of Melbourne
Draft Two

Significance and Contribution of the Project:

It is anticipated that this proposed study exploring a parents musicality and
emerging parental identity across a NU journey will lead to a greater
understanding of a currently absent area of research and practice within both
neonatal music therapy practice and further afield. With powerful results from
the initial inquiry highlighting a connection between developing parental
identity and singing and voice interactions, coupled with a wealth of scholarship
documenting a parents threatened identity and role as a parent to a preterm
infant, this warrants further investigation. Through exploring a parents sense of
musicality and their engagement in musical moments of companionship with
their baby in a NU, this could allow for music therapists and other health
professionals to be more aware of musics potential influence on a parents sense
of role and identity. Moreover, it is intended that this study will allow for greater
exploration of the different stages of a NU journey for parents and how this
relates to delivery of supportive interventions. Specifically, the role of music
therapy services within the neonatal care of preterm infants and their parents
will be more closely explored to contribute to a deeper understanding and
dialogue of optimal times of service delivery across a parent and infants journey
through the NU to ensure best practice, while investigating the role of the music
therapist in fostering a parents musicality in the NU.

References:

Brecht, C. J., Shaw, R. J., St. John, N. H., & Horwitz, S. M. (2012). Effectiveness of
therapeutic and behavioral interventions for parents of low-birth-weight
premature infants: A review. Infant Mental Health Journal, 33(6), 651-665.
doi: 10.1002/imhj.21349
Charmaz, K. (2006). Constructing grounded theory : a practical guide through
qualitative analysis: London : SAGE, 2006.
Elizabeth McLean
Study Protocol
Monash Health & The University of Melbourne
Draft Two

Charmaz, K. (2014). Constructing grounded theory: Los Angeles : Sage, c2014.

2nd ed.
Crathern, L. (2009). Dads matter too: a review of the literature focusing on the
experiences of fathers of preterm infants. MIDIRS Midwifery Digest, 19(2),
159-167.
Feeley, N., Waitzer, E., Sherrard, K., Boisvert, L., & Zelkowitz, P. (2013). Fathers'
perceptions of the barriers and facilitators to their involvement with their
newborn hospitalised in the neonatal intensive care unit. J Clin Nurs, 22(3/4),
521-530. doi: 10.1111/j.1365-2702.2012.04231.x
Fenwick, J., Barclay, L., & Schmied, V. (2008). Craving closeness: a grounded theory
analysis of women's experiences of mothering in the Special Care Nursery.
Women Birth, 21(2), 71-85. doi: 10.1016/j.wombi.2008.03.006
Glaser, B. G. (1967). The discovery of grounded theory : strategies for qualitative
research: Aldine.
Helth, T. D., & Jarden, M. (2013). Fathers' experiences with the skin-to-skin method
in NICU: Competent parenthood and redefined gender roles. Journal of
Neonatal Nursing, 19, 114-121. doi: 10.1016/j.jnn.2012.06.001
Johnson, A. N. (2008). Engaging Fathers in the NICU: Taking Down the Barriers to
the Baby. The Journal of Perinatal & Neonatal Nursing, 22(4), 302-306
310.1097/1001.JPN.0000341361.0000337822.0000341334.
Malloch, S., Shoemark, H., rnec, R., Newnham, C., Paul, C., Prior, M., . . .
Burnham, D. (2012). Music therapy with hospitalized infants-the art and
science of communicative musicality. Infant Mental Health Journal, 33(4),
386-399. doi: 10.1002/imhj.21346
Malloch, S., & Trevarthen, C. (2010). Communicative musicality : exploring the basis
of human companionship: Oxford : Oxford University Press, 2010.
Malloch, S. N. (2000). Mothers and Infants and Communicative Musicality. Musicae
Scientiae, 3(1 suppl), 29-57. doi: 10.1177/10298649000030s104
McKechnie, A. C., Pridham, K., & Tluczek, A. (2014). Preparing Heart and Mind for
Becoming a Parent Following a Diagnosis of Fetal Anomaly. Qualitative
Health Research.
McLean, E. (2015). Exploring Parents' Experiences and Perceptions of Singing and
Using their Voice with their Baby in a Neonatal Unit: An Interperative
Phenomenological Analysis Monograph submitted for publication.
Miles, M. S., Holditch-Davis, D., Burchinal, P., & Nelson, D. (1999). Distress and
growth outcomes in mothers of medically fragile infants. Nursing Research,
48(3), 129-140.
Papouek, H. (1996). Musicality in infancy research: biological and cultural origins
of early musicality: Oxford University Press.
Reid, T. (2000). Maternal identity in preterm birth. Journal of Child Health Care,
4(1), 23-29.
Sikorova, L., & Kucova, J. (2012). The needs of mothers to newborns hospitalised in
intensive care units. Biomedical Papers Of The Medical Faculty Of The
University Palack, Olomouc, Czechoslovakia, 156(4), 330-336. doi:
10.5507/bp.2011.046
Swartz, M. K. (2005). Parenting preterm infants: a meta-synthesis. MCN: The
American Journal of Maternal Child Nursing, 30(2), 115-120.
Trehub, S. E. (2001). Musical predispositions in infancy. Ann N Y Acad Sci, 930, 116.
Trevarthen, C., & Malloch, S. (2002). Musicality and music before three: human
vitality and invention shared with pride. Zero to Three, 23(1), 10-18.
Elizabeth McLean
Study Protocol
Monash Health & The University of Melbourne
Draft Two

Vazquez, V., & Cong, X. (2014). Orginal Article: Parenting the NICU infant: A metaethnographic synthesis. International Journal of Nursing Sciences, 1, 281-290.
doi: 10.1016/j.ijnss.2014.06.001
Whittingham, K. R. M. P. (2014). Parenting and Prematurity: Understanding Parent
Experience and Preferences for Support. Journal of Child & Family Studies,
23(6), 1050-1061. doi: 10.1007/s10826-013-9762-x
Zabielski, M. T. (1994). Recognition of maternal identity in preterm and fullterm
mothers. Maternal-Child Nursing Journal, 22(1), 2-36.

Elizabeth McLean
Study Protocol
Monash Health & The University of Melbourne
Draft Two