- Email: [email protected]
The effect of different types of music on patients' preoperative anxiety: A randomized controlled trial
Accepted Manuscript The effect of different types of music on patients' preoperative anxiety: A randomized controlled trial Gülay Altun Uğraş, Güven Yıldırım, Serpil Yüksel, Yusuf Öztürkçü, Mustafa Kuzdere, Seher Deniz Öztekin PII:
S1744-3881(18)30066-5
DOI:
10.1016/j.ctcp.2018.02.012
Reference:
CTCP 835
To appear in:
Complementary Therapies in Clinical Practice
Received Date: 24 January 2018 Accepted Date: 13 February 2018
Please cite this article as: Uğraş GüAltun, Yıldırım Gü, Yüksel S, Öztürkçü Y, Kuzdere M, Öztekin SD, The effect of different types of music on patients' preoperative anxiety: A randomized controlled trial, Complementary Therapies in Clinical Practice (2018), doi: 10.1016/j.ctcp.2018.02.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE PAGE TITLE: The Effect of Different Music Types on Patients’ Preoperative Anxiety: A Randomized Controlled Trial* *Presented (only summary) at The 8thCongress of the European Operating Room Nurses
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Association “The Colossus of Perioperative Nursing” 2017 in Rhodes Island, Greece. AUTHORS: Gülay Altun Uğraş, PhD, RN,
Assistant Professor, Mersin University, Health School of Surgical Nursing Department,
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Mersin, Turkey.
Postal address: Mersin Üniversitesi Sağlık Yüksekokulu, Hemşirelik Bölümü Cerrahi
Turkey. E-mail: [email protected]
Güven Yıldırım, MD,
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Hastalıkları Hemşireliği Anabilim Dalı, Çiftlikköy Kampüsü, 33169 Yenişehir/Mersin,
Associate Professor, Giresun University, Giresun Medical Faculty, Department of
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Otolaringology, Giresun, Turkey.
Postal address: Giresun Üniversitesi, Giresun Tıp Fakültesi, KBB Anabilim Dalı, Gazi Yerleşkesi, Giresun, Turkey.
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E-mail: [email protected]
Serpil Yüksel, PhD, RN,
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AssistantProfessor, Necmettin Erbakan University, Faculty of Health Science, Division of Nursing, Department of Surgical Nursing, Konya, Turkey. Postal address:Necmettin Erbakan Üniversitesi, Sağlık Bilimleri Fakültesi, Cerrahi Hastalıkları Hemşireliği Anabilim Dalı, İhsaniye Mah. Kazım Karabekir Cad. 42040. Selçuklu/Konya, Turkey.
E-mail: [email protected]
Yusuf Öztürkçü, MD MedicalDoctor, Haseki Training and Research Hospital, Department of Otolaringology, İstanbul, Turkey.
ACCEPTED MANUSCRIPT Postal address: Haseki Training and Research Hospital, Department of Otolaringology, İstanbul, Turkey. E-mail: [email protected] Mustafa Kuzdere, MD
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Medical Doctor, Selahattin Pınar Cad. Sağlık Apt. No: 6/4 Mecidiyeköy/Şişli, İstanbul, Turkey.
Postal address: Selahattin Pınar Cad. Sağlık Apt. No: 6/4 Mecidiyeköy/Şişli, İstanbul,
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Turkey.
Seher Deniz Öztekin, PhD, RN,
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E-mail:[email protected]
Professor, Istanbul University Florence Nightingale Faculty of Nursing, Department of Surgical Nursing, Istanbul, Turkey.
Postal address: Istanbul University Florence Nightingale Faculty of Nursing, Department of
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Surgical Nursing, Abidei Hürriyet Caddesi, 34381, Şişli, Istanbul, Turkey. E-mail:[email protected]
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CORRESPONDENCE AUTHOR:
Gülay Altun Uğraş, PhD, RN, Assistant Professor, Mersin University, Health School of Surgical Nursing Department, Mersin, Turkey.
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e-mail:[email protected] Telephone number: +90 505 217 01 88 Faxnumber: +90 3243610571 FUNDING:This research did not receive any specific Grant from funding agencies in the public, commercial, or not-for-profit sectors. CONFLICT OF INTEREST: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.
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The Effect of Different Types of Music on Patients’ Preoperative Anxiety: A Randomized Controlled Trial Objective: The purpose of this study was to determine effect of three different types of music on
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patients’ preoperative anxiety. Method: This randomized controlled trial included 180 patients who were randomly divided into four groups. While the control group didn’t listen to music, the experimental groups respectively listened to natural sounds, Classical Turkish or Western Music for 30 minutes. The State Anxiety
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Inventory (STAI-S), systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) and cortisol levels were checked.
Findings: The post-music STAI-S, SBP, DBP, HR and cortisol levels of the patients in music
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groups were significantly lower than pre-music time. All types of music decreased STAI-S, SBP, and cortisol levels; additionally natural sounds reduced DBP; Classical Turkish Music also decreased DBP, and HR.
Conclusions: All types of music had an effect on reducing patients’ preoperative anxiety, and listening to Classical Turkish Music was particularly the most effective one.
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Key Words: Music, preoperative anxiety, blood pressure, heart rate, cortisol levels.
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1. Introduction Surgical intervention leads to anxiety no matter what the cause of any disease is. Anxiety in the preoperative period is due to various reasons such as the possibility of postoperative pain, loss of independence and control, fear of uncertainty, fear of death, a change in the body image,
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undesired diagnosis and inability to return to normal life [9,13-15, 20]. High preoperative anxiety causes negative physiological manifestations such as an increase in patients’ serum cortisol levels, blood pressures and heart rates. Furthermore, since anxious patients report more pain during the postoperative period, the use of analgesics, the risk of infection and complication
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development and the incidence of sleep problems can increase, the wound healing can be delayed and the duration of hospitalization can be prolonged [2,4,13-15,20].
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Various pharmacological agents can be used in order to bring patients’ anxiety under control in the preoperative period. These medications frequently have negative effects on the postoperative recovery process [4]. Music, on the other hand, is an effective non-pharmacological method with a high level of proof in decreasing preoperative anxiety and no side effects [2,4]. Music suppresses the sympathetic branch of the autonomic nervous system, which is activated by anxiety, and shows a positive impact by activating the parasympathetic branch that stimulates the
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relaxation response [19]. Music distracts patients’ attention from pain and anxiety, eliminates the feeling of being in an unfamiliar environment, increases their adaptation to the environment and helps them relax [4,9,13,19]. Thus, music creates some physiological responses such as decreased
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blood pressure, heart rate and respiration rate as well as its psychological effect such as decreasing anxiety [14,15,19]. Furthermore, especially in the course of listening to music with
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headphones, the noisy movements of healthcare staff in the waiting hall of the operating room and the ambient noise can be masked. Therefore, the anxiety caused by external agents can be prevented [9,19].
A systematic review of 25 studies on the effect of music in reducing the anxiety felt by
adult patients in waiting areas showed that music reduced anxiety (STAI-S; −5.1±0.53 points) [2]. Also, a Cochrane Database of Systematic Reviews with 26 randomized controlled experimental studies reported that music might be an alternative to sedative and anti-anxiety drugs in reducing the preoperative anxiety [4]. Another study found that preoperative anxiety was reduced significantly in Turkish patients who were allowed to listen to music of their own choice 2
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[1]. However, that study did not make it clear which type of music was more effective in reducing anxiety (e.g., Turkish Classical Music, Folk Music, Turkish Art Music or Pop Music). Many factors such as individual characteristics (e.g., age, gender, education, etc.), emotional status, music choice and culture may affect patients’ response to music [4,6]. In the light of these
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considerations, the aim of this study was to determine which of the three different types of music that Turkish patients listened to in surgery waiting room during the preoperative period had more impact on State Anxiety Inventory, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) and serum cortisol levels.
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2. Method
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2.1. Study design
This was a randomized controlled trial study designed to determine the effect of different types of music that patients listened to in surgery waiting room during the preoperative period on their anxiety levels. 2.2. Participants
The research sample consisted of patients who met the research inclusion criteria, stayed
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in Otorhinolaryngology Department of a public hospital in Istanbul, Turkey between November 2013 and May 2015 and received elective surgery. Based on Ni et al.’s (2011) [15] study, when the sample size was taken as at least 80% power and Type I error value as 2.5% (bi-directional), a
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total of 180 patients were divided into four groups, each of which consisted of 45 patients [21]. On the other hand, 32 patients were excluded from the sample because they were taken to the operation room before their preoperative data collection processes were completed although they
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had already given their consents to participate in the study, and another five patients were excluded from the sample because they were unwilling to participate in the study (Figure 1). 2.3. Data collection tools
The data collection tools used in this study include:
(1) Demographic information: Age, gender, marital status, educational status, diagnosis, and operational type of the patients.
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(2) The patients’ physiological responses of anxiety to music: SBP, DBP, HR and serum cortisol levels. (3) State-Trait Anxiety Inventory (STAI): This scale was developed by Spielberger et al. in 1970
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to measure state and trait anxiety levels. In 1983, it was adapted to Turkish by Öner and Le Compte. This Likert scale is split into “State Anxiety Inventory” (STAI-S)” and “Trait Anxiety Inventory” (STAI-T)”, each having 20 items [1,14,15]. STAI-S, which determines how the respondents “feel right now”, was used in this study. Participants rated their anxiety levels on a 4point scale ranging from 1 (not at all) to 4 (the most). The score ranged from 20 to 80 points and
variables of the STAI-S was 0.89 for this study.
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2.4. Study protocol
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the higher scores indicated higher levels of anxiety [12]. Total Cronbach’s Alpha value for all the
First, all the patients were taken to the surgery waiting room and then STAI-S was applied and SBP, DBP, HR were measured. At the same time, blood samples were taken in order to determine the patients’ serum cortisol levels.
The patients meeting the inclusion criteria were divided into four groups as three
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experimental groups and one control group according to the randomization table made on computer [21]. The decisions on which type of music to be listened by the three experimental groups were made through random draws. The 1st experimental group listened to 3rd part of the “Relaxing Exercises CD” prepared by Turkish Psychologists Association. This part consists of
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relaxing music consisting of natural sounds only. The 2nd experimental group listened to samples of Classical Turkish Music, which were played by reed flute in tune Hüseyni and used in similar
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previous studies to create a sense of tranquility and relaxation [22,23]. The 3rd experimental group listened to samples of Classical Western Music (e.g., Four Seasons from Vivaldi), which were also used in previous studies [3,8]. The control group, however, did not listen to any music at all. While choosing the types of music for this study, the following suggestions were considered for the selection criteria: slow and fluent, including no lyrics, made up of instrumental or natural sounds, lasting at least 30 minutes into consideration and a tempo of 60–80 beats per minute [5,9,13,15,16]. The patients listened to music with headphones closing the ear completely so that the patients would not be affected by the environmental stimuli. The volume level of the music was adjusted according to the patients’ preferences. 4
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Finally, all the patients were administered the STAI-S again 30 minutes after the first measurement. Also, their SBP, DBP and HR were measured again and their blood samples were retaken to check their serum cortisol levels.
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2.5. Ethical considerations Written permission to use the relaxation exercise CD was obtained from the Turkish Psychologists Association. Before beginning the study, the required permissions were taken from Istanbul Health Directorate and the Ethics Committees of Istanbul University Cerrahpaşa School
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of Medicine (Number: 23649). Finally, written and oral permissions were obtained from all the patients who participated in the study.
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2.6. Data analysis
Descriptive data were expressed in frequency, percentage, mean and standard deviation. The homogeneous distribution of the demographic data over the groups was checked by Pearson’s Chi-square test for categorical data and by one-way analysis of variance (ANOVA) for continuous data. Even though the participants in the study were distributed randomly to the groups, which is clinically not important, significant differences in their ages, educational
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statuses and diagnoses were found between the experimental groups and the control group (p<0.05) (Table 1). This difference was due to the fact that the number of samples falling into each group was not too large. In order to prevent this from affecting the results of the study, the effects of age, gender and education were adjusted by the model analysis while comparing the
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pre- and post-music mean values between the groups analyzed with ANOVA. The differences between pre-music and post-music STAI-S, SBP, DBP, HR and serum cortisol levels for each
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group were calculated. The effects of music between the experimental groups and the control group were analyzed with ANOVA and Post Hoc Tukey HSD tests. The results were evaluated in 95% confidence interval, and at 0.05 Type I error level. 3. Results
Patients’ demographic characteristics The mean age of the patients was 35.7±11.2 years. Most of the patients were male (70.6%), and 71.1% were married, 65% were primary school graduate and most of their diagnosis was septum deviation (73.3%) (Table 1).
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State anxiety While post-music STAI-S scores decreased compared to pre-music period in the music groups, this score increased in the control group. There was a statistically significant difference
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between the pre-music and post-music STAI-S values of the control and the music groups (p<0.001). In the post-hoc analysis, it was determined that the types of music significantly reducing the STAI-S scores were Classical Turkish Music, Classical Western Music and natural sounds, respectively (p<0.001) (Table 2).
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Physiologic response
Post-music SBP, DBP, HR and cortisol levels decreased compared to pre-music period in the music groups. However, these values increased in the control group. There was a statistically
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significant difference between the pre-music and post-music SBP, DBP, HR and cortisol levels of the control and the music groups (p<0.001; p=0.003; p=0.039; p<0.001, respectively). As the post-hoc analysis indicated, natural sounds, Classical Turkish Music and Classical Western Music significantly reduced the patients’ SBP, respectively; natural sounds and Classical Turkish Music significantly decreased the patients’ DBP and only Classical Turkish Music reduced the
4. Discussion
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patients’ HR (Table 2).
Music is an effective, simple, noninvasive and cheap method in reducing preoperative anxiety [2,4,9,11,14,19]. In the current study, different types of music that the patients listened to
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showed significant difference on the psychological and physiological parameters of anxiety. The patients being more affected by Classical Turkish Music proved the reality of people’s being
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affected more from the music of their own culture [10]. State Anxiety
Similar to the previous studies [1,5,9,11,14,15,19], music significantly reduced
preoperative anxiety and STAI-S score of all the patients who listened to music compared to premusic time in the current study. Various types of music like classical music [9,11,14], relaxing music (e.g., new age, calm, soothing) [5,9,12,13,17], jazz, religious and natural sounds [14], low-tone, slow rhythm pop songs [13,15], folk music [1,13] were listened by patients in previous studies on the effect of 6
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music on preoperative anxiety. Preoperative anxiety is caused by the feeling of insecurity because of patients’ being in a different environment like surgery waiting room. This is why a familiar music listened by a patient may decrease anxiety by helping him or her regain autonomy [19]. What is more, music provides relaxation by calming the heart when it does not have high
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dynamic amplitude and has 60-80 beats per minute [5]. In their integrative review on the effect of music on preoperative anxiety, Pittman and Kridli (2011) [20] stated that STAI-S score decreased in patients who listened to music. In a similar study, it was found that classical and new age music played to the patients in surgery waiting room, who underwent elective surgery, lowered
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anxiety [9]. In another study, it was shown that relaxing music was just as effective as midazolam in reducing preoperative anxiety [5]. McClurkin and Smith (2016) [14] also indicated that STAI-
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S score of the day surgery patients listening to types of music of their own choice (e.g., jazz, classical, religious and natural sounds) for 30 minutes was significantly lower than those listening to music for only 15 minutes. Similarly, Arslan et al. (2008) [1] stated that music decreased preoperative anxiety significantly in Turkish patients listening to types of music of their own choice (e.g., Turkish Classical Music, Folk Music, Turkish Art Music, and Pop Music). In these studies, music was implied to be effective in decreasing STAI-S score, but it was not clear which
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type of music was the most effective in this sense [1,14]. Ciğerci and Özbayır (2016) [6] found that music did not decrease STAI-S score significantly in coroner artery surgery patients listening to Classical Turkish Music and Turkish Folk Music for an hour before the operation and every day for 30 minutes until their discharge. However, in the mentioned study [6], STAI-S was only
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applied within the first 24 hours prior to the surgery, and no pre- or post-music evaluation was repeated. This shows that the effect of music on preoperative anxiety was not detected in the
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study. Firmeza et al. (2017) [8] found that Classical Western Music sample (Vivaldi) was influential in lowering anxiety in patients with head and neck cancer. Similarly, in the current study, was determined that Classical Turkish Music including reed flute, natural sounds and Classical Western Music (Vivaldi) were effective in decreasing preoperative anxiety, but that Classical Turkish music was more effective. As individuals’ music preference is impacted by their social and cultural structures of the society [10], this result is important to show that the type of music peculiar to the Turkish culture was more influential in reducing preoperative anxiety in Turkish patients.
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Physiologic Response Various physiologic variables have been very frequently used in studies on the effect of music on anxiety [5,8,9,13-15]. While anxiety’s stimulating the sympathetic branch of autonomous nerve system causes physiological responses like increase in blood pressure, HR and
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breathing rate; music decreases these responses by activating parasympathetic branch [9,15,19]. In the current study, when compared with the control group, SBP, DBP, HR and serum cortisol levels of all the patients listening to music, independent from the type of music, decreased compared to pre-music time. This decline in the vital signs indicates that patients can cope with
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anxiety more effectively as a result of the impact of familiar melodies and rhythmic music on autonomous nerve system.
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Previous studies [5,8,915] showed that SBP of the patients listening to different types of music was reduced significantly. Similar studies [8,14] also determined that natural sounds and Classical Western Music caused a significant decrease in SBP, but DBP was not affected at all [8]. A systematic review on the subject reported that music caused an average of 4.82 mmHg difference in SBP, but the difference was not significant [4]. In the present study, it was found
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that Classical Turkish music and natural sounds lowered SBP and DBP, and Classical Western Music only decreased SBP significantly.
The relevant literature findings are inconsistent in terms of the music effect on HR. A Cochrane Database of Systematic Reviews remarked that the effect of music on HR was low and
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there was inconsistency in the results [4]. However, in an integrative review, music was reported to lower HR in preoperative period [20]. In similar studies [5,13,14] relaxing music was found to
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decrease HR. In contrast to these findings, the present study showed that natural sounds, in characteristics of relaxing music, did not impact HR, but only Classical Turkish Music reduced HR. This result suggests that music peculiar to the Turkish culture was more effective on HR of the patients.
Anxiety and stress experienced in preoperative period causes increase in serum cortisol
and catecholamines [2,20]. One of the most commonly used biomarkers in the evaluation of the stress effect is cortisol [4]. However, the findings of the studies showing the music’s effect on decreasing anxiety on serum cortisol levels are limited. In a systematic review examining the
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impact of music on anxiety and pain, cortisol levels was checked in only 4 of the 12 randomized controlled studies on anxiety [16]. Similar to the previous studies [12,17], in the current study, the serum cortisol levels of the patients listening to music were determined to be significantly lower. Additionally, the types of music decreasing cortisol levels most were identified as Classical
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Turkish Music, Classical Western Music and natural sounds, respectively. The relevant result indicates that the most effective type of music in reducing serum cortisol levels in the patients was a type of music related to the Turkish culture. Considering the limited literature on the subject, future research could focus on determining the types of music that are most effective in
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reducing serum cortisol levels. 5. Research limitations
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The present study has a few limitations. One of these was that the types of music listened by the patients were chosen based on the literature suggestions instead of asking them what kind of music they preferred despite the literature reporting that the music preferred is more effective on anxiety. However, the critical appraisal of studies examining the effect of music on anxiety stated that the chosen type of soothing music does not impact the effectiveness of music, and it was concluded that the effective music was enough to have slow rhythms [7]. Another limitation
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of this study was that the music was listened only in preoperative period, not during intraoperative and postoperative periods. Finally, the music was listened only in an otolaryngology department, so it cannot be generalized to other groups of patients.
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6. Relevance to clinical practice
Patients experience high anxiety during the preoperative period. Surgical nurses should
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provide care for reducing anxiety to control the complications that may occur in the postoperative period. It is beneficial that the use of music -a simple, effective, noninvasive and cheap method in decreasing preoperative anxiety, negatively affecting preoperative period – is popularized. While the types of music listened by the patients in a surgery waiting room are chosen, it should be paid attention that, as well as being the type the patient prefers, it should be slow, fluent and instrumental, made up of natural sounds with no lyrics, it should have a pace of 60-80 beats/min, and it should be suitable to the cultural characteristics of patients. It is advised that studies examining the effect of music peculiar to the culture of different patient groups on preoperative anxiety are conducted in the future.
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7. Conclusion This study demonstrated that Classical Turkish Music, natural sounds and Classical Western Music are effective in decreasing the preoperative anxiety of patients and in keeping
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SBP and serum cortisol levels in normal limits. Classical Turkish Music in particular is the most effective one that reduced the patient’s preoperative anxiety and in providing normal DBP, HR, and serum cortisol levels. Conflict of interest statement
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The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.
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Acknowledgement
We would like to thank Rukiye Gulsen Altun for her assistance in providing language counseling
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and Professor Arzu Kanık for statistical counseling.
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References [1] S. N. Arslan, Özer, F. Özyurt, Effect of music on preoperative anxiety in men undergoing urogenital surgery, Australian Journal of Advanced Nursing. 26 (2008) 46-54.
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[2] E. Biddiss, T.J. Knibbe, A. McPherson, The effectiveness of interventions aimed at reducing anxiety in health care waiting spaces: a systematic review of randomized and nonrandomized trials. Anesth Analg. 119 (2014) 433-448.
[3] W.S. Bittencourt, M.A. Salício, S. de Freitas Pinheiro, D. Lell, O efeito da música clássica no
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alívio da dor de crianças com câncer. UNICiências. 14 (2010) 95-111.
[4] J. Bradt, C. Dileo, M. Shim, Music interventions for preoperative anxiety (review). Cochrane
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Database of Systematic Reviews. 6 (2013) CD006908.
[5] H. Bringman, K. Giesecke, A. Thörne, S. Bringman, Relaxing music as pre-medication before surgery: a randomised controlled trial. Acta Anaesthesiol Scand, 53 (2009) 759-764. [6] Y. Ciğerci, T. Özbayır, The effects of music therapy on anxiety, pain and the amount of analgesics following coronary artery surgery. Turkish Journal of Thoracic and
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Cardiovascular Surgery. 24 (2016) 44-50.
[7] M. Cooke, W. Chaboyer, M.A. Hiratos, Music and its effect on anxiety in short waiting periods: a critical appraisal. J Clin Nurs. 14 (2005) 145-155.
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[8] M.A. Firmeza, A.B. Rodrigues, G.A.A. Melo, M.I.F. Aguiar, G.H. Cunha, P.P. Oliveira, A.S.M. Grangeiro, Control of anxiety through music in a head and neck outpatient clinic: a randomized clinical trial. Rev Esc Enferm USP. 51 (2017) e03201.
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[9] G. Kipnis, N. Tabak, S. Koton, Background music playback in the preoperative setting: does it reduce the level of preoperative anxiety among candidates for elective surgery? J Perianesth Nurs. 31 (2016) 209-216. [10] H. Koç, G. Erk, Y. Apaydın, E. Horasanlı, B. Yiğitbaşı, B. Dikmen, Epidural anestezi ile herni operasyonu uygulanan hastalarda klasik Türk müziğinin intraoperatif sedasyon üzerine etkileri. Türk Anest Rean Der Dergisi. 37 (2009) 366-373.
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[11] C. Kongsawatvorakul, C. Charakorn, K. Paiwattananupant, N. Lekskul, S. Rattanasiri, A. Lertkhachonsuk, Limited impact of music therapy on patient anxiety with the large loop excision of transformation zone procedure - a randomized controlled trial. Asian Pac J Cancer Prev. 17 (2016) 2853-2856.
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[12] S. Leardi, R. Pietroletti, G. Angeloni, S. Necozione, G. Ranalletta, B. Del Gusto, Randomized clinical trial examining the effect of music therapy in stress response to day surgery. Br J Surg. 94 (2007) 943–947.
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[13] K.C. Lee, Y.H. Chao, J.J. Yiin, H.Y. Hsieh, W.J. Dai, Y.F. Chao, Evidence that music listening reduces preoperative patients' anxiety. Biol Res Nurs. 14 (2012) 78-84.
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[14] S.L. McClurkin, C.D. Smith, The duration of self-selected music needed to reduce preoperative anxiety. J Perianesth Nurs. 31 (2016) 196-208.
[15] C.H. Ni, W.H. Tsai, L.M. Lee, C.C. Kao, Y.C. Chen, Minimising preoperative anxiety with music for day surgery patients – a randomised clinical trial. J Clin Nurs. 21 (2011) 620-625. [16] U. Nilsson, The anxiety- and pain-reducing effects of music interventions: a systematic
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review. AORN J. 87 (2008) 780-807.
[17] U. Nilsson, The effect of music intervention in stres response to cardiac surgery in a randomized clinical trial. Heart Lung. 38 (2009) 201–207. [18] N. Öner, A. Le Compte, Süreksiz Durumluluk/Sürekli Kaygı Envanteri. 2. Basım, Boğaziçi
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Üniversitesi Yayınevi, İstanbul, 1998. [19] B.J. Palmer, D. Lane, D. Mayo, M. Schluchter, R. Leeming, Effects of music therapy on
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anesthesia requirements and anxiety in women undergoing ambulatory breast surgery for cancer diagnosis and treatment: a randomized controlled trial. J Clin Oncol. 33 (2015) 31623168.
[20] S. Pittman, S. Kridli, Music intervention and preoperative anxiety: an integrative review. Int Nurs Rev. 58 (2011) 157-163. [21] www.e-picos.com
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[22] M. Yıldız, D. Yılmaz, The effects of classical and Turkish music samples on the autonomic nervous system. In Biomedical Engineering Meeting, (2009) 1-4. [23] D. Yılmaz, M. Yıldız, K. Işıldak, The effect of classical Turkish musics on the autonomic
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nervous system. In Signal Processing and Communications Applications Conference, (2009)
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973-976.
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Table 1. Demographic characteristics of the patients (n=180)
Age (years) *
Total
35.7±11.2
Classical
Classical
Control
Test
Sounds
Turkish
Western
Group
p value
Music
Music
36.3±10.8
33.4±11.8
40.5±13.0
F=4.758
32.7±6.9
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Characteristics
Natural
p=0.003
Gender † 53 (29.4%)
9 (20%)
12(26.7%)
16 (35.6%)
16 (35.5%)
x2=1.237
Male
127 (70.6%)
36 (80%)
33(73.3%)
29 (64.4%)
29 (64.4%)
p=0.298
Single
52(28.9%)
10(22.2%)
12(26.7%)
17(37.8%)
13(28.9%)
x2=0.931
Married
128(71.1%)
35(77.8%)
33(73.3%)
28(62.2%)
32(71.1%)
p=0.427
117(65.0%)
35(77.8%)
22(48.9%)
28(62.2%)
32(71.1%)
x2=2.886
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Marital status†
Education† Elementary
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Female
school
p=0.037
49(27.2%)
6(13.3%)
19(42.2%)
13(28.9%)
11(24.4%)
University
14(7.8%)
4(8.9%)
4(8.9%)
4(8.9%)
2(4.4%)
35(77.8%)
26(57.8%)
Septum deviation Chronic sinusitis
18(10.0%)
16(8.9%)
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Chronic
132(73.3)
41(91.1%)
0(0%)
30(66.7%)
x2=4.949 p=0.003
4(8.9%)
4(8.9%)
10(22.2%)
3(6.7%)
4(8.9%)
2(4.4%)
7(15.6%)
1(2.2%)
7(15.6%)
4(8.9%)
2(4.4%)
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Diagnosis
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High school
tonsillitis Othersѱ
14(7.8%)
Data are presented as mean±SD. *One-way analysis of variance (ANOVA) was used in the analysis. †
Pearson Chi-square was used in the analysis.
ѱ
Others items included were antrochoanal polyp (n=3), concha hypertrophy (n=2), larynx cancer
(n=2), nasal polyposis (n=2), paratis tumor (n=2), submandibular mass (n=2), neck cyst (n=1).
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Table 2.The comparison of patients’ pre-Music and post-music STAI-S, SBP, DBP, HR, cortisol levels Natural Soundsa Classical Turkish
Classical
Control
Musicb
Western Musicc
State Anxiety Inventory-State
F/p
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Variables
Groupd
difference
F=16.801†
39.11±4.71
41.71±9.89
41.93±9,51
Post- music
34.38±5.71
35.44±7.66
35.71±10.28
44.09±6.47
Effect*
-4.73±3.21
-6.27±5.37
-6.22±5.63
0.56±6.44
Pre-music
115.77±11.02
115.82±12.18
112.89±9.91
113.00±8.49
F=17.857†
Post- music
104.88±13.46
107.77±7.80
109.33±9,86
115.44±9.99
p<0.001
-10.89±8.74
-8.04±12.54
-3.56±7.43
2.44±7.20
Pre-music
73.67±7.34
76.56±9.50
72.89±8.15
72.11±8.49
Post- music
69.89±10.79
72.11±7.94
72.44±10.04
73.89±8,91
-3.78±9.36
-4.44±10.31
-0.44±8.52
1.78±7.32
Effect* Heart rate
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Diastolic blood pressure
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Effect*
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Pre-music
Systolic blood pressure
43.51±6.64
Significant
b>c>a>d
p<0.001
a>b>c>d
F= 4.783†p=0.003
b>a>d
b>d
Pre-music
77.00±5.46
80.13±7.42
78.44±5.57
78.31±5.69
F= 2.840†
Post- music
75.33±7.22
77.93±4,36
78.04±6,84
79.18±5.54
p= 0.039
Effect*
-1.67±7.75
-2.20±5.82
-0.40±4.21
0.86±2.72
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Cortisol levels
10.66±2.74
11.58±2.85
11.45±3.03
10.24±3.33
F= 12.491†p<0.001
Pre-music 9.17±2.66
9.74±2.70
9.76±2.86
Effect*
-1.49±2.60
-1.84±2.76
-1.69±2.63
1.25±3.13
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Data are presented as mean±SD.
11.49±3.43
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Post- music
b>c>a>d
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Significant difference between pre- and post-music effects in each groups using one-way analysis of variance (ANOVA), p < 0.05.
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†
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* Effect is the difference calculated by subtracting the pre-music values from the post-music ones.
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Figure 1. The sample flow chart
- A total of 32 patients whose consents were already obtained but taken to the operation room before the completion of preoperative data collection
n=180 patients
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- Five patients unwilling to participate
Patients excluded from study - have been diagnosed with anxiety and panic attack and using drugs against anxiety, - have a hearing loss and/or use a hearing aid, - have surgical operation aimed at the ear, - have an emergency surgical operation, - has had professional music training, - have had surgical operation before.
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N= 217 patients
Patients included in the study - are willing to take participate, - are open to communication, - have been operated for the first time, - are having elective surgery, - are 18-65 years old, - are able to read and write in Turkish, - have no problems hindering cognitive, affective and verbal communication, - have not taken any sedative drugs before surgery.
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Complete STAI-S Measure SBP, DBP, HR Take blood samples for cortisol levels
2nd group Classical Turkish Music
3rd group Classical Western Music
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1st group Natural sounds
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Divided into four groups randomly
No music played
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The music played to the patients with headphones for 30 minutes
4th group Control group
Complete STAI-S Measure SBP, DBP, HR Take blood samples for cortisol levels
1
S1744-3881(18)30066-5
DOI:
10.1016/j.ctcp.2018.02.012
Reference:
CTCP 835
To appear in:
Complementary Therapies in Clinical Practice
Received Date: 24 January 2018 Accepted Date: 13 February 2018
Please cite this article as: Uğraş GüAltun, Yıldırım Gü, Yüksel S, Öztürkçü Y, Kuzdere M, Öztekin SD, The effect of different types of music on patients' preoperative anxiety: A randomized controlled trial, Complementary Therapies in Clinical Practice (2018), doi: 10.1016/j.ctcp.2018.02.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT TITLE PAGE TITLE: The Effect of Different Music Types on Patients’ Preoperative Anxiety: A Randomized Controlled Trial* *Presented (only summary) at The 8thCongress of the European Operating Room Nurses
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Association “The Colossus of Perioperative Nursing” 2017 in Rhodes Island, Greece. AUTHORS: Gülay Altun Uğraş, PhD, RN,
Assistant Professor, Mersin University, Health School of Surgical Nursing Department,
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Mersin, Turkey.
Postal address: Mersin Üniversitesi Sağlık Yüksekokulu, Hemşirelik Bölümü Cerrahi
Turkey. E-mail: [email protected]
Güven Yıldırım, MD,
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Hastalıkları Hemşireliği Anabilim Dalı, Çiftlikköy Kampüsü, 33169 Yenişehir/Mersin,
Associate Professor, Giresun University, Giresun Medical Faculty, Department of
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Otolaringology, Giresun, Turkey.
Postal address: Giresun Üniversitesi, Giresun Tıp Fakültesi, KBB Anabilim Dalı, Gazi Yerleşkesi, Giresun, Turkey.
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E-mail: [email protected]
Serpil Yüksel, PhD, RN,
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AssistantProfessor, Necmettin Erbakan University, Faculty of Health Science, Division of Nursing, Department of Surgical Nursing, Konya, Turkey. Postal address:Necmettin Erbakan Üniversitesi, Sağlık Bilimleri Fakültesi, Cerrahi Hastalıkları Hemşireliği Anabilim Dalı, İhsaniye Mah. Kazım Karabekir Cad. 42040. Selçuklu/Konya, Turkey.
E-mail: [email protected]
Yusuf Öztürkçü, MD MedicalDoctor, Haseki Training and Research Hospital, Department of Otolaringology, İstanbul, Turkey.
ACCEPTED MANUSCRIPT Postal address: Haseki Training and Research Hospital, Department of Otolaringology, İstanbul, Turkey. E-mail: [email protected] Mustafa Kuzdere, MD
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Medical Doctor, Selahattin Pınar Cad. Sağlık Apt. No: 6/4 Mecidiyeköy/Şişli, İstanbul, Turkey.
Postal address: Selahattin Pınar Cad. Sağlık Apt. No: 6/4 Mecidiyeköy/Şişli, İstanbul,
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Turkey.
Seher Deniz Öztekin, PhD, RN,
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E-mail:[email protected]
Professor, Istanbul University Florence Nightingale Faculty of Nursing, Department of Surgical Nursing, Istanbul, Turkey.
Postal address: Istanbul University Florence Nightingale Faculty of Nursing, Department of
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Surgical Nursing, Abidei Hürriyet Caddesi, 34381, Şişli, Istanbul, Turkey. E-mail:[email protected]
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CORRESPONDENCE AUTHOR:
Gülay Altun Uğraş, PhD, RN, Assistant Professor, Mersin University, Health School of Surgical Nursing Department, Mersin, Turkey.
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e-mail:[email protected] Telephone number: +90 505 217 01 88 Faxnumber: +90 3243610571 FUNDING:This research did not receive any specific Grant from funding agencies in the public, commercial, or not-for-profit sectors. CONFLICT OF INTEREST: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.
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The Effect of Different Types of Music on Patients’ Preoperative Anxiety: A Randomized Controlled Trial Objective: The purpose of this study was to determine effect of three different types of music on
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patients’ preoperative anxiety. Method: This randomized controlled trial included 180 patients who were randomly divided into four groups. While the control group didn’t listen to music, the experimental groups respectively listened to natural sounds, Classical Turkish or Western Music for 30 minutes. The State Anxiety
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Inventory (STAI-S), systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) and cortisol levels were checked.
Findings: The post-music STAI-S, SBP, DBP, HR and cortisol levels of the patients in music
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groups were significantly lower than pre-music time. All types of music decreased STAI-S, SBP, and cortisol levels; additionally natural sounds reduced DBP; Classical Turkish Music also decreased DBP, and HR.
Conclusions: All types of music had an effect on reducing patients’ preoperative anxiety, and listening to Classical Turkish Music was particularly the most effective one.
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Key Words: Music, preoperative anxiety, blood pressure, heart rate, cortisol levels.
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1. Introduction Surgical intervention leads to anxiety no matter what the cause of any disease is. Anxiety in the preoperative period is due to various reasons such as the possibility of postoperative pain, loss of independence and control, fear of uncertainty, fear of death, a change in the body image,
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undesired diagnosis and inability to return to normal life [9,13-15, 20]. High preoperative anxiety causes negative physiological manifestations such as an increase in patients’ serum cortisol levels, blood pressures and heart rates. Furthermore, since anxious patients report more pain during the postoperative period, the use of analgesics, the risk of infection and complication
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development and the incidence of sleep problems can increase, the wound healing can be delayed and the duration of hospitalization can be prolonged [2,4,13-15,20].
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Various pharmacological agents can be used in order to bring patients’ anxiety under control in the preoperative period. These medications frequently have negative effects on the postoperative recovery process [4]. Music, on the other hand, is an effective non-pharmacological method with a high level of proof in decreasing preoperative anxiety and no side effects [2,4]. Music suppresses the sympathetic branch of the autonomic nervous system, which is activated by anxiety, and shows a positive impact by activating the parasympathetic branch that stimulates the
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relaxation response [19]. Music distracts patients’ attention from pain and anxiety, eliminates the feeling of being in an unfamiliar environment, increases their adaptation to the environment and helps them relax [4,9,13,19]. Thus, music creates some physiological responses such as decreased
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blood pressure, heart rate and respiration rate as well as its psychological effect such as decreasing anxiety [14,15,19]. Furthermore, especially in the course of listening to music with
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headphones, the noisy movements of healthcare staff in the waiting hall of the operating room and the ambient noise can be masked. Therefore, the anxiety caused by external agents can be prevented [9,19].
A systematic review of 25 studies on the effect of music in reducing the anxiety felt by
adult patients in waiting areas showed that music reduced anxiety (STAI-S; −5.1±0.53 points) [2]. Also, a Cochrane Database of Systematic Reviews with 26 randomized controlled experimental studies reported that music might be an alternative to sedative and anti-anxiety drugs in reducing the preoperative anxiety [4]. Another study found that preoperative anxiety was reduced significantly in Turkish patients who were allowed to listen to music of their own choice 2
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[1]. However, that study did not make it clear which type of music was more effective in reducing anxiety (e.g., Turkish Classical Music, Folk Music, Turkish Art Music or Pop Music). Many factors such as individual characteristics (e.g., age, gender, education, etc.), emotional status, music choice and culture may affect patients’ response to music [4,6]. In the light of these
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considerations, the aim of this study was to determine which of the three different types of music that Turkish patients listened to in surgery waiting room during the preoperative period had more impact on State Anxiety Inventory, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR) and serum cortisol levels.
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2. Method
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2.1. Study design
This was a randomized controlled trial study designed to determine the effect of different types of music that patients listened to in surgery waiting room during the preoperative period on their anxiety levels. 2.2. Participants
The research sample consisted of patients who met the research inclusion criteria, stayed
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in Otorhinolaryngology Department of a public hospital in Istanbul, Turkey between November 2013 and May 2015 and received elective surgery. Based on Ni et al.’s (2011) [15] study, when the sample size was taken as at least 80% power and Type I error value as 2.5% (bi-directional), a
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total of 180 patients were divided into four groups, each of which consisted of 45 patients [21]. On the other hand, 32 patients were excluded from the sample because they were taken to the operation room before their preoperative data collection processes were completed although they
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had already given their consents to participate in the study, and another five patients were excluded from the sample because they were unwilling to participate in the study (Figure 1). 2.3. Data collection tools
The data collection tools used in this study include:
(1) Demographic information: Age, gender, marital status, educational status, diagnosis, and operational type of the patients.
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(2) The patients’ physiological responses of anxiety to music: SBP, DBP, HR and serum cortisol levels. (3) State-Trait Anxiety Inventory (STAI): This scale was developed by Spielberger et al. in 1970
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to measure state and trait anxiety levels. In 1983, it was adapted to Turkish by Öner and Le Compte. This Likert scale is split into “State Anxiety Inventory” (STAI-S)” and “Trait Anxiety Inventory” (STAI-T)”, each having 20 items [1,14,15]. STAI-S, which determines how the respondents “feel right now”, was used in this study. Participants rated their anxiety levels on a 4point scale ranging from 1 (not at all) to 4 (the most). The score ranged from 20 to 80 points and
variables of the STAI-S was 0.89 for this study.
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2.4. Study protocol
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the higher scores indicated higher levels of anxiety [12]. Total Cronbach’s Alpha value for all the
First, all the patients were taken to the surgery waiting room and then STAI-S was applied and SBP, DBP, HR were measured. At the same time, blood samples were taken in order to determine the patients’ serum cortisol levels.
The patients meeting the inclusion criteria were divided into four groups as three
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experimental groups and one control group according to the randomization table made on computer [21]. The decisions on which type of music to be listened by the three experimental groups were made through random draws. The 1st experimental group listened to 3rd part of the “Relaxing Exercises CD” prepared by Turkish Psychologists Association. This part consists of
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relaxing music consisting of natural sounds only. The 2nd experimental group listened to samples of Classical Turkish Music, which were played by reed flute in tune Hüseyni and used in similar
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previous studies to create a sense of tranquility and relaxation [22,23]. The 3rd experimental group listened to samples of Classical Western Music (e.g., Four Seasons from Vivaldi), which were also used in previous studies [3,8]. The control group, however, did not listen to any music at all. While choosing the types of music for this study, the following suggestions were considered for the selection criteria: slow and fluent, including no lyrics, made up of instrumental or natural sounds, lasting at least 30 minutes into consideration and a tempo of 60–80 beats per minute [5,9,13,15,16]. The patients listened to music with headphones closing the ear completely so that the patients would not be affected by the environmental stimuli. The volume level of the music was adjusted according to the patients’ preferences. 4
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Finally, all the patients were administered the STAI-S again 30 minutes after the first measurement. Also, their SBP, DBP and HR were measured again and their blood samples were retaken to check their serum cortisol levels.
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2.5. Ethical considerations Written permission to use the relaxation exercise CD was obtained from the Turkish Psychologists Association. Before beginning the study, the required permissions were taken from Istanbul Health Directorate and the Ethics Committees of Istanbul University Cerrahpaşa School
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of Medicine (Number: 23649). Finally, written and oral permissions were obtained from all the patients who participated in the study.
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2.6. Data analysis
Descriptive data were expressed in frequency, percentage, mean and standard deviation. The homogeneous distribution of the demographic data over the groups was checked by Pearson’s Chi-square test for categorical data and by one-way analysis of variance (ANOVA) for continuous data. Even though the participants in the study were distributed randomly to the groups, which is clinically not important, significant differences in their ages, educational
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statuses and diagnoses were found between the experimental groups and the control group (p<0.05) (Table 1). This difference was due to the fact that the number of samples falling into each group was not too large. In order to prevent this from affecting the results of the study, the effects of age, gender and education were adjusted by the model analysis while comparing the
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pre- and post-music mean values between the groups analyzed with ANOVA. The differences between pre-music and post-music STAI-S, SBP, DBP, HR and serum cortisol levels for each
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group were calculated. The effects of music between the experimental groups and the control group were analyzed with ANOVA and Post Hoc Tukey HSD tests. The results were evaluated in 95% confidence interval, and at 0.05 Type I error level. 3. Results
Patients’ demographic characteristics The mean age of the patients was 35.7±11.2 years. Most of the patients were male (70.6%), and 71.1% were married, 65% were primary school graduate and most of their diagnosis was septum deviation (73.3%) (Table 1).
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State anxiety While post-music STAI-S scores decreased compared to pre-music period in the music groups, this score increased in the control group. There was a statistically significant difference
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between the pre-music and post-music STAI-S values of the control and the music groups (p<0.001). In the post-hoc analysis, it was determined that the types of music significantly reducing the STAI-S scores were Classical Turkish Music, Classical Western Music and natural sounds, respectively (p<0.001) (Table 2).
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Physiologic response
Post-music SBP, DBP, HR and cortisol levels decreased compared to pre-music period in the music groups. However, these values increased in the control group. There was a statistically
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significant difference between the pre-music and post-music SBP, DBP, HR and cortisol levels of the control and the music groups (p<0.001; p=0.003; p=0.039; p<0.001, respectively). As the post-hoc analysis indicated, natural sounds, Classical Turkish Music and Classical Western Music significantly reduced the patients’ SBP, respectively; natural sounds and Classical Turkish Music significantly decreased the patients’ DBP and only Classical Turkish Music reduced the
4. Discussion
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patients’ HR (Table 2).
Music is an effective, simple, noninvasive and cheap method in reducing preoperative anxiety [2,4,9,11,14,19]. In the current study, different types of music that the patients listened to
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showed significant difference on the psychological and physiological parameters of anxiety. The patients being more affected by Classical Turkish Music proved the reality of people’s being
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affected more from the music of their own culture [10]. State Anxiety
Similar to the previous studies [1,5,9,11,14,15,19], music significantly reduced
preoperative anxiety and STAI-S score of all the patients who listened to music compared to premusic time in the current study. Various types of music like classical music [9,11,14], relaxing music (e.g., new age, calm, soothing) [5,9,12,13,17], jazz, religious and natural sounds [14], low-tone, slow rhythm pop songs [13,15], folk music [1,13] were listened by patients in previous studies on the effect of 6
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music on preoperative anxiety. Preoperative anxiety is caused by the feeling of insecurity because of patients’ being in a different environment like surgery waiting room. This is why a familiar music listened by a patient may decrease anxiety by helping him or her regain autonomy [19]. What is more, music provides relaxation by calming the heart when it does not have high
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dynamic amplitude and has 60-80 beats per minute [5]. In their integrative review on the effect of music on preoperative anxiety, Pittman and Kridli (2011) [20] stated that STAI-S score decreased in patients who listened to music. In a similar study, it was found that classical and new age music played to the patients in surgery waiting room, who underwent elective surgery, lowered
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anxiety [9]. In another study, it was shown that relaxing music was just as effective as midazolam in reducing preoperative anxiety [5]. McClurkin and Smith (2016) [14] also indicated that STAI-
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S score of the day surgery patients listening to types of music of their own choice (e.g., jazz, classical, religious and natural sounds) for 30 minutes was significantly lower than those listening to music for only 15 minutes. Similarly, Arslan et al. (2008) [1] stated that music decreased preoperative anxiety significantly in Turkish patients listening to types of music of their own choice (e.g., Turkish Classical Music, Folk Music, Turkish Art Music, and Pop Music). In these studies, music was implied to be effective in decreasing STAI-S score, but it was not clear which
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type of music was the most effective in this sense [1,14]. Ciğerci and Özbayır (2016) [6] found that music did not decrease STAI-S score significantly in coroner artery surgery patients listening to Classical Turkish Music and Turkish Folk Music for an hour before the operation and every day for 30 minutes until their discharge. However, in the mentioned study [6], STAI-S was only
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applied within the first 24 hours prior to the surgery, and no pre- or post-music evaluation was repeated. This shows that the effect of music on preoperative anxiety was not detected in the
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study. Firmeza et al. (2017) [8] found that Classical Western Music sample (Vivaldi) was influential in lowering anxiety in patients with head and neck cancer. Similarly, in the current study, was determined that Classical Turkish Music including reed flute, natural sounds and Classical Western Music (Vivaldi) were effective in decreasing preoperative anxiety, but that Classical Turkish music was more effective. As individuals’ music preference is impacted by their social and cultural structures of the society [10], this result is important to show that the type of music peculiar to the Turkish culture was more influential in reducing preoperative anxiety in Turkish patients.
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Physiologic Response Various physiologic variables have been very frequently used in studies on the effect of music on anxiety [5,8,9,13-15]. While anxiety’s stimulating the sympathetic branch of autonomous nerve system causes physiological responses like increase in blood pressure, HR and
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breathing rate; music decreases these responses by activating parasympathetic branch [9,15,19]. In the current study, when compared with the control group, SBP, DBP, HR and serum cortisol levels of all the patients listening to music, independent from the type of music, decreased compared to pre-music time. This decline in the vital signs indicates that patients can cope with
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anxiety more effectively as a result of the impact of familiar melodies and rhythmic music on autonomous nerve system.
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Previous studies [5,8,915] showed that SBP of the patients listening to different types of music was reduced significantly. Similar studies [8,14] also determined that natural sounds and Classical Western Music caused a significant decrease in SBP, but DBP was not affected at all [8]. A systematic review on the subject reported that music caused an average of 4.82 mmHg difference in SBP, but the difference was not significant [4]. In the present study, it was found
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that Classical Turkish music and natural sounds lowered SBP and DBP, and Classical Western Music only decreased SBP significantly.
The relevant literature findings are inconsistent in terms of the music effect on HR. A Cochrane Database of Systematic Reviews remarked that the effect of music on HR was low and
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there was inconsistency in the results [4]. However, in an integrative review, music was reported to lower HR in preoperative period [20]. In similar studies [5,13,14] relaxing music was found to
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decrease HR. In contrast to these findings, the present study showed that natural sounds, in characteristics of relaxing music, did not impact HR, but only Classical Turkish Music reduced HR. This result suggests that music peculiar to the Turkish culture was more effective on HR of the patients.
Anxiety and stress experienced in preoperative period causes increase in serum cortisol
and catecholamines [2,20]. One of the most commonly used biomarkers in the evaluation of the stress effect is cortisol [4]. However, the findings of the studies showing the music’s effect on decreasing anxiety on serum cortisol levels are limited. In a systematic review examining the
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impact of music on anxiety and pain, cortisol levels was checked in only 4 of the 12 randomized controlled studies on anxiety [16]. Similar to the previous studies [12,17], in the current study, the serum cortisol levels of the patients listening to music were determined to be significantly lower. Additionally, the types of music decreasing cortisol levels most were identified as Classical
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Turkish Music, Classical Western Music and natural sounds, respectively. The relevant result indicates that the most effective type of music in reducing serum cortisol levels in the patients was a type of music related to the Turkish culture. Considering the limited literature on the subject, future research could focus on determining the types of music that are most effective in
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reducing serum cortisol levels. 5. Research limitations
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The present study has a few limitations. One of these was that the types of music listened by the patients were chosen based on the literature suggestions instead of asking them what kind of music they preferred despite the literature reporting that the music preferred is more effective on anxiety. However, the critical appraisal of studies examining the effect of music on anxiety stated that the chosen type of soothing music does not impact the effectiveness of music, and it was concluded that the effective music was enough to have slow rhythms [7]. Another limitation
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of this study was that the music was listened only in preoperative period, not during intraoperative and postoperative periods. Finally, the music was listened only in an otolaryngology department, so it cannot be generalized to other groups of patients.
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6. Relevance to clinical practice
Patients experience high anxiety during the preoperative period. Surgical nurses should
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provide care for reducing anxiety to control the complications that may occur in the postoperative period. It is beneficial that the use of music -a simple, effective, noninvasive and cheap method in decreasing preoperative anxiety, negatively affecting preoperative period – is popularized. While the types of music listened by the patients in a surgery waiting room are chosen, it should be paid attention that, as well as being the type the patient prefers, it should be slow, fluent and instrumental, made up of natural sounds with no lyrics, it should have a pace of 60-80 beats/min, and it should be suitable to the cultural characteristics of patients. It is advised that studies examining the effect of music peculiar to the culture of different patient groups on preoperative anxiety are conducted in the future.
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7. Conclusion This study demonstrated that Classical Turkish Music, natural sounds and Classical Western Music are effective in decreasing the preoperative anxiety of patients and in keeping
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SBP and serum cortisol levels in normal limits. Classical Turkish Music in particular is the most effective one that reduced the patient’s preoperative anxiety and in providing normal DBP, HR, and serum cortisol levels. Conflict of interest statement
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The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.
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Acknowledgement
We would like to thank Rukiye Gulsen Altun for her assistance in providing language counseling
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and Professor Arzu Kanık for statistical counseling.
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References [1] S. N. Arslan, Özer, F. Özyurt, Effect of music on preoperative anxiety in men undergoing urogenital surgery, Australian Journal of Advanced Nursing. 26 (2008) 46-54.
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[2] E. Biddiss, T.J. Knibbe, A. McPherson, The effectiveness of interventions aimed at reducing anxiety in health care waiting spaces: a systematic review of randomized and nonrandomized trials. Anesth Analg. 119 (2014) 433-448.
[3] W.S. Bittencourt, M.A. Salício, S. de Freitas Pinheiro, D. Lell, O efeito da música clássica no
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alívio da dor de crianças com câncer. UNICiências. 14 (2010) 95-111.
[4] J. Bradt, C. Dileo, M. Shim, Music interventions for preoperative anxiety (review). Cochrane
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Database of Systematic Reviews. 6 (2013) CD006908.
[5] H. Bringman, K. Giesecke, A. Thörne, S. Bringman, Relaxing music as pre-medication before surgery: a randomised controlled trial. Acta Anaesthesiol Scand, 53 (2009) 759-764. [6] Y. Ciğerci, T. Özbayır, The effects of music therapy on anxiety, pain and the amount of analgesics following coronary artery surgery. Turkish Journal of Thoracic and
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Cardiovascular Surgery. 24 (2016) 44-50.
[7] M. Cooke, W. Chaboyer, M.A. Hiratos, Music and its effect on anxiety in short waiting periods: a critical appraisal. J Clin Nurs. 14 (2005) 145-155.
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[8] M.A. Firmeza, A.B. Rodrigues, G.A.A. Melo, M.I.F. Aguiar, G.H. Cunha, P.P. Oliveira, A.S.M. Grangeiro, Control of anxiety through music in a head and neck outpatient clinic: a randomized clinical trial. Rev Esc Enferm USP. 51 (2017) e03201.
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[9] G. Kipnis, N. Tabak, S. Koton, Background music playback in the preoperative setting: does it reduce the level of preoperative anxiety among candidates for elective surgery? J Perianesth Nurs. 31 (2016) 209-216. [10] H. Koç, G. Erk, Y. Apaydın, E. Horasanlı, B. Yiğitbaşı, B. Dikmen, Epidural anestezi ile herni operasyonu uygulanan hastalarda klasik Türk müziğinin intraoperatif sedasyon üzerine etkileri. Türk Anest Rean Der Dergisi. 37 (2009) 366-373.
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[11] C. Kongsawatvorakul, C. Charakorn, K. Paiwattananupant, N. Lekskul, S. Rattanasiri, A. Lertkhachonsuk, Limited impact of music therapy on patient anxiety with the large loop excision of transformation zone procedure - a randomized controlled trial. Asian Pac J Cancer Prev. 17 (2016) 2853-2856.
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[12] S. Leardi, R. Pietroletti, G. Angeloni, S. Necozione, G. Ranalletta, B. Del Gusto, Randomized clinical trial examining the effect of music therapy in stress response to day surgery. Br J Surg. 94 (2007) 943–947.
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[13] K.C. Lee, Y.H. Chao, J.J. Yiin, H.Y. Hsieh, W.J. Dai, Y.F. Chao, Evidence that music listening reduces preoperative patients' anxiety. Biol Res Nurs. 14 (2012) 78-84.
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[14] S.L. McClurkin, C.D. Smith, The duration of self-selected music needed to reduce preoperative anxiety. J Perianesth Nurs. 31 (2016) 196-208.
[15] C.H. Ni, W.H. Tsai, L.M. Lee, C.C. Kao, Y.C. Chen, Minimising preoperative anxiety with music for day surgery patients – a randomised clinical trial. J Clin Nurs. 21 (2011) 620-625. [16] U. Nilsson, The anxiety- and pain-reducing effects of music interventions: a systematic
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review. AORN J. 87 (2008) 780-807.
[17] U. Nilsson, The effect of music intervention in stres response to cardiac surgery in a randomized clinical trial. Heart Lung. 38 (2009) 201–207. [18] N. Öner, A. Le Compte, Süreksiz Durumluluk/Sürekli Kaygı Envanteri. 2. Basım, Boğaziçi
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Üniversitesi Yayınevi, İstanbul, 1998. [19] B.J. Palmer, D. Lane, D. Mayo, M. Schluchter, R. Leeming, Effects of music therapy on
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anesthesia requirements and anxiety in women undergoing ambulatory breast surgery for cancer diagnosis and treatment: a randomized controlled trial. J Clin Oncol. 33 (2015) 31623168.
[20] S. Pittman, S. Kridli, Music intervention and preoperative anxiety: an integrative review. Int Nurs Rev. 58 (2011) 157-163. [21] www.e-picos.com
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[22] M. Yıldız, D. Yılmaz, The effects of classical and Turkish music samples on the autonomic nervous system. In Biomedical Engineering Meeting, (2009) 1-4. [23] D. Yılmaz, M. Yıldız, K. Işıldak, The effect of classical Turkish musics on the autonomic
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nervous system. In Signal Processing and Communications Applications Conference, (2009)
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973-976.
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Table 1. Demographic characteristics of the patients (n=180)
Age (years) *
Total
35.7±11.2
Classical
Classical
Control
Test
Sounds
Turkish
Western
Group
p value
Music
Music
36.3±10.8
33.4±11.8
40.5±13.0
F=4.758
32.7±6.9
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Characteristics
Natural
p=0.003
Gender † 53 (29.4%)
9 (20%)
12(26.7%)
16 (35.6%)
16 (35.5%)
x2=1.237
Male
127 (70.6%)
36 (80%)
33(73.3%)
29 (64.4%)
29 (64.4%)
p=0.298
Single
52(28.9%)
10(22.2%)
12(26.7%)
17(37.8%)
13(28.9%)
x2=0.931
Married
128(71.1%)
35(77.8%)
33(73.3%)
28(62.2%)
32(71.1%)
p=0.427
117(65.0%)
35(77.8%)
22(48.9%)
28(62.2%)
32(71.1%)
x2=2.886
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Marital status†
Education† Elementary
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Female
school
p=0.037
49(27.2%)
6(13.3%)
19(42.2%)
13(28.9%)
11(24.4%)
University
14(7.8%)
4(8.9%)
4(8.9%)
4(8.9%)
2(4.4%)
35(77.8%)
26(57.8%)
Septum deviation Chronic sinusitis
18(10.0%)
16(8.9%)
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Chronic
132(73.3)
41(91.1%)
0(0%)
30(66.7%)
x2=4.949 p=0.003
4(8.9%)
4(8.9%)
10(22.2%)
3(6.7%)
4(8.9%)
2(4.4%)
7(15.6%)
1(2.2%)
7(15.6%)
4(8.9%)
2(4.4%)
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Diagnosis
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High school
tonsillitis Othersѱ
14(7.8%)
Data are presented as mean±SD. *One-way analysis of variance (ANOVA) was used in the analysis. †
Pearson Chi-square was used in the analysis.
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Others items included were antrochoanal polyp (n=3), concha hypertrophy (n=2), larynx cancer
(n=2), nasal polyposis (n=2), paratis tumor (n=2), submandibular mass (n=2), neck cyst (n=1).
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Table 2.The comparison of patients’ pre-Music and post-music STAI-S, SBP, DBP, HR, cortisol levels Natural Soundsa Classical Turkish
Classical
Control
Musicb
Western Musicc
State Anxiety Inventory-State
F/p
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Variables
Groupd
difference
F=16.801†
39.11±4.71
41.71±9.89
41.93±9,51
Post- music
34.38±5.71
35.44±7.66
35.71±10.28
44.09±6.47
Effect*
-4.73±3.21
-6.27±5.37
-6.22±5.63
0.56±6.44
Pre-music
115.77±11.02
115.82±12.18
112.89±9.91
113.00±8.49
F=17.857†
Post- music
104.88±13.46
107.77±7.80
109.33±9,86
115.44±9.99
p<0.001
-10.89±8.74
-8.04±12.54
-3.56±7.43
2.44±7.20
Pre-music
73.67±7.34
76.56±9.50
72.89±8.15
72.11±8.49
Post- music
69.89±10.79
72.11±7.94
72.44±10.04
73.89±8,91
-3.78±9.36
-4.44±10.31
-0.44±8.52
1.78±7.32
Effect* Heart rate
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Diastolic blood pressure
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Effect*
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Pre-music
Systolic blood pressure
43.51±6.64
Significant
b>c>a>d
p<0.001
a>b>c>d
F= 4.783†p=0.003
b>a>d
b>d
Pre-music
77.00±5.46
80.13±7.42
78.44±5.57
78.31±5.69
F= 2.840†
Post- music
75.33±7.22
77.93±4,36
78.04±6,84
79.18±5.54
p= 0.039
Effect*
-1.67±7.75
-2.20±5.82
-0.40±4.21
0.86±2.72
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Cortisol levels
10.66±2.74
11.58±2.85
11.45±3.03
10.24±3.33
F= 12.491†p<0.001
Pre-music 9.17±2.66
9.74±2.70
9.76±2.86
Effect*
-1.49±2.60
-1.84±2.76
-1.69±2.63
1.25±3.13
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Data are presented as mean±SD.
11.49±3.43
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Post- music
b>c>a>d
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Significant difference between pre- and post-music effects in each groups using one-way analysis of variance (ANOVA), p < 0.05.
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†
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* Effect is the difference calculated by subtracting the pre-music values from the post-music ones.
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Figure 1. The sample flow chart
- A total of 32 patients whose consents were already obtained but taken to the operation room before the completion of preoperative data collection
n=180 patients
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- Five patients unwilling to participate
Patients excluded from study - have been diagnosed with anxiety and panic attack and using drugs against anxiety, - have a hearing loss and/or use a hearing aid, - have surgical operation aimed at the ear, - have an emergency surgical operation, - has had professional music training, - have had surgical operation before.
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N= 217 patients
Patients included in the study - are willing to take participate, - are open to communication, - have been operated for the first time, - are having elective surgery, - are 18-65 years old, - are able to read and write in Turkish, - have no problems hindering cognitive, affective and verbal communication, - have not taken any sedative drugs before surgery.
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Complete STAI-S Measure SBP, DBP, HR Take blood samples for cortisol levels
2nd group Classical Turkish Music
3rd group Classical Western Music
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1st group Natural sounds
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Divided into four groups randomly
No music played
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The music played to the patients with headphones for 30 minutes
4th group Control group
Complete STAI-S Measure SBP, DBP, HR Take blood samples for cortisol levels
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