- Email: [email protected]
Music
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Music Mary W. Stewart, PhD, RN HOW DO YOU RELAX? When you have had a very trying day at work, do you ever turn on your favorite music to lower the stress level? What about an infant who needs their lullabies to meet the Sandman? If you are lucky enough to get a spa day, what kind of tunes are playing in the background? All of us can relate to the power of music in our lives. From soothing relaxation to motivating us to exercise, music holds an important place in this world. The following authors purposed to capture the influence of music on patients undergoing anesthesia. Intra-operative Music Listening for Anxiety, the BIS Index, and the Vital Signs of Patients Undergoing Regional Anesthesia by Bae I, Man Lim H, Hur M, Lee M. Complementary Therapies in Medicine. 2014;22:251-257. Background and Purpose Surgery is a threatening experience. Consequently, many patients experience uncommon anxiety surrounding the situation. If conscious sedation or local anesthesia is used, the stress can be especially high. Additionally, the sympathetic nervous system is on alert, resulting in elevations in vital signs. Medications may be effective in minimizing anxiety; however, medications have side effects and pose risks for some individuals. Nurses have been engaged in providing alternatives to medications for a long time. Education, massage, presence, aromatherapy, and music have all been Mary W. Stewart, PhD, RN, Professor and Director of PhD Program, and Special Assistant to the Dean, School of Nursing, University of Mississippi Medical Center, Jackson, MS. Conflict of interest: None to report. Address correspondence to Mary W. Stewart, School of Nursing, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505; e-mail address: [email protected]. Ó 2015 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.11.010
Journal of PeriAnesthesia Nursing, Vol 30, No 1 (February), 2015: pp 71-73
documented as potentially efficacious in patients undergoing surgery. Studies of music as an anxiolytic reveal varying results with primarily subjective outcome measures. Furthermore, patients have had choice in regard to the type of music used in the intervention. The purpose of this quasi-experimental study was to describe the effect of music on anxiety and sedation levels in patients undergoing regional anesthesia. These patients did not receive sedative medications. Outcome measures included anxiety level (the State-Trait Anxiety Inventory, STAI—Korean YZ form; and Visual Analog Scale, VAS), sedation level (bispectral index), and vital signs (electrocardiograph and noninvasive blood pressure monitor). Method and Analysis The study took place in a South Korean hospital and included patients who met the following criteria: 1. American Society of Anesthesiologists grade 1 or 2; 2. Ages 20 to 60 years; 3. Scheduled surgery with local spinal, peridural, or brachial plexus anesthesia; 4. Supine position during surgery; 5. No medications that would affect vital signs or bispectral index (BIS); 6. Communicative with freely given consent to participate. Objectivity was strengthened by limiting recruitment to patients previously assigned by non-study personnel to two particular, but similar operating rooms. One operating room was used for the control group and the second operating room for the experimental group. Therefore, researchers knew which patients would receive the intervention. After consent was obtained, both groups received information about the data collection method and the $5 gift for participating. Additionally, the experimental group participants selected the music that they wanted to hear during the procedure from a collection of 10 prerecorded
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MARY W. STEWART
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options. Patients in the experimental group began listening to their musical selection via headphones 15 minutes after entry into the operating room and continued until the end of their time in the operating room. Although participants and staff in the operating area knew group assignments, the individuals who collected study data in the postanesthesia care unit were blind to the assignment. Data were collected over a period of 2 months in 2010. All participants completed the STAI and VAS before surgery. The vital signs and VAS were assessed in the surgical waiting room. On entry to the operating room, patient monitoring was initiated to measure the BIS index, blood pressure, and heart rate. These three variables were recorded every 5 minutes during surgery. Finally, vital signs were recorded on entry to the postanesthesia care unit (PACU) and every 15 minutes until discharge from the PACU. Immediately before leaving the PACU, patients completed the STAI and VAS for a final time. After excluding one participant who received intraoperative warming, 40 patients comprised the experimental group, and 40 patients comprised the control. Researchers used appropriate descriptive and parametric tests to determine differences between and across groups. Results indicated the two groups were similar at baseline on all study variables. However, patients in the experimental and/or music group reported a significantly lower level of anxiety on the VAS (1 to 10) after surgery (mean 5 2.3) compared with their preoperative scores (mean 5 6.0). VAS scores for the control group after surgery (mean 5 5.3) were only slightly lower than their scores before surgery (mean 5 6.5). The change in anxiety scores was also significantly different between the two groups (t 5 28.79, P , .001). Changes in BIS scores differed between the two groups at 30 minutes after the music began (79.7 for music group; 98 for control) and remained lower for the music group until the end of time in the operating room (80.7 for music group; 98.7 for control). Changes in blood pressure reflected a decrease in the music group over time during the intraoperative period. Heart rate was not reported. Conclusions Findings indicated consistency with previous literature on the influence of music on anxiety.
Because patients in this study did not receive any sedatives, one may imply that BIS and blood pressure changes are related to the use of music during the surgical procedure. We do not have qualitative data, eg, patient comments, to analyze in concert with the quantitative findings. Although this study was limited by lack of randomization and blinding to treatment, these researchers were forthcoming about the limitations and study protocol. They also provided detailed information about sampling power and the instruments. The use of headphones, versus piping music into the operating room for everyone to hear, was a useful intervention, tailored to the needs of the particular patient. Intraoperative Stress and Anxiety Reduction with Music Therapy: A Controlled Randomized Clinical Trial of Efficacy and Safety by Jimenez-Jimenez M, Garcıa-Escalona A, MartınL opez A, De Vera-Vera R, De Haro J. Journal of Vascular Nursing. 2013;31:101-106. Background and Purpose The National Association for Music Therapy defines music therapy (MT) as music used to achieve therapeutic objectives, including promotion, restoration, and maintenance of physical and mental health. When music is synchronized with cardiovascular rhythms, sympathetic nervous system activity may decrease and relaxation occurs. Physiologic indicators of this change include lowered levels of heart rate, blood pressure, respirations, oxygen consumption, muscle tension, epinephrine levels, and gastric acidity. Also, listening to music triggers endorphins and decreases difficult feelings through its influence on the limbic system. Recognizing the inherent stress associated with surgery, the researchers aimed to assess if MT affects intraoperative anxiety levels in patients having venous crossectomy and great saphenous vein stripping. Method and Analysis Patients scheduled for elective varicose vein crossectomy with great saphenous vein stripping during a 3-month period at one hospital in Spain comprised the sample. All participants underwent spinal anesthesia without sedation during the procedure; thus, patients were conscious and awake. The participants were randomly assigned
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to one of two groups: (1) control group who received standard care and (2) experimental group who received MT via headphones during the surgery. The MT was operationalized as Henryk Gorecki’s Symphony Number 3, Slow Cantabile Semplice. This particular piece was chosen because of its prior use in research and validated emphasis (uniform vs progressive loudening) and phrasing rhythm (6 cycles per minute), which coincides with hemodynamic fluctuations. Twenty minutes before surgery, each participant was interviewed using a structured survey that included the State-Trait Anxiety Instrument (STAI), a Visual Analog Scale of anxiety, and the investigator-developed Scale of Stress Feeling (a set of closed-ended questions). Similarly, 10 minutes after surgery in the postanesthesia care unit, participants were given the STAI and a set of closed questions. During the operation, the following variables were measured heart rate, blood pressure, respiratory rate, oxygen saturation, and plasma levels of adrenaline and noradrenaline. A second venous blood sample was taken 20 minutes after entry to the postanesthesia care unit. Descriptive and inferential statistics were applied to the data. Results Of the 48 patients eligible for inclusion, 40 consented and completed the study. The authors noted that five of the eligible eight did not comply with the study protocol, but details were not provided. Demographics, baseline hemodynamic levels, and initial STAI scores did not differ between the two groups. Intraoperatively, heart rate and blood pressure remained consistent between the groups. What did differ were the levels of adrenaline and noradrenaline; the MT group had a significantly lower increase among the intraoperative and postoperative values. This differential was adrenaline 113.7 pg/mL in the MT group and 520.5 pg/mL in the control group. Correspondingly, the differential for noradrenaline was 77.2 pg/mL in the MT group and 305.6 pg/mL in the control. The scores on the Scale of Stress Feeling also differed between the two groups, with the MT group feeling less stressed. One aspect of the Scale of Stress Feeling involved the patient’s sense of control over intraoperative anxiety. In the MT group, 94.7% of the
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patients affirmed a sense of control; whereas, 57.9% of those in the control group did. Conclusions As hoped, patients in the MT group reported less anxiety and had smaller increases in catecholamine measures compared with the control group. This may imply that music has a preventative effect on stress-induced changes for patients undergoing this procedure with spinal anesthesia. The use of a well-established piece of music for all patients in the experimental group was a strength to this study. No participants had formal music training, and only a few were familiar with the selected music. Nonetheless, this study offers support to the efficacy of music as an intervention for surgical anxiety.
PeriAnesthesia Nursing Implications It was not surprising that teams that included registered nurses led both studies. A major point of relevance for music therapy in the perianesthesia context is that it is a safe, feasible, economic, and presumably effective nursing intervention. The roles of the surgeon, surgical technician, and anesthesia provider seem to dominate actions that occur in the operating arena. The registered nurse is doing everything else! As a result of those many tasks and the more prominent roles registered nurses have in the preanesthesia and postanesthesia periods, one has little time to consider additional responsibilities. Yet, recognizing the innocuous and easy nature of adding a set of headphones with music opens possibilities for authentic, nursingdriven, improved patient outcomes. Caring for our patients is the central goal of nursing. With that understanding, perianesthesia nurses seek ways to improve the experience of patients undergoing surgery. Musical interventions offer the potential to lower anxiety and heighten sedation in certain patient populations. In addition to the benefits of MT, patients may be spared the negative consequences and side effects of anxiolytic medications. This research represents the valuable contribution that nurse scientists make to practice. The challenge is for those of us in practice. Will we take these findings and evaluate them for our patients?
Music Mary W. Stewart, PhD, RN HOW DO YOU RELAX? When you have had a very trying day at work, do you ever turn on your favorite music to lower the stress level? What about an infant who needs their lullabies to meet the Sandman? If you are lucky enough to get a spa day, what kind of tunes are playing in the background? All of us can relate to the power of music in our lives. From soothing relaxation to motivating us to exercise, music holds an important place in this world. The following authors purposed to capture the influence of music on patients undergoing anesthesia. Intra-operative Music Listening for Anxiety, the BIS Index, and the Vital Signs of Patients Undergoing Regional Anesthesia by Bae I, Man Lim H, Hur M, Lee M. Complementary Therapies in Medicine. 2014;22:251-257. Background and Purpose Surgery is a threatening experience. Consequently, many patients experience uncommon anxiety surrounding the situation. If conscious sedation or local anesthesia is used, the stress can be especially high. Additionally, the sympathetic nervous system is on alert, resulting in elevations in vital signs. Medications may be effective in minimizing anxiety; however, medications have side effects and pose risks for some individuals. Nurses have been engaged in providing alternatives to medications for a long time. Education, massage, presence, aromatherapy, and music have all been Mary W. Stewart, PhD, RN, Professor and Director of PhD Program, and Special Assistant to the Dean, School of Nursing, University of Mississippi Medical Center, Jackson, MS. Conflict of interest: None to report. Address correspondence to Mary W. Stewart, School of Nursing, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216-4505; e-mail address: [email protected]. Ó 2015 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2014.11.010
Journal of PeriAnesthesia Nursing, Vol 30, No 1 (February), 2015: pp 71-73
documented as potentially efficacious in patients undergoing surgery. Studies of music as an anxiolytic reveal varying results with primarily subjective outcome measures. Furthermore, patients have had choice in regard to the type of music used in the intervention. The purpose of this quasi-experimental study was to describe the effect of music on anxiety and sedation levels in patients undergoing regional anesthesia. These patients did not receive sedative medications. Outcome measures included anxiety level (the State-Trait Anxiety Inventory, STAI—Korean YZ form; and Visual Analog Scale, VAS), sedation level (bispectral index), and vital signs (electrocardiograph and noninvasive blood pressure monitor). Method and Analysis The study took place in a South Korean hospital and included patients who met the following criteria: 1. American Society of Anesthesiologists grade 1 or 2; 2. Ages 20 to 60 years; 3. Scheduled surgery with local spinal, peridural, or brachial plexus anesthesia; 4. Supine position during surgery; 5. No medications that would affect vital signs or bispectral index (BIS); 6. Communicative with freely given consent to participate. Objectivity was strengthened by limiting recruitment to patients previously assigned by non-study personnel to two particular, but similar operating rooms. One operating room was used for the control group and the second operating room for the experimental group. Therefore, researchers knew which patients would receive the intervention. After consent was obtained, both groups received information about the data collection method and the $5 gift for participating. Additionally, the experimental group participants selected the music that they wanted to hear during the procedure from a collection of 10 prerecorded
71
MARY W. STEWART
72
options. Patients in the experimental group began listening to their musical selection via headphones 15 minutes after entry into the operating room and continued until the end of their time in the operating room. Although participants and staff in the operating area knew group assignments, the individuals who collected study data in the postanesthesia care unit were blind to the assignment. Data were collected over a period of 2 months in 2010. All participants completed the STAI and VAS before surgery. The vital signs and VAS were assessed in the surgical waiting room. On entry to the operating room, patient monitoring was initiated to measure the BIS index, blood pressure, and heart rate. These three variables were recorded every 5 minutes during surgery. Finally, vital signs were recorded on entry to the postanesthesia care unit (PACU) and every 15 minutes until discharge from the PACU. Immediately before leaving the PACU, patients completed the STAI and VAS for a final time. After excluding one participant who received intraoperative warming, 40 patients comprised the experimental group, and 40 patients comprised the control. Researchers used appropriate descriptive and parametric tests to determine differences between and across groups. Results indicated the two groups were similar at baseline on all study variables. However, patients in the experimental and/or music group reported a significantly lower level of anxiety on the VAS (1 to 10) after surgery (mean 5 2.3) compared with their preoperative scores (mean 5 6.0). VAS scores for the control group after surgery (mean 5 5.3) were only slightly lower than their scores before surgery (mean 5 6.5). The change in anxiety scores was also significantly different between the two groups (t 5 28.79, P , .001). Changes in BIS scores differed between the two groups at 30 minutes after the music began (79.7 for music group; 98 for control) and remained lower for the music group until the end of time in the operating room (80.7 for music group; 98.7 for control). Changes in blood pressure reflected a decrease in the music group over time during the intraoperative period. Heart rate was not reported. Conclusions Findings indicated consistency with previous literature on the influence of music on anxiety.
Because patients in this study did not receive any sedatives, one may imply that BIS and blood pressure changes are related to the use of music during the surgical procedure. We do not have qualitative data, eg, patient comments, to analyze in concert with the quantitative findings. Although this study was limited by lack of randomization and blinding to treatment, these researchers were forthcoming about the limitations and study protocol. They also provided detailed information about sampling power and the instruments. The use of headphones, versus piping music into the operating room for everyone to hear, was a useful intervention, tailored to the needs of the particular patient. Intraoperative Stress and Anxiety Reduction with Music Therapy: A Controlled Randomized Clinical Trial of Efficacy and Safety by Jimenez-Jimenez M, Garcıa-Escalona A, MartınL opez A, De Vera-Vera R, De Haro J. Journal of Vascular Nursing. 2013;31:101-106. Background and Purpose The National Association for Music Therapy defines music therapy (MT) as music used to achieve therapeutic objectives, including promotion, restoration, and maintenance of physical and mental health. When music is synchronized with cardiovascular rhythms, sympathetic nervous system activity may decrease and relaxation occurs. Physiologic indicators of this change include lowered levels of heart rate, blood pressure, respirations, oxygen consumption, muscle tension, epinephrine levels, and gastric acidity. Also, listening to music triggers endorphins and decreases difficult feelings through its influence on the limbic system. Recognizing the inherent stress associated with surgery, the researchers aimed to assess if MT affects intraoperative anxiety levels in patients having venous crossectomy and great saphenous vein stripping. Method and Analysis Patients scheduled for elective varicose vein crossectomy with great saphenous vein stripping during a 3-month period at one hospital in Spain comprised the sample. All participants underwent spinal anesthesia without sedation during the procedure; thus, patients were conscious and awake. The participants were randomly assigned
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to one of two groups: (1) control group who received standard care and (2) experimental group who received MT via headphones during the surgery. The MT was operationalized as Henryk Gorecki’s Symphony Number 3, Slow Cantabile Semplice. This particular piece was chosen because of its prior use in research and validated emphasis (uniform vs progressive loudening) and phrasing rhythm (6 cycles per minute), which coincides with hemodynamic fluctuations. Twenty minutes before surgery, each participant was interviewed using a structured survey that included the State-Trait Anxiety Instrument (STAI), a Visual Analog Scale of anxiety, and the investigator-developed Scale of Stress Feeling (a set of closed-ended questions). Similarly, 10 minutes after surgery in the postanesthesia care unit, participants were given the STAI and a set of closed questions. During the operation, the following variables were measured heart rate, blood pressure, respiratory rate, oxygen saturation, and plasma levels of adrenaline and noradrenaline. A second venous blood sample was taken 20 minutes after entry to the postanesthesia care unit. Descriptive and inferential statistics were applied to the data. Results Of the 48 patients eligible for inclusion, 40 consented and completed the study. The authors noted that five of the eligible eight did not comply with the study protocol, but details were not provided. Demographics, baseline hemodynamic levels, and initial STAI scores did not differ between the two groups. Intraoperatively, heart rate and blood pressure remained consistent between the groups. What did differ were the levels of adrenaline and noradrenaline; the MT group had a significantly lower increase among the intraoperative and postoperative values. This differential was adrenaline 113.7 pg/mL in the MT group and 520.5 pg/mL in the control group. Correspondingly, the differential for noradrenaline was 77.2 pg/mL in the MT group and 305.6 pg/mL in the control. The scores on the Scale of Stress Feeling also differed between the two groups, with the MT group feeling less stressed. One aspect of the Scale of Stress Feeling involved the patient’s sense of control over intraoperative anxiety. In the MT group, 94.7% of the
73
patients affirmed a sense of control; whereas, 57.9% of those in the control group did. Conclusions As hoped, patients in the MT group reported less anxiety and had smaller increases in catecholamine measures compared with the control group. This may imply that music has a preventative effect on stress-induced changes for patients undergoing this procedure with spinal anesthesia. The use of a well-established piece of music for all patients in the experimental group was a strength to this study. No participants had formal music training, and only a few were familiar with the selected music. Nonetheless, this study offers support to the efficacy of music as an intervention for surgical anxiety.
PeriAnesthesia Nursing Implications It was not surprising that teams that included registered nurses led both studies. A major point of relevance for music therapy in the perianesthesia context is that it is a safe, feasible, economic, and presumably effective nursing intervention. The roles of the surgeon, surgical technician, and anesthesia provider seem to dominate actions that occur in the operating arena. The registered nurse is doing everything else! As a result of those many tasks and the more prominent roles registered nurses have in the preanesthesia and postanesthesia periods, one has little time to consider additional responsibilities. Yet, recognizing the innocuous and easy nature of adding a set of headphones with music opens possibilities for authentic, nursingdriven, improved patient outcomes. Caring for our patients is the central goal of nursing. With that understanding, perianesthesia nurses seek ways to improve the experience of patients undergoing surgery. Musical interventions offer the potential to lower anxiety and heighten sedation in certain patient populations. In addition to the benefits of MT, patients may be spared the negative consequences and side effects of anxiolytic medications. This research represents the valuable contribution that nurse scientists make to practice. The challenge is for those of us in practice. Will we take these findings and evaluate them for our patients?