Music therapy for patients undergoing regional anesthesia

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Music therapy for patients undergoing regional anesthesia ospital admission and surgical procedures are wellknown stressors, and regional anesthesia, which allows patients to be aware of thcir surroundings, is even more stressful. We attempted to rcduce the fear and anxiety levels of patients by allowing them to listcn to their favorite music during their surgical procedures. The results we obtained were positive. Undergoing a surgical procedure, even a minor one, can cause abnormal stress levels in patients. Some patients would rather risk their health or their lives than undergo surgery because of their fears. This is particularly true of surgical procedures in which regional or local anesthesia is used and patients are conscious of their surroundings. This increase in anxiety and stress is due mainly to three causes: fear of ancsthcsia, fear of eventual pathological findings in the procedure, and fear of pain and discomfort. One of the challcnges perioperative nurses face is finding ways to minimize patient anxiety and ensure that patients are as comfortable as possible throughout their surgical procedures. Allowing patients to listen to music while undergoing surgical procedures and regional anesthesia may constitute an effective means of reducing anxiety and stress levels. To the best of our knowledge, no previous controlled trial has been conducted to validate this assumption or investigate the possiblc

effects of music on patients undcrgoing surgical procedures. One researcher emphasizes the relation between music, physiology, and emotions.' The assumption provided by the researcher is that music, when used therapeutically, may offer emotional support to surgical patients. Perioperative nurses, therefore, should consider using music as an anxiety and stress reducer when developing surgical paticnts' care plans.

rcsearchcr's ability to translate endocrine t'unctions and sympathetic reactions into physical expressions (eg, palpitations, increased blood pressure, tachypnea, profuse sweating, restlessness, paleness, diarrhea, vomiting, polyuria). The intensity of these reactions differs from person to person and depends on individual coping methods and the frequency, as well as duration, of stress stimuli.?

REVIEW OF THE LITERATURE The amount of literature about stress is vast; however, two main theories regard stress from different, yet complementary, points of view. Physiological causes of stress. Onc theory postulates that stress is a nonspecific, unique reaction 01' tissue groups toward any stimulus threatening to disrupt the body's physiological homeostasis. This assertion is based on the

One theory is based on the recorded dialogue between man and his surroundings. It presents the idea that stress is a sum of phenomena considered to be threatening and takes into account man's character and the nature of the surrounding event.? Surgery is a slresslul experience because of patients' fears and anxieties, unfamiliar surroundings, and the foreign atmosphere of the operating theater. Surgery requires patients to exert a tremendous amount of mental and physical strength. Although perioperative morbidity and mortality rates are caused by unrelated cardiovascular complications, there is no definite correlation between the metabolic price required of surgical patients and the type or duration of the surgical procedures.4 Anxiety, however, increases oxygen consumption, cardiac output, and blood pressure. The accumulation of catecholamines produced by stress may contribute to overt heart failure in

Psychological causes of stress.

ARlE EISENMAN, MD, is senior-physic,iun, internul medicine.. Ranihum Medical Cuiter-,Halfa, Israel. BATSHEVA COHEN, RN, BA, is senior- surgical nwse, Runiham Medical Center, Haifa, Is,trel.

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Table 1 patients. Tranquilizers given bcforc a surgical procedure do not guarantee patients will avoid anxiety or stress. Furthemiore, anxiety and strcss may cvcn incrcase the nccd for higher dosages of anesthetics and scdativcs during proccdurcs and may have it negative impact on patients’ recoverics. STUDY DESIGN AND RESULTS The following summarizes our study’s design and the results of our data collection methods. Materials. Our study focused on an opemting theater o f approximately 900 beds in a university medical center. We chose a theater in which orthopedic procedures usually are performed. We used personal audiocasscttc players equipped with earphones. The earphones were cleaned and sterilized in gas autoclaves after each use, similar to the process that airline personnel use, and were wrapped in hermetically sealed plastic bags before being given to patients. The avertge length of time for the surgical procedures was one to two hours. During this time, it oftcri was necessary to change the music audiocassette tapes for the patients. This was accomplished by the circulating nurse or the anesthetist without compromising (he integrity of the surgical field. The patients could turn the audiocassette players on or off according to their wishes. Patients sclcctcd thcir favorite music beliire their surgical procedures from our selection or from thcir own collection. The physicians and nurses involved with the procerlures were informed o f the study and its purpose, and we asked for their coopcration. Methods. The study was a primary, open pilot research study. We selected 30 surgical pnlients between 18 and 80 years of age who were scheduled for clcctivc

EVALUATION OUESTlONNAlRE

1. Did you listen to music during your last surgical procedure?

2. Are you fond of music? 3.

Do you think that music played during the surgical procedure provided you with any kind of support?

4. Can you describe your feelings in words? 5. Please rote the support you feel the music provided: A. Excellent

B. Very good

C. Good

D. Helpful

E. No change

6. Would you like to hove the option to choose your favorite type of music from the choices provided? 7. Were you encouraged to choose the music to which you would listen? 8 . Was the selection offered varied enough for you? 9. Would you rather bring recorded music from home?

10. Did anylhing interrupt or limit your listening to music? 1 1 , Did you choose not to listen to music during your surgical procedure? 12. If the answer to question 1 1 is yes, is there any possibility you would change your mind for another surgical procedure? Can you specify the reasons you preferred not to listen to music during your surgical procedure?

orthopedic surgical procedures and regional anesthesia. There was no conlrol group. The evenings before their procedures, the patients were interviewed in their respective wards by the study coordinator (ie, a regislered surgical nurse). She carefully explained the goal of the study (ie, to use music to reduce anxiety). She also acquainted patients with the scenery and atmosphere of the OR as well as thc different techniques used for regional anesthesia, introduced the main theories concerning the psychological influence of music on the human soul, and dcscribcd the assortment of music and the vitrious listening devices available during the procedures. Thc study coordinator then reccivcd patients’ otal consents to participate in the study. A written consent was not necessary, because listening to music is not 948 AORN JOURNAL

recognized as a medication or as an invasive therapy, and it does not constitute a risk to patients. The patients’ willingness and enthusiasm to participate, as well as thcir rcactions during their surgical procedures, were observed and documented carefully. After the surgical procedures, the study coordinator asked patients to comment on their impressions by completing a questionnaire (Table I). The questionnaire’s structure was based on a 1990 questionnaire that was designed to obtain feedback about paticnts’ sclcction of and feelings about music during surgical procedures.’ Evaluation. The study evaluation was based on thc patients’ rcactions as reflected by their questionnaire answers and as observed by OR staff members, the reactions and evaluations of different OR staff membcrs to the study, and

DECEMBER 199S, VOL 62, NO 6

achicvcmcnt of thc prcstatcd goal. Results. As a whole, periopcrative patients’ reactions towiird the use of music during surgical proccdurcs wcrc encouraging. There were no negative comments from any of the patients. Patients said that the music helped their time in the OR to pass quickly and that it masked background noises and diverted their minds from the surgical procedures by allowing them to concentrate on their favorite music. They said they felt peaceful and less tense during their surgical procedures. There was not a predominant type of music chosen by surgical patients in our study. The type of music varied according to age, origin, and cultural background. Many patients said that they would repeat the experience if they had to undergo another surgical procedure and that they would recommend it to others. Observation of the patients revealed that they looked rather doubtful of the effects of music at the beginning of the surgical procedures, but shortly thereafter, they became pcaccful and relaxed. They closed their eyes and remained motionless during thcir surgical procedures. Some patients began dozing and woke up only when their procedures were finished. A positive attitude toward the use of music also was shared by the OR staff members. The most positive feedback came from the anesthetists. They noticed that patients were more calm throughout their procedures, their pulses and blood pressures were more stable, and

less anestheqia was required.

DEflNlTlON OF MUSIC AND STUDY GOAL Music is defined as the science or art of the composition of sounds that are comprehended by the human brain as enjoyable and expressive. It first was used in hospitals early in this century for its preventive and therapeutic Several studies have shown that music affects human physiology through electric conduction, heart rhythm, circulation, and respiration.’ It may relieve stress by diverting attention away from, or by masking, annoying noises. It also may provide imaginative thoughts, and hence make temporary escape from reality Rhythm is important as well because it influences anxiety levels considerably. Slow and moderate rhythms are more effective in promoting a rclaxed atmosphere than fast and dramatic rhythms.‘J Although relaxing music theoretically might create a positive process of psychological and physiological drives, our preliininary hypothesis was that to derive the best reaction to music in the OR, one should pay careful attention to its choice. Music chosen and favored by the patient should have the greatest impact; therefore, respect for everyone’s choice and taste is crucial.“’ Our goal was to reduce anxiety and stress levels by letting patients listen to their favorite music while undergoing surgical procedures and regional anesthesia. This choice should be offered only after

NOTES 1. R Jacobhi. Work ~ f H { t in p Crin!w/cwr,rcr P r o u w AFer Sui;yrry (PhD thesis, University of Haifa, Israel, 1987). 2. H Selye, “The stress syndrome,” Arnokun Jouinal

other conventional steps are carried out. This includes acquainting patients with the human and physical atmosplicre of the OR and explaining the different types of anesthesia. It also should be clarified from the beginning that although patients will not feel any pain, they will be awake and aware of what is occurring during their procedures.

CONCLUSION All of the prestated goals were achieved. The primary hypothesis regarding the effect of music on patients undergoing surgery and regional anesthesia was confirmed. The use of music made it possible to convert potentially traumatic and stressful experiences to more pleasant ones. Anxiety and fear were less substantial, and the overall quality of patient care was improved. Perioperative nurses may play a crucial role in encouraging patients to use music while undergoing regional anesthesia. This may create a special bond between nurses and patients and increase patients’ confidence levels. W e will be conducting another study to clarify the underlying physiological mechanism of stress reduction through the use of music. This will add an indispensable quantitative dimension to the qualitative dimension presented in this article. W e hope that in spite of the tremendous technological progress being made as we near the twenty-first century, health care providers will still take advantage of the simple and aesthetic mean called music. A

(March 1965)97-99; H Selye, Thc Strrss of.lifi (New York: McGraw-Hill Co, 19?6); H Selye, Strcss Without Distress (Philadelphia: J B Lippincott Co, 1974). ofNui.si/i,p65

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3. K S Lazarus, S Folkman, S / w x ~Appruistd, , t r ~ i C ‘ o p i y y (New York: Springer Publishing Co, Inc, 19x4) 11-21; R S Lazarus, S Folkman, “Coping and adaptation,” in Hundbook of Bchavior.al Medic,irie, ed W D Gentry

(New York: Guilford Press, 1984). 4. F D Moore, “Homeostasis: Bodily changes in trauTrrthook of ma and surgery,” in Da\~is-C/ir.i.stoi/~hcr. S i q e / y : Thc Biological Basis of‘Morler.ri Sio;qical Pract i w , 12th ed, D C Sabiston, Jr. etl (Philatlelphia: W H Saunders Co, 1981) 23-57. 5. K Stevens, “Paiients’ perceptions of music during surgery,” Joirrwd of’ A h w i c w l Niri:virig IS (September 1990) 1045-1051. 6. 0 B Taylor, “Subject responses to precategorized

stimulativc and scdativc music,” Joi~uitilof Mirsic Tirrrtr[ ~ 10 y (Summer 1973) X6-94; D C MacClelland, “Music in the operating room,” AORN ./muia/ 29 (February 1979) 252-260. 7. R Lundin, Aii Ohjcc~rivcPsycholog\? o f M i 4 ~ i (New c York: Ronald Prcss Co, 1953). X. Stevens. “Patients’ perceptions of music during surgery,” 1045-105 I . 9. MacClellond,“Music in the operating room,” 252260. 10. W B Davis, M H ’l‘haut, ‘”l’heirilluencc o f preferred relaxing music on measures of sta~eanxiety, reaction, and physiological responses,” Jorwiruf of Mtrsic, T/iuupy 26 (Winter 19x9) 16X-1x7.

Low-Salt Diets May Be Linked to Myocardial Infarctions Low urinary sodium in hypertensive men can signal a greater risk of myocardial infarctions (MIS), according to a news brief in the July 13, 1995, issue of Medical 7iYtmne jbr. the Family Pliysiciau. A study of 1,900 hypertensive men between 198 1 and 1990 found that men with the lowest amounts of sodium in their urine were four times more likely to suffer MIS as those with the highest levels of sodium. Researchers found no causal relationship between low sodium levels and MIS among the 1,037 women in the study. According to the news brief, researchers speculated that these findings could be linked to the inverse relationship between the body’s sodium

intake and renin, ii renal enzyme that has been shown to increase the risk of MIS in hypertensive patients. Other explanations include the different levels of hypertension in the men involved and the lack of detailed inforniation about smoking and alcohol consumption. Men should not begin increasing their sodium intake, however. Researchers said their findings must be studied further, because the results are based on one urine sample from each man and may not provide a true picture of the patients’ sodium intake.

B Lewis, “Low-Salt Diet Linked to Heav Attack, “ Medical Tribune for the Family Physician, 13 July 1995, 19.

Cars and Airplanes Major Sources of Back Problems Rack problems can be caused by stress on the lower back and neck as a result of sitting for extended periods of time in car and airplane seats, according to a July 18, 1995, news release from the American Chiropractic Association. Scats in cars and plancs arc designed for short-term comfort rather than longterm support, and because of this, pcoplc on vacation are likely to suffer back problems immediately following their trip. It is becoming clearer thiit the correlation between back and leg pain episodes and vacations is not because people are more active without proper conditioning and rest, but rather because of the positioils in which travelers are forced to sit. Sitting i n oirplane or ciir seats distorts the spine and cramps

muscles, thereby predisposing travelers to back pain. The new release rccommcnds the following actions to reduce postvacation back problems. Take standing breaks. If you are on an airplane, walk thc length of thc planc cvcry half hour. If you are traveling by c‘iir, stop every hour to stretch and walk around. Keep your seat erect or in a position that does not strain your lower back, tailbone, and neck. 0 Do muscle lightening arid relaxing exercises while seated. TWO Major Sources of Vacation Back Problems (news

release, Ar/ington, Vu: American ChiropracticAssociation, July 18, 1995) 1-3.

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