The influence of music on the surgical task performance: A systematic review

Journal Pre-proof The influence of music on the surgical task performance: A systematic review Michael El Boghdady, Beatrice Marianne Ewalds-Kvist PII:

S1743-9191(19)30333-4

DOI:

https://doi.org/10.1016/j.ijsu.2019.11.012

Reference:

IJSU 5146

To appear in:

International Journal of Surgery

Received Date: 14 July 2019 Revised Date:

26 October 2019

Accepted Date: 12 November 2019

Please cite this article as: El Boghdady M, Ewalds-Kvist BM, The influence of music on the surgical task performance: A systematic review, International Journal of Surgery, https://doi.org/10.1016/ j.ijsu.2019.11.012. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. 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. © 2019 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

THE INFLUENCE OF MUSIC ON THE SURGICAL TASK PERFORMANCE: A SYSTEMATIC REVIEW

Michael El Boghdady (1), Beatrice Marianne Ewalds-Kvist (2)(3) (1) University of Dundee, UK (2) Stockholm University, Sweden (3) Turku University, Finland

Contributions: Michael El Boghdady: Substantial contributions to conception and design, detailed literature search, interpretation and analysis of data, drafting the article and final approval of the version to be published. Beatrice Marianne Ewalds-Kvist: Substantial contributions to conception and design, analysis of data, drafting the article, revising it critically for important intellectual content and final approval of the version to be published.

Disclosures: The authors declare no conflict of interests. Corresponding author: Michael El Boghdady MBChB, MD, MRCS, MHPE, MFSTEd, FHEA University of Dundee DD19SY Dundee, UK [email protected] [email protected]

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THE INFLUENCE OF MUSIC ON THE SURGICAL TASK PERFORMANCE: A SYSTEMATIC REVIEW

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Certain music elements affect the surgical task performance in a positive or negative way. The total and significant outcome of the present study was that the positive effect of music on surgeon’s task performance, overrides its negative effect. Classic music when played with a low to medium volume can improve the surgical task performance by increasing both accuracy and speed. The distracting effect of music should also be put in consideration when playing a loud or high-beat type of music in the operating theatres.

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Keywords:

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Music; surgery; operating theatre; surgical training; surgical education; performance; laparoscopy

Abstract: Introduction: Music is commonly played in operating theatres. Music was shown to diminish stress of the surgical team along with reducing the patient’s anxiety before surgery. On the other hand, it has been revealed that music might give rise to negative effects of divided attention causing distraction in surgical routines. Therefore, we aimed to systematically review the effect of music on the surgeon’s task performance. Methods: A systematic review was performed in compliance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. A literature search using PubMed /Medline, ScienceDirect and Google Scholar, was performed by means of the search terms: “music and operating theatre”, as well as ”music and surgery“. The search was limited to citations in English from year 2009 to 2018. Search items were considered from the nature of the articles, date of publication, forum of publication, aims and main findings in relation to use of music in operating theatres. Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were applied. Studies were included based on predetermined inclusion criteria where after the papers’ quality assessments and evidence grading were completed by two independent reviewers. The protocol was registered with the PROSPERO register of systematic reviews. Results: Out of 18 studies that formed the base for evidence evaluations, 6 studies were assessed as having high quality and 8 studies of moderate quality. Five studies, provided both strong and moderate scientific evidence for a positive effect of music on surgeon’s task performance. In contrast, strong scientific evidence for a negative effect of music on surgeon’s task performance also was revealed in 2 high-quality studies. Nevertheless, there positive effect of music on the surgical task performance was significantly different when compared to its negative effect (p< 0.0001). Conclusion:

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Introduction:

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Music is commonly played in the operating theatres (1). It has been proven that playing music has significant effects on reducing patients’ anxiety during endoscopy and before surgery while acting as a distractor, and increasing patients’ threshold of pain (2, 3, 4, 5). Music also has a positive effect on decreasing the operative time and on reducing stress of the surgical team (6,7). In contrast, a previous research mentioned the negative effect of divided attention with auditory distraction on the surgical task performance (8), while others concluded that performance can remain unchanged with music as the intense concentration required by a complex surgical task allows experienced surgeons to effectively block out noise as well as music (9). In order to answer whether playing music in the operating theatres should be encouraged or discouraged, we aimed to systematically review the effect of music on the surgeon’s task performance. Therefore, we asked the following questions: Does surgeon’s task performance get improved by music? Does surgeon’s task performance get impaired by music? Which music essentials impact the surgical task performance positively or negatively? Methods: Protocol: A systematic review was developed in compliance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. The study protocol was registered with the PROSPERO register for systematic reviews. Search strategy: The search was performed using the database PubMed/Medline, ScienceDirect and Google Scholar (Fig. 1) by the first author. The following search terms were used: “music and operating theatre’’ and using the MeSH terms ”music and surgery “. Procedure: The procedure for developing a systematic review comprised two authors’ inspection of titles, abstracts, and full-text papers, which were systematically reviewed against the inclusion and exclusion criteria. The first author performed the detailed literature search. The final list of citations (n=18) was completed by both authors. Search items were studied from the nature of the article, date of publication, and aim and main findings in relation to the effect of music on surgeon’s task performance. Key stressors in terms of auditive stimulation, music or noise affected though all staff members in the operation theatre, although our focus was laid on eventual changes in surgeon’s performance tasks under non-silent conditions. The procedure followed examples from Forsberg and Wengström, (10); Willman, Stoltz and Bahtsevani (11). The quality assessments and evidence grading were performed following the protocol of The Grading of Recommendations Assessment Development and Evaluation Working Group (GRADE) (12).

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Inclusion criteria:

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We assessed the risk of bias in a blind manner; and the assessments were completed by the two authors, independently. If the assessments did not agree, we calculated the mean score of

The search was limited to citations in English from year 2009 to 2018. Search items were considered by the nature of the studies, date of publication, aims and main findings in relation to the use of music in operating theatres. The included references existed in the form of published papers in peer-reviewed journals. Exclusion criteria: Citations not related to the use of music in operating theatres and those not available in English were omitted. Articles for the effect of music on patients and on specific staff members other than surgeons were also excluded. Quality assessment: A chart-method was applied (10, 12), with a maximum of 30 scores for the quality assessment of each of the 18 individual studies intended for inclusion in the review (Table 1). The chart method agrees in major parts with the PRISMA checklist that assesses our completed review. Assessment of the selected articled were blindly performed by 2 reviewers, who reached inter-rater agreement by taking the mean score of two assessments in case these differed between the two raters. We checked by the chart-method, the accuracy of the study’s title, abstract, introduction and rational for the report in addition to the research question/s (4 questions), design, inclusion and exclusion criteria (4 questions), subjects’ selection method and missing status (6 questions), where and when the study was done (2 questions), data collection, measurements and statistics (3 questions), results, study implications and limitations, conclusion, ethics as well as internal and external validity of the study (9 questions). The quality ratings adhered to the following strict principles: A paper evaluated to maintain High quality fulfilled 90% (27-30) out of 30 criteria; a study fulfilling 80% (24-26) of 30 criteria was rated as being of Moderate quality. Low-quality studies completed 70 % (21-23) of the 30 criteria. Insufficient quality was denoted by filling < 69% (< 20) of the criteria for studies included in Table 1. Evidence grading: Quality of evidence for grading the studies are presented in Table 1, it was based on the principles previously put forward (11, 13); and elaborated by GRADE (12). The assessments were based on 6 criteria for using GRADE, comprising four grades of evidence: Evidence grade 1: strong scientific evidence based on at least 2 studies with high evidential value or a systematic review / meta-analysis with high evidential value Evidence grade 2: moderate scientific basis: A study with high evidential value and at least 2 studies with moderate evidential value Evidence grade 3: low scientific evidence: A study with high evidential value or at least 2 studies with moderate evidence value Evidence grade 4: insufficient scientific evidence: 1 study with moderate evidence and / or at least 2 studies with low evidential value Risk of bias within and across studies:

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the given scores. We considered that we filled the GRADE’s criteria for consideration of an individual study’s risk of bias or quality in order to judge the study’s suitability for constituting a basis for the ratings about its strength to contribute to the body of evidence of the findings in this systematic review. Thereafter we controlled for accumulated risk of bias by calculating and grading the body of evidence of the findings according to GRADE’s recommendations.

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Results:

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Study selection and characteristics:

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The results of the present searches provided a total of 94 042 studies. These studies were screened and assessed for eligibility. After the inspection of the titles and abstracts, these elements were systematically reviewed against the inclusion and exclusion criteria, 23 papers were retrieved out of which 3 papers were excluded (Fig. 1). After administration of inclusion and exclusion criteria, 18 articles remained and defended their place in this review. Search items were studied from the nature of the article, date of publication, forum of publication, aim and main findings in relation to the effect of music on surgical performance, as well as quality scores (n out of max 30, Appendix I) were administered and compared as a basis for evidence grading (four grades) in agreement with the GRADE protocol (Table 1).

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Results of individual studies: The operation theatre’s music’s impact on surgeon’s task performance was scrutinized in 18 studies, which reported different categories of surgeons such as novices, trainees and experts, while few studies stated only "surgeons". Diverse categories of multiple separate surgical skills and surgical task-performances of several problematic levels necessitated the training surgeons to exercise and perfect skills in simulators. The diverse specialties and subspecialties demanded different set of skills such as intensity of concentration for surgeon’s performance varied depending on the task difficulty, previous task training and infrequency of task occurrence. Participants consisted of surgeons working with general surgery, colorectal surgery, hepato-pancreato-biliary surgery, laparoscopy, micro-neurosurgery, ophthalmology, orthopaedic surgery, plastic surgery, robotic surgery, as well as urology and gynaecology. Does surgeon’s task performance get improved by music? Scientific evidence for a positive effect of music on surgeon’s task performances: Strong scientific evidence for a positive or beneficial effect of music on surgeon’s task performances was given in two high-quality studies (21, 25) (Tables 1 & 2). The first study about plastic-surgery task performance showed improved efficiency of skin repair in a simulated wound closure model at the same time as trainees listened to music during their preference. There was an overall reduction of the operative time of 8% in trainees. The reduced time improved to 10% in upper-level trainees. The quality of skin repair also improved slightly in the music-listening group. The second study showed improvement in a test of hand–eye coordination in ring, rope and capping activities as laparoscopic training tasks, and a Mozart Effect was discovered in two forms: Quantitatively, an average improvement in performance time and qualitatively in terms of participants exposed to music 4

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differed from those with no music: initially slower participants were more influenced by music. Listening to Mozart enhanced spatial temporal reasoning while Wiseman’s results extended this further by showing that qualities in music influence the performance of a complicated physical task. The Mozart effect is not tied to Mozart, but to music in general. It can be applied to improve surgeon efficiency in a personalized way to his/her music taste and learning pattern.

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Moderate scientific evidence for a positive effect of music was provided from one highquality study (26) where it was demonstrated that listening to relaxing music leads to improved surgical motor learning. By correlating auditory stress with mental stress on surgical performance, positive implications for postgraduate surgical training were found. It was advised that music could be a low-cost yet efficient device to reverse some of the mental stressors’ negative effects on surgical motor learning. Classic music promoted surgical memory consolidation and could produce the possibility to predict surgeon’s performance and learning under stress. In addition, moderate scientific evidence for a positive effect of music, especially Mozart in a broad sense, improved surgical skills and memory consolidation (16). Researchers (17) found that surgeons, in general, enjoyed music and did not consider music as a distractive element.

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Does surgeon’s task performance get impaired by music? Strong scientific evidence for a negative effect of music on surgeon’s task performances was received from two high-quality studies (20, 27), (Tables 1 & 2). The first study computed quantitative analyses of music and communication from 20 operations and found that out of 5303 requests/responses, 69 were repeated requests, 6 of which were from cases with music off as opposed to 63 from cases with music on. The researchers found strong evidence that playing music in the operating theatre during task performances correlates with significantly more repeated requests between surgical team members compared to a no-music situation. Neither situation’s confidence intervals overlapped, implying a factual difference in the outcome of playing music versus not playing music. The calculated risk difference was highly significant and not likely to be due to chance. Analysis of the repeated requests revealed an increase per repeat to operation time of 4–68 seconds and uncovered increased tensions due to frustration from unproductive communication. The impact of loud music on communication hindered the nurses to hear the surgeon’s requests. Surgeons had to repeat themselves and therefore, it took a longer time for nurses to respond with assistance. Furthermore, it was found (27) that intraoperative noise volume relates to successive surgical-site infection (SSI) measured 30 days after surgery possibly due to the surgical team’s lack of concentration in a stressful environment and may represent a surrogate parameter by which to assess the team’s performance. Type of noise (spoken language or music) was not registered. To eliminate general background noise, the baseline was set to the lowest decibel level measured during the operation for each of 35 patients. Noise-tapes were made in two operating theatres of the same size with identical equipment. The overall median sound level (25·2 dB) constituted a cut-off value in noise-groups above, or below this value. Noise values for comparison were: a quiet situation of 20 dB, normal conversation of 50 dB and street traffic of 70 dB. Non-patient-related conversation correlated with sound level. Median sound-levels during surgery were higher for patients who developed SSI than for those with primary healing. Also, peak noise levels of at least 4 dB above the median were found for 22,5% of peaks for patients with SSI compared with 10,7% in those with primary healing (Table 2). 5

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Which music essentials impact the surgical task performance positively or negatively? Table 2 answers the question which music essentials impact surgical task performance positively or negatively. Answer summation: Music improved efficiency in time of wound closing plus enhanced the quality of skin repair in plastic surgery. General qualities in music, not only Mozart sonata for 2 pianos in D-K448, influenced the performance of a complicated surgical task during surgery as well as before surgical task performance. Music improved memory consolidation and could serve as a resourceful device to reverse some of the stressorinduced negative effects on surgical motor learning. Yet, if the sound level during surgery was high, the patients suffered a significant risk to contract SSI in 17% of the operations. In other words, median sound levels during surgery were higher for patients who developed SSI, than for those with primary healing. In addition, the median sound levels above baseline were higher for patients who developed SSI. Further negative effect of music during surgery consisted of repeated requests, altogether 91% repeated requests were from operation theatres with music on. Every repeated request increased operation time with 4–68 seconds per repeat. This ineffective staff communication produced frustration while surgeons had to repeat themselves and it took the nurses longer to respond with satisfactory backing. Synthesis of results: A total of 5 studies, provided both strong and moderate scientific evidence for a positive effect of music on surgeon’s task performance (table 2). In contrast, also strong scientific evidence for a negative effect of music on surgeon’s task performance was revealed in 2 high-quality studies. The significant difference between positive and negative effect of music on surgeons (27) was calculated by means of Fisher’s exact test (2-tailed) and was found to be p< 0.0001. As Table 1 shows 3 studies were rated as being of low quality and one study was assessed as being of insufficient quality and these 4 studies were omitted from further analyses, which move reduced the risk for a biased evidence grading. Out of 18 studies 6 studies were assessed as having high quality and 8 studies were judged of being of moderate quality. Therefore, our result was based on strong scientific evidence comprising at least 2 studies with high evidential value or on moderate scientific evidence including one study with high evidential value and at least 2 studies with moderate evidential value (Table 2). The results revealed that surgeon’s task performance was improved by music. However, surgeon’s performance was also impaired by music. Certain music essentials impacting on surgical task performance positively or negatively. The total and significant outcome of the present study was that the positive effect of music on surgeon’s performance tasks overrides music’s negative effect on surgeon’s performance tasks in the operation theatre. Discussion: Research question 1: Does surgeon’s task performance get improved by music? Our current systematic review presented scientific evidence for a positive effect of music on surgeon’s task performance. Music enhanced spatial temporal reasoning while Wiseman’s results extended this further by showing that qualities in music influence the performance of a complicated physical task. In a previous study about laparoscopic training tasks the effect of music was observed in two forms: Quantitatively, as an average improvement in performance time and qualitatively in forms of participants exposed to music pieces (Mozart or Dream 6

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Theatre) differed from participants not exposed to music (25). Likewise, initially slower participants compared to those faster, were more influenced by music. This association varied with task complexity, practice, and order of music exposure. The result thereby extended the Mozart effect by showing that qualities in music influence the performance of a complicated physical task, but is not tied to Mozart per se, yet, to music in general. A study from plasticsurgery task-performance revealed that when surgeon trainees listened to preferred music, they improved their time efficiency of skin repair in a simulated wound-closure model along with a slightly improved quality of their skin repair (21). In addition, classic music – such as Mozart- caused an improvement of surgeons’ memory consolidation and motor learning skills (16).

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Soft sounds benefit patients by increasing the pain treasure and reducing the mental stress level. Soft, silent classic or mediation music reduces the need for sedative drugs and pain killers (32). In

general, music prevents stress-induced increase in heart rate and systolic blood pressure, more so than silence (32,33,34). This means that the use of music in the preoperative setting as well as in the endoscopy suite (35), reduces anxiety to a greater extent than orally administered midazolam (32). Also outcome from surgical performance as a result of surgeons being subjected to auditory stress combined with mental stress (30) revealed that mental stressors impaired surgical motor learning, but the researchers claimed that music could restore or reverse the negative effects. Music’s positive effects on staff members and patient in the operating theatre, could have an encouraging effect on the surgical team’s performance (14, 26). Our review providing both strong and moderate scientific evidence for a positive effect of music on surgeon’s task performance based on 3 high-quality and 2 moderate-quality studies aggregated contribution to this body of evidence. Research question 2: Does surgeon’s task performance get impaired by music? It has been found that music can interfere with communication but was hardly ever documented as a safety hazard in the operating theatre (20). Yet, the calculated risk difference between music versus non-music surgery revealed that the risk was highly significant and unlikely to be due to chance. Music brought about repeated requests, their analysis revealed an increase in operation time and an increase in tensions due to frustration from ineffective communication. Furthermore, listening to rock music can increase heart rate (36), but heavy-metal music or techno-sounds are either ineffective or may even be dangerous while leading to stress and/or life-threatening arrhythmia (32). Techno-music can induce physiological and neuroendocrine changes in normal subjects. These facts support the findings that cortisol, norepinephrine and β-endorphin do change in response to music, in agreement with findings that fast music is able to activate the noradrenergic system along with the hypothalamic pituitary axis, more so than slow music (37) The World Health Organization (WHO) recommends that the noise level in the operating theatre should not exceed 30 dB(A) (38). High-volume noises produce detrimental effects not only for surgeons, but also for the patient and staff members (38, 39, 40, 41, 42). The main harmful effect comprised staff’s impaired performance due to worsened communication. The noise caused disruptions, which resulted in impaired speech discrimination and speech intelligibility (39, 41). Consequently, the staff raised their voices to be heard, which amplified the noise level even more (40). Miscommunication is one of the most frequently identified causes for medical errors and adverse events, therefore, miscommunication must be considered when playing music in the operating theatres. 7

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Research question 3: Which music elements influence the surgical task performance positively or negatively? The positive music elements’ effects were as follows: Music saved time during wound closing and enhanced the quality of skin repair in plastic surgery (21). General qualities in music, not only those written by Mozart, (Mozart sonata for 2 pianos in D-K448), improved the performance of a complicated surgical task, also for those who listened before to music before the performance task. Altogether, music improved spatial temporal reasoning, memory consolidation, surgical motor learning along with qualities influencing the performance of a complicated physical task. (17, 21, 25, 26) (table 2). The negative effects were as follows: If the sound level during surgery was high, 17% of the patients contracted surgical‐site infection. In addition, the median sound levels above baseline were higher for patients who developed SSI (27). Music forced surgeons to repeat their requests and it took the nurses longer to respond with assistance. This fruitless communication produced frustration in the surgical team (20). A high volume in the operating theatre constitutes a real risk for complications (39, 40, 41, 42)

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Clinical implication of the findings:

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The “Mozart effect” is debated as a momentary positive effect of cognitive improvement on the surgical performance in forms of decreased anxiety and stress, increased speed and accuracy, as well as improved acquisition of technical skills of novice surgeons (17). Low to medium volume reduces speech interference; high-volume music can disturb the surgical performance by distracting the surgeons from the tasks and harm the communication between the operating-theatre staff members as well as between surgeons (20, 27). People differ in their sensitivity to music, more musically educated persons are also more selective in their music taste and do not like background music. Unwanted music turns to noise and noise raises blood pressure and exacerbates depression and anxiety. For those with autism and other sensory-processing issues, or with hearing disorders like tinnitus and hyperacusis, music can aggravate symptoms, impede their ability to hear conversation, and even interfere with how they get around (38, 39, 40, 41, 42). Therefore, a discussion about playing music and what type of music between all persons concerned in the operating theatre, needs to be advanced as a routine.

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Limitations of the study:

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Papers that studied the effect of noise along with music in the methodology were included, as opposed to those that only studied the effect of noise as a distractor on the surgical performance. The effect of pure noise on the surgical performance was not the study focus of this paper, which emphasis was laid on the effect of music.

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Limiting our study to a ten-year systematic review, might predispose to bias. However, we assessed the risk of bias in a blind manner and the assessments were completed by the two authors, independently. If the assessments did not agree, we calculated the mean score of the given scores. After this quality-assessment of the 18 studies we finally got 5 studies with strong or moderate evidence for a positive effect of music in the operating theatre. On the other hand, we also got 2 studies indicating strong evidence for a negative effect of music in the operating theatre. These findings are not contradictory, they only indicate the fact that

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music and other sounds might interfere with communication between surgeons and operating theatre staff. Miscommunication might lead to unnecessary longer operation time.

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Future study:

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In patient’s life-threatening situation, when a medical device emits an alarm, the extra noise exposure induced by music is distracting. Therefore, we suggest future experiments with groups of surgeons, subjected to their preferred type of music compared to those listening to classic music. Further, we compare effects of music on experts compared to novice surgeons. Moreover, we study the effect of music on surgical performances in crises, during simulated emergency surgical scenarios, with the addition of a device, compared to those without the device that turns off music automatically in real time, as soon as a medical device emits an alarm. This devise can effortlessly be applied to alarm-generating medical devices and to each music apparatus and pair of speakers, assuming that the player is connected to its speakers via a 3.5 mm audio jack cable (43).

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Conclusion:

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Certain music elements affect the surgical task performance in a positive or negative way. The total and significant outcome of the present study communicates that the positive effect of music on surgeon’s task performance, overrides its negative effect. Classic music when played with a low to medium volume can improve the surgical task performance by increasing both accuracy and speed. The distracting effect of music should be put into consideration when playing a loud or high-beat type of music in the operating theatre.

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Disclosures: The authors declare no conflict of interests. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Provenance and peer review Not commissioned, externally peer-reviewed

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References:

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Table 1. Reviewed studies, their quality scores and evidence grades Author (Year)

Journal / country

Study design

Subjects and Sample size

Narayana n and Gray (2018)14

New Zealand Medical Journal

Observational study

Altogether 106 of the entire operating theatre staff participated.

6 studies on To study the effect of 164 music on microparticipants. neurosurgical performance and training.

.

Belykh et al (2018)15

World Neurosurgery

Systematic review.

Kyrillos and Caissie

Canadian Journal of Opthal-

Prospective stratified and randomized

Aims of the study

To examine the attitudes and perceptions of theatre staff towards the presence of music during operations on (Response rate the theatre environment. 45%)

Findings

Impact on surgical performance

Altogether 98% of people said that music is Positive played in their operating theatres, 60% liked hearing it. The genre Easy Listening was most played closely followed by Pop and Classical. Easy Listening was also most preferred and classical music the subsequent genre. Music was preferred for longer, more familiar and non-urgent surgical procedures, at a low to medium volume, though 84% felt that music was a distraction in crisis. Surgeons were the most empowered group when it came to choosing music. Most respondents felt music improved calmness, overall mood, overall team performance and surgeon's performance. Music though worsened communication.

Music has both positive and negative effects on Positive or surgical performance. Various types of music negative have been shown to improve concentration and efficiency when performing recurring tasks among experienced surgeons; however, it has also been shown that music can distract novice surgeons performing complex or unfamiliar tasks. The pleasant or classic music had a beneficial effect on surgical performance. Altogether 14 To evaluate the Mozart Exposure to music did not negatively impact Positive ophthalmologi effect compared to surgical skills. Moreover, a trend for improvement sts and 12 silence on anterior was shown while listening to Mozart music.

Quality scores (n/30)

Evidence grade EG

25/30 scores

EG= 2 Moderate quality

27/30 scores

EG=1 High quality

25/30 scores

EG= 2 Moderate quality

(2017)16

mology

noninferiority trial.

Yamasaki et al (2016)17

Surgery

Crosssectional multicentre research.

Shambo et al (2015)18

American Association of Nurse Anaesthetis ts

Review.

Faraj et al (2015)19

Weldon et al (2015)20

trainees in segment surgical skill ophthalmology in the context of . simulated intraocular surgery. Out of 692 To acquire knowledge Surgeons gave high median scores for enjoyment Positive participants of the impact of music of music and low median scores for music as a 390 belonged on operating theatre distraction. to the team’s concentration operating and communication. theatre team. 27 articles

To provide further insight into the ramifications of the presence of music in the operating theatre, evaluate its appropriateness in relation to care and safety for the patient and staff, and provide information for future research. Operating Observational 121 health To find out if playing Room study. staff working music in the operating Nurses in theatre is beneficial Association operating theat of Canada res. (Response rate 43%) Journal of Quantitative Video To observe the impact Advanced and qualitative recordings of of extent and details of Nursing data analyses. 20 operations music on

The review of the literature established that music Negative contributed to the overall stress of the environment, disturbed communication, inhibited accomplishment of tasks safely, and posed a threat to patient and staff health and safety.

25/30 scores

EG= 2 Moderate quality

24/30 scores

EG= 2 Moderate quality

Most medical staff found listening to music while More positive 22/30 they work to be a positive experience. than negative scores Nevertheless, the potential for music to exhibit a distracting or unfavorable effect on a minority of individuals should always be kept in mind.

EG= 3 Low quality

Music played in the operating theatre can get in Negative the way of team communication. Yet, music was seldom identified as a potential safety hazard.

EG=1 High quality

27/30 scores

over six communication in the Decisions about whether music is played and months operating theatre. about the choice of music and its volume, are duration in factors controlled mainly by surgeons. two operating theatres. Lies and Zhang (2015)21

Aesthetic Surgery

Prospective randomized double-blinded crossover controlled trial.

15 plastic To evaluate the effect of music on simple surgery wound closure trainees.

Katz (2014)22

Anaesthesi ology

Editor’s commentary

Literature search

Moris and Linos (2013)23

Surgical Endoscopy

Systematic review.

To examine the common sources and consequences of excessive operatingtheatre noise and to suggest some remedies. Literature To give a theoretical search using contribution about the Medline effect that music has database. on the pre- and postoperative sequence of surgical patients and about the efficiency of the surgical work performed by both physicians and staff.

Playing preferred music made plastic surgery trainees faster in completing wound closure with a 10% improvement in senior trainees. Music also improved quality of skin repair as judged by blinded faculty members. Music improves efficiency of wound closure, which may translate to healthcare cost savings. Music is a special type of noise. Carefully selected music has a well-known calming effect during stressful situations. Music has variously been shown to have a positive, neutral, or negative effect on different measures of surgeons’ performance.

Positive

27/30 scores

Positive, 14/30 neutral or scores negative effect

Surgeons who themselves played a musical Positive instrument were found to perform surgical tasks faster, but anesthesiologists found music to be associated with difficulties in communicating and offering a firm level of sedation. The most suitable music in the operating theatre appeared to be of the classical kind. Music in the operating theatre can have beneficial effects on patients by decreasing their stress, anxiety, and the request for analgesic and anesthetic drugs. For the surgical staff, music can distract their task performance.

24/30 scores

EG=1 High quality

EG= 4 Insufficient quality

EG= 2 Moderate quality

Way et al (2013) 24

Journal of American College of Surgeons

Prospective experimental investigation.

Wiseman (2012) 25

Surgical Innovation

Randomised double blinded controlled trial.

Operating theatre noise can cause a decrease in Negative the auditory processing function, particularly in the presence of music. This becomes even more difficult when the communication involves conversations that carry critical information which is unpredictable. To avoid miscommunication in the operating theatre, a reduction of ambient noise levels is beneficial. 55 male To study whether the A test of hand–eye coordination involving Positive laparoscopic Mozart Effect can laparoscopic surgical skills and practice effect novices. improve the surgical performance was studied along with the performance. interaction between practice and music exposure. Prior exposure to certain classic music may enhance spatial temporal reasoning. Neuroplastic changes may be produced by music-related cognition; the Mozart Effect has improved mental rotation in nonmusicians while those musically trained already experienced neuroplastic changes and have less room for improvement. The rocky electrical instrumentation of Dream Theater brought about a greater improvement than Mozart exposure on a combined ring and rope task but is no contradiction to the fact that listening to Mozart improves spatial temporal reasoning. More exactly, it confirms music can influence the performance of a complicated physical task. The type of piece that was better for acknowledging the Mozart Effect lacks importance. Perhaps, some would perform better under a familiar Mozart condition than under the unfamiliar Dream Theater condition.

15 subjects ranging from 1 to 30 years of operative experience

To simulate operating theatre listening conditions and evaluate the effect of operating noise on auditory function.

26/30 scores

EG=2 Moderate quality

28/30 scores

EG=1 High quality

Conrad et al (2012)

Annal Surgery

Randomised triple blinded controlled trial.

31 laparoscopic novices.

British Journal of Surgery

Descriptive/ observational analytical

By questionnaire the behavior of the surgical team during operation was assessed. The outcome parameter was the SSI rate within 30 days of surgery. 100 staff, To evaluate the including 44 perception of influence surgeons. of music among surgeons, anesthesiologist and nurses as well as to critically evaluate whether music can be used as an aid in improving the work

26

Kurmann et al (2011) 27

.

George et al (2011) 28

Observational Journal of Anaesthesi- cross-sectional ology study Clinical Pharmacolo gy

To explore how the 2 most important components of surgical performancespeed and accuracyare influenced by different forms of stress and what the impact of music has on these factors. To evaluate the noise level in an operating theatre as a possible surrogate marker for intraoperative behavior, and to detect any correlation between sound level and subsequent surgical‐site infection.

Classical music during the first of two attempts Positive was played to find out if music during performance enhanced surgical memory consolidation and improved the relative increase in performance during the second attempt. Classical music may positively affect surgical memory consolidation if used appropriately.

27/30 scores

EG=1 High quality

Intraoperative noise volume was associated with Negative SSI. The median sound-level (43·5 (range 26 ·0– 60·0) versus 25·0 (25 ·0–60·0) dB; P =0·040) and median level above baseline (10·7 (0·6–33·3) versus 0·6 (0 ·5–10·8); p =0·001) were higher for patients who developed a SSI. This may be due to a lack of concentration, or a stressful environment, and may therefore represent a surrogate parameter by which to assess the behavior of a surgical team.

EG=1 (27/30) High quality

EG=1 High quality

Majority of the respondent's preferred playing Positive music in the operating theatre which helped them relax. Music improved the cognitive function of the staff and created a sense of well- being among them and elevated their mood. It also helped in reducing the autonomic reactivity in stressful surgeries allowing the staff to approach their surgeries in a more thoughtful and relaxed manner. Different effects of specific music types varied with different individuals. Music can aid in

22/30 scores

EG=3 Low quality

Makama et al (2010) 29

African Health Science.

Observational study

Conrad et al (2010)

Surgical Endoscopy

Experimental Randomised crossover trial.

Surgical Innovation

Case control study.

30

Siu et al (2010) 31

efficiency of the staff improving the work efficiency of medical in the operation personnel in the operating theatre. In brief, this theatre. study highlighted the beneficial effects of playing music in the OT outweighing its deleterious outcomes. 162 staff. To study the About 90% of the respondents agree that music Positive (Response rate application of music in should be played in the operating theatre. (97.5%) 97%) operating theatres in considered low tone being the most appropriate in Nigeria. the OT, while 3(1.9%), and 1(0.6%) considered moderate and high tone respectively to be most appropriate. (71.6%) preferred jazz music while (11.7%) reggae, (6.8%) African music, (8.0%) others (not specify), (1.2%) classical, and (0.6%) Irish folk. The majority of the participants were aware of the role of music in terms of its anxiolytic effect, reduction of stress and enhancement of performance when familiar type of music is played. Music in the operating theatre has immeasurable effects. It can prevent distraction, minimize annoyance, reduce stress and diminish the anxiety of staff. Eight To study the effects of Surgical proficiency does not protect against Positive laparoscopic defined auditory stressful auditory effects or the influence of experts. conditions on the mental preoccupation. Relaxing auditory performance of influences such as classical music can have a laparoscopic surgery positive impact on the accuracy of experts. In experts. addition, previous musical experience could help to identify surgeons whose performance may be affected by music or noise. Ten To study the effect of A significant music effect was found with Positive participants music on robot- decreased time to task completion. Participants with limited assisted laparoscopic improved their performance significantly when

22/30 scores

EG=3 Low quality

25/30 scores

EG= 2 Moderate quality

26/30 scores

EG= 2 Moderate quality

experience surgical performance. with the da Vinci robotic surgical system.

they listened to either hip-hop or Jamaican music. Music with high rhythmicity has a beneficial effect on robotic surgical performance. Music may benefit surgical training and can help in the acquisition of surgical skills.

Table 2. Music-induced changes in the surgical performance Surgeons n + trainees

Level of quality

Level of scientific evidence

Music’s effect on surgeon

Surgeon’s performance-task changes from listening to music

Surgeon’s performance tasks improved by music High

Lies and Zhang

15

Wiseman

55

High

Conrad et al.

31

High

Strong

Positive

Positive

Details

Music improved efficiency in time The average time to execute the skin repair for all trainees in of wound closing plus enhanced the plastic surgery was 11.5 minutes without music and 10.6 quality of skin repair minutes with music (7% difference). When excluding trainees, the average time to complete skin repair took 10.3 minutes without music and 9.5 minutes with music (8% difference). Senior trainees with a higher level of training, were 11% faster with music. Also quality of skin repair was improved. The complex Mozart Effect improved laparoscopic surgical skills requiring spatial temporal reasoning

Moderate

Essentials, that may change surgical performance tasks

Music improved surgical memory consolidation and classical music may produce the possibility to predict surgeon’s performance and learning under stress

Wiseman speculated that prior experience of a particular music piece can “override” the covariance between practice and music, which rests on the nature of the task and along with the music piece. While listening to Mozart enhances spatial temporal reasoning, Wiseman showed and extended the Mozart effect by revealing that subjects surgical performance tasks of listening to music before surgery improved. It was disclosed that the qualities in music, that impacted the performance of a complicated physical task, do not stem solely from Mozart’s music and does not need to accompany the actual performance during the surgery. Relaxing music improved surgical motor learning of a surgical procedure. By studying auditory stress combined with mental stress in forms of resolving arithmetic tasks, Conrad et al.’s found that music could serve as an efficient device to reverse some of the stressors’ impact on surgical performance such as negative effects on surgical motor learning.

Kyrillos and Caissie

14 + 12

Moderate

Music improved surgical skills and memory consolidation

Two parameters for the Capsulorhexis task showed a strong trend for improvement with exposure to music, especially to the Mozart sonata for 2 pianos in D-K448

Yamasaki et al.

39 + 60

Moderate

In general, surgeons enjoyed music. Music was given low scores for being a distraction. However, a discussion about music in the operation theatre is necessary to take all opinions into account.

Surgery providers are the predominant decision makers about music played in the operation theatre. They enjoyed music, they liked top 40 hits- and preferred a higher volume, more so than anesthesia providers. Yet, both groups preferred music being played at moderate tempos. Surgery providers preferred music that was familiar to them.

Surgeon’s performance impaired by music Weldon et al.

4+5

High

Strong

Negative

tasks

Music can interfere with communication but was seldom recognized as a safety hazard in the operation theatre. Yet, the calculated risk difference between music and non-music surgery situations, revealed that the risk was highly significant and unlikely to be due to chance. Analysis of repeated requests revealed an increase in operation time per repeat and an increase in tensions due to frustration from ineffective communication, was exposed. When music masks the audibility of speech, the surgeons often must repeat themselves and it takes longer for nurses to respond with assistance.

Out of 20 surgeries 69 repeated requests out of which 63 were from operation theatres with music on, were exposed. Weldon et al. found that playing music during task performances vs. not playing music during task performances, augmented the numbers of repeated requests with an increase of 4–68 seconds per repeat added to operation time. The researchers uncovered also increased pressures due to frustration from unproductive communication. The impact of loud music on communication hindered the nurses to hear the surgeon’s speech. Surgeons had to repeat themselves and therefore, it took longer time for nurses to respond with assistance.

Kurmann et al.

35 elective High open abdominal procedures (n surgeons not mentioned)

Strong

Negative

Intraoperative noise volume (music or other sound) is a possible marker of a difficult operation, which relates volume to 30 days later surgical‐site infection (SSI) in 17% of the 35 operations. An association between non-patientrelated conversation and sound level was found. Median sound levels during surgery were significantly higher for patients who developed SSI than for those primary healed 43,5 versus 25, 0 dB.

Kurmann et al. found that duration of surgery was not influenced by sound level (they did notseparate between music and other sounds in the recording) (median 300 (150– 540) versus 270 (60–660) min for operations with a sound level above and below the overall median. There was no difference in the median sound level between colorectal and hepatopancreatobiliary surgery. However, median sound levels during surgery were higher for patients who developed SSI than for those with primary healing. In addition, the median sound levels above baseline were higher for patients who developed SSI.

Highlights: • • •

Surgeon’s task performance can significantly be improved by music Elements of music can influence the surgical task performance both positively or negatively The distracting effect of loud or high-beat type of music should be put in consideration in operating theatres

The data used to support the findings of this systematic review study are included within the article.

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