Running head: REFLECTION OF RESEARCH
Reflection of Research
Patricia Moon
Ferris State University
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Abstract
This paper discusses a PICO question regarding the use of music as an intervention to reduce
anxiety in preoperative patients. It reviews three research articles concerning this topic. The first
article is based on a Cochrane review that covers 26 studies involving 2051 participants. The
second article is a random controlled trial of sixty patients. The final article is a quasiexperimental study of 20 breast biopsy patients. All studies reviewed used the State Trait
Anxiety Index (STAI) and in some cases physiological observations. Results from all studies are
considered. Review of data results support the use of music as a potential nursing intervention
to help reduce preoperative anxiety. Consideration is given related to the need for collaboration
between disciplines in order to promote institution of this implementation. Education for staff
members is necessary in order to maintain appropriate communication of the implementation.
Significance to nursing is reported along with factors that support increased promotion of patient
safety, patient satisfaction and a potential for cost savings for health care institutions.
Key words: music therapy, preoperative anxiety, nursing significance, patient safety
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Reflection of Research
Patients who about to undergo surgery experience many criteria that could cause potential
emotional turmoil or worry. Unfamiliarity of surroundings, procedures, along with fear over
potentially life changing diagnoses can cause patients to have heightened anxiety while being
prepared for surgery and waiting for the procedure to begin. Nursing interventions include
various measures to treat preoperative anxiety. This study will try to determine if listening to
music preoperatively is an effective way to reduce anxiety levels in patients preparing to go to
surgery.
PICO Question
The PICO question that I am discussing is: Does listening to music reduce anxiety levels
compared to not listening to music in adult perioperative patients as measured on a visual analog
scale (VAS) and decreased heart rate within the 30 minutes prior to going to surgery? The
surgical setting that this question refers to has the potential to be a very challenging environment
for many individuals. The area is often unfamiliar to patients with medical equipment that
appears daunting. Those who are familiar with surgery may have prior unpleasant memories of
discomfort or negative diagnoses. There may be unpleasant images from media or family that
weigh on the patient’s mind. Any of these things can cause the patient to feel anxious. Anxiety
can have a negative effect on a patient’s wellbeing which can become a safety issue. Anxiety can
cause problems during induction, intraoperative difficulties with maintaining anesthesia, and
during the emergence period at the end of the case (Watkins, Smith, & Guinn, 2010).
Anxiolytic medications are often used to help patient relax prior to surgery. However
numerous studies have been done on nonpharmacological methods to reduce anxiety. One of
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these methods is music therapy. Listening to music is a noninvasive relaxation technique that
may help reduce anxiety levels in surgical patients. Music is a cost-effective, non-labor intensive
nursing intervention that could easily be adapted into many preoperative settings. The outcome
for nurses is anxiety reduction in preoperative patients as evidenced by indicators such as
decreased heart rates, respirations, and rating on anxiety scales. The results for patients include
reduction in unpleasant side effects from antianxiety medications and faster recovery and
discharge (Braft, J., Dileo, C., & Shim, M., 2013).
Development of a plan to incorporate music therapy in the perioperative setting must
include interdisciplinary collaboration. It is necessary for all participants to be fully engaged in
the proposal prior to implementation. While music therapy can be implemented by the nursing
staff, all of the disciplines involved in preoperative care should be informed and supportive of
the plan of action.
Plans for music interventions should be reviewed during educational staff meetings
through the use of powerpoints, poster sessions, and policy manuals. These materials should also
be offered to the medical surgical staff and the anesthesia providers to ensure that everyone is
receiving the same education. Since music therapy is a non-invasive measure, there is little or no
safety risk to the patient. Concern for infection or the unavailability of headphones could be
remedied through the use of speakers which have been found to be an effective substitute ( Lee,
et.al, 2011).
Research Findings
Numerous studies have been performed regarding the use of music to help decrease
anxiety in the preoperative patient. Some studies review a variety of non-pharmacological
methods of anxiety reduction and include music as one of them. Additional studies investigate
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specific types of music and its ability to provide relaxation. The studies that I have chosen to
review focus on the use of music in the preoperative patient population as a means to reduce
anxiety.
The Cochrane review by Dileo & Shim is a systematic review that includes data from 26
trials that involved 2051 participants (Dileo & Shim, 2013). Studies involved patient care in
inpatient settings with comparisons between an experimental group that received the intervention
of music preoperative compared to a control group that received standard care. This article is
level of evidence (LOE) 1 and provides strong evidence that supports the use of music as an
anxiety reducing intervention preoperatively. Measurement of anxiety was done using the StateTrait Anxiety Inventory (STAI) test in addition to a Visual Analog Scale (VAS) and
physiological measurements of blood pressure, heart rate and respiratory rate. In addition, the
reliability of this review is increased due to the consistency of its results compared with two
other Cochrane reviews that also demonstrated the ability of music to help decrease preoperative
anxiety (Dileo & Shim, 2013).
An additional study by Cooke, Chaboyer, Schluter, & Hiratos was a LOE 2 randomized
control study that was performed in an adult day surgical center. The sample size was 60
participants which were equally male and female. The experimental group received the music
intervention, placebo patients wore headphones with no music, while the control group received
standard care. Pre and post testing was done. Patient anxiety was measured using the STAI test
which measures apprehension, tension, nervousness, and worry (Cooke et.al, 2005). Nurses
participated in the study but were not aware of which patients were receiving the music
intervention and which patients were simply wearing headphones (Cooke et al, 2005). Results
were in favor of supporting the use of music as an intervention to reduce preoperative anxiety.
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Data analyzed results showed that the “mean difference between intervention and
control/placebo patients was statistically significant (P<0.001)” but there was no statistical
significance between control and placebo patients (P=0.77) (Cooke et al., 2005). This meant that
listening to music was statistically significant in reducing mean anxiety scores when compared to
not listening to music (Cooke et al., 2005). The significance for nursing is that providing music
to preoperative patients can be done as a non-invasive intervention that nurses can do on their
own to help reduce preoperative stress. It is an easy, practical, non-labor intensive action that can
increase patient autonomy and self-care (Cooke, et al., 2005).
In a LOE 4 study of preoperative breast biopsy patients, Haun, Mainous, & Looney
(2001) performed a quasi-experimental study to determine if listening to music could help reduce
anxiety in this group. Breast biopsy patients were chosen due to the increased element of anxiety
due to the possible diagnosis of cancer that may be an outcome of their surgery (Haun, Mainous,
& Looney, 2001). The study consisted of a convenience sample of 20 consecutive patients who
were alternately assigned to control or experiment groups. The control group received usual
preoperative care without music while the experimental group listened to music preoperatively.
Once again, STAI testing was used for both pre and post testing with the addition of vital sign
monitoring. The results showed lower STAI results and a decrease in respiratory rate among
patients in the experimental group. Blood pressure and heart rate did not coincide with
supporting music therapy as an antianxiety intervention. While this study has a small sample size
and uses only one gender in its population, the evidence gained in this LOE 4 study does support
the use of music as a preoperative intervention that can help reduce anxiety levels in preoperative
patients.
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A clinical control study by Lee, Chao, Yiin, Chiang, & Chao was conducted to determine
if there is a difference in preoperative anxiety in patients who either listened to music that was
broadcast, listened to music wearing headphones, or were in the control group and did not listen
to music at all. This randomized clinical control study was a LOE 2 and consisted of a total of
180 patients who were blocked by day randomization into one of the three groups. A heart rate
device and a visual analog scale (VAS) were used to obtain both subjective and objective
measures of anxiety (Lee et al., 2011). Results supported the intervention as a means to reduce
anxiety using music that was either broadcast or listened to on headphones using the indicators
of heart rate and VAS.
Recommendations to Improve Quality and Safety
Preoperative patient anxiety presents a challenge for nurses and other members of the
healthcare team. Studies have shown that preoperative sedation medications and antianxiety
medications can have negative side effects, increase recovery time, and delay discharge (Dileo &
Shim, 2013). Anxiety also has physiological effects such as increased heart rate, respiratory rate,
and blood pressure that may deter best patient outcomes (Cooke et al., 2005). In addition to
decreased anxiety, quality indicators also include enhanced patient comfort and enhanced patient
overall well-being ( Cooke et al., 2005). Safety factors include reduced use of antianxiety
medications which could have detrimental side effects and increased risk of falls and the need for
closer supervision by nursing staff. Music is a “non-labor intensive relaxation strategy” which
has an additional potential to increase patient autonomy (Cooke, et al, 2005). Music therapy can
easily be integrated into the preoperative setting through the use of broadcasting devices, hospital
supplied headphones, or patient supplied headphones. Encouraging patients to bring their
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favorite relaxing music to the preoperative area can help patients reduce anxiety prior to surgery
in a simple, non-invasive fashion.
Conclusion
Holistic healthcare and health promotion includes interventions that help patients their
highest level of well-being. Current studies into the use of music as an anxiety reducing method
suggest that nurses can implement music to help patients attain best outcomes in the surgical
setting. Promotion of noninvasive measures of care enables preoperative nurses the opportunity
to provide patients and their families with a viable alternative to the use of sedatives and can help
nurses encourage their patients to experience autonomy and a heightened ability for self-care.
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References
Bradt, J., Dileo, C., & Shim, M., (2013), Music interventions for peroperative anxiety (Review),
Cochrane Database of Systematic Reviews, (2013), Issue 6. Art. No.:CD006908. doi:
10.1002/14651858.CD006908.pub2.
Cooke, M., Chaboyer, W., Schluter, P., & Hiratos, M., (2005), The effective of music on
preoperative anxiety in day surgery. Journal of Advanced Nursing, 52(1), 47-55
Lee, K., Chao, Y., Yiin, J., Chiang, P., Chao, Y., (2011). Effectiveness of different musicplaying devices for reducing preoperative anxiety: A clinical control study. International
Journal of Nursing Studies,48, 1180-1188. doi: 10.1016/j.ijnurstu.2011.04.001
Watkin, J., Smith, S., Guinn, C., (2010), The efficacy of music therapy. Journal of
PeriAnesthesia Nursing, (25)4, 226-232. doi: /j.jopan.2010.05.009