Music therapy for reducing surgical anxiety - Clinical Innovations

Michele Brunges

Environmental sounds are part of people's everyday lives, and they elicit many different psychological and emotional responses. For example, the shriek of a police siren might induce surprise or fear; a baby's wail might provoke edginess and irritation; and a song on the radio might stimulate joy. Music in particular affects people deeply.

Past studies have demonstrated that the use of music can be an effective technique in the clinical area because it can distract patients and muffle the many sounds (eg, monitors, alarms) of a normal busy hospital. Researchers have confirmed that music that promotes relaxation can provide a noninvasive method of decreasing patients' anxiety and improving their emotional state. One study investigated listening to music as a method of reducing patients' anxiety during minor surgery with local anesthesia. The results showed that patients who listened to their choice of music during surgery experienced significantly lower anxiety levels, heart rates, and blood pressure than patients who did not listen to music. (1) Another study that produced similar results measured the effects of listening to music intraoperatively on patients' anxiety and blood pressure. (2)

Many studies have shown patients' psychological response to music. A study compared the effectiveness of playing music with the effectiveness of using a different kind of distraction, such as counting, to lessen procedure pain and anxiety in patients with cancer. Outcomes achieved with music did not differ from those achieved with simple distraction. Some patients found the interventions were bothersome and reported that they wanted to focus on the activities of the surgeon and the medical procedure itself. Patients were asked to choose between being distracted and listening to music before and during the procedure. The effects of music, distraction, and treatment were inconclusive. (3)

Recent research has looked at physiological responses associated with musical stimuli. One study that investigated event-driven skin conductance responses to musical emotions in humans demonstrated that music was a powerful elicitor of emotion and might induce autonomic nervous system response. Emotional arousal caused by music in that study evoked and modulated skin or conductance responses. (4)

Researchers also found that music can help reduce pain. For example, patients who listened to music and controlled their own pain with analgesia after gynecologic surgery experienced less pain man patients who only administered their own analgesia. (5)

PATIENTS AND MUSIC

Patients waiting for surgery experience anxiety and a fear of pain, and reducing their anxiety preoperatively may produce beneficial postoperative outcomes. Music is one method of enhancing patients' preoperative experience and decreasing anxiety. Researchers used findings from past studies and added new studies to develop the project in this article, which tested the use of music as a therapy during the preoperative period.

The effects of the music intervention were measured by physiological responses (ie, epinephrine secretion) and psychological responses (ie, questionnaire completion) to music.

Patients selected for this project were scheduled for total joint replacement, a stressful surgery that can alter patients' lifestyles. Researchers chose this group of patients because they easily could measure both types of responses to music therapy. Patients who undergo this type of procedure routinely have an indwelling catheter inserted before surgery, so researchers could measure urine epinephrine without applying additional invasive techniques.

EPINEPHRINE AND THE STRESS RESPONSE

During the neuroendocrine response to stress, the adrenal medulla is sympathetically stimulated to secrete dopamine, norepinephrine and epinephrine hormones--collectively called catecholamines. The adrenal glands release epinephrine, also called adrenaline, in response to signals from the sympathetic nervous system. Stress, exercise, and emotions, such as fear, trigger these signals.

Epinephrine commonly is referred to as the hormone that induces the tight or flight response. When epinephrine is released, the heart beats more strongly, blood pressure rises, more blood flows to the brain and muscles, and the rate of breathing increases. (6) Blood and urine can be tested for epinephrine.

STUDY PROCEDURE

After the project was explained to potential participants, they were asked if they wanted to be involved. Patients who agreed to be part of the study were assigned to one of two groups. One group did not listen to music. The other group listened with headphones to music from portable compact disc (CD) players while they waited for a minimum of 30 minutes in the preoperative holding area. The music selection consisted of music-enhanced nature sounds, such as the sea, thunder, rainstorms, wind, and waterfalls. The patients ranged in age from 39 to 81. Twenty-three males and 21 females participated. Patients who listened to the music agreed to complete a questionnaire that asked them about their perceptions of the music's effect.

Epinephrine was measured by urine collection, which began during surgery when the indwelling urinary catheter was inserted and continued for 24 hours.

STUDY RESULTS

Epinephrine levels were lower in patients who listened to music than in those who did not (Table 1). These findings concur with those of past research that music decreases physiological response to anxiety and the stress of a surgical intervention.

Patients who listened to music were asked on the questionaire whether they believed that it helped decrease their anxiety. There was no questionnaire for the group who did not listen to music; however, many in that group offered voluntary opinions. Some asked, "Where is my music?" and some expressed disappointment when they learned they were not in the group that would listen to music. All participating patients had positive comments and suggestions regarding the implementation of music therapy and said they felt that the music decreased their anxiety toward their upcoming surgery.

Most significantly, researchers also noted that there was a difference in the length of hospital stay between patients who listened to music and those who did not (Figure 1). Patients who listened to preoperative music experienced shorter lengths of stay. Whether this result was related to the decrease in anxiety preoperatively is unknown. In a hospital that maximizes its average daily census, these results become very important for the strategic plan.

[FIGURE 1 OMITTED]

DISCUSSION

This project demonstrated the importance of providing music for surgical patients who want it. Music therapy had positive effects on this group, and patients perceived they had received a higher quality of care. The use of music preoperatively for some patients appears to be an excellent noninvasive technique that can offer patients additional comfort in a stressful situation. Music therapy contributes to reduced anxiety, blood pressure, and heart rate and to relaxed muscle tension. This project demonstrates that many opportunities may exist for additional controlled investigations during surgical experiences to improve patient outcomes.

TABLE 1
Epinephrine Secretion Results

        Reference   Music results   Nonmusic results

Range   0-20 mcg      5-10 mcg          8-32 mcg

Epinephrine secretion was lower in total joint-replacement
patients who listened to music preoperatively.

Editor's note: The authors thank Kimberly-Clark Corp for their funding support and the anesthesia nurses for their help in providing music for patients awaiting surgery.

NOTES

(1.) E Mok, K Y Wong, "Effects of music on patient anxiety," AORN Journal 77 (February 2003) 396-410.

(2.) V M Steelman, "Intraoperative music therapy: Effects on anxiety, blood pressure," AORN Journal 52 (November 1990) 1026-1034.

(3.) K L Kwckkeboom, "Music versus distraction for procedural pain and anxiety in patients with cancer," Oncology Nursing Forum Online 30 (May-June 2003) 433-40.

(4.) S Khalfa et al, "Event-related skin conductance responses to musical emotions in humans," Neuroscience 9 (August 2002).

(5.) M Good et al, "Relaxation and music reduce pain after gynecologic surgery," Pain Management Nursing 3 (June 2002) 61-70.

(6.) J R Stratton et al, "Hemodynamic effects of epinephrine: Concentration-effect study in humans," Journal of Applied Physiology 58 (April 1985) 1199-1206.

MICHELE J. BRUNGES

RN, BSN

OUTCOMES COORDINATOR

SHANDS HEALTHCARE

GAINESVILLE, FLA

GAIL AVIGNE

RN, BS

NURSE MANAGER

SHANDS HEALTHCARE

GAINESVILLE, FLA

COPYRIGHT 2003 Association of Operating Room Nurses, Inc.
COPYRIGHT 2003 Gale Group