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The Effect of Complementary Music
Therapy on th e Patient s Postoperative
State Anxiety, Pa in Control, an d
Environmental Noise Satisfaction
Tressa
Comeaux
Susan
Steele Moses
U
nrelieved postoperative pain
remains a common problem
despite advances in pain
management. Lack of sleep, often
caused by environmental noise in
hospitals, can contribute to irritabili-
ty, anxiety, and increased pain.
While analgesia is capable of modify-
ing many of the pathophysiological
responses to pain (Layzell, 2008),
pain in the postoperative patient is
of ten unre l ieved. Complementary
music therapy can create a distrac-
tion ftom pain, anxiety, worry, and
sadness, thereby increasing patient
satisfaction with the postoperative
experience (Koelsch, 2009).
Background
Our Lady of the Lake Regional
Medical Center (OLOLRMC) is a
M agne t®-d esigna ted, DAISY® Hos-
pital Partner with surgical volume of
11,270 cases annually. Postopera-
tively, patients are admitted primari-
ly to the inpatient surgical unit
(SURG). SURG is a 27-bed inpatient
uni t with two wings (A ha ll= ll beds;
B hall=1 6 beds) . Its staff ma nag es
care of patients after planned surgi-
cal procedures, predominately ab-
dominal , vascular , and oncology
diagnoses. In fiscal year 2010, 2,191
patients were discharged ftom SURG
with an average length of stay of
3.57 days.
Theoretical Model
As part of the professional model
of care at OLOLRMC, principles
inherent to Relationship-Based Care®
Postoperative pain is difficult to m anage with analgesia alone.
Com plementary interventions such as music therapy provide a level o f
distraction thus prom oting com fort. In this study decreased pain and
environmental noise were demonstrated without diminishing state
nxiety in a group of postoperative patients.
(RBC) delivery model supported the
study. Three crucial relafionships in
RBC include care of self care of col-
leagues, and care of patients and fam-
ilies. Nurses convey caring and com-
passion thro ugh touch, kindness, clin-
ical interventions, active listening,
and und erstandin g of the pafient s
experience (Koloroutis, 2009). The
purpose of this study was to deter-
mine if the use of music therapy was
an effective adjunct to decrease state
anxiety while increasing pain man-
agement and environmental noise
satisfaction in the postoperative
pafient.
Literature Review
The review of literature was con-
ducted ufilizing th e following d atabas-
es: Cumulafive Index to Nursing and
Allied Health Literature (CINAHL)
Plus,
The Cochrane Library, Lexis-
Nexis® Academic, PubM ed, Med line,
and the Joanna Briggs Ins t i tute .
Literature reviewed was limited to
the period ftom 2007-2012. Search
terms included
complementary music
therapy postoper tive pain postopera-
tive anxiety relationship-based care
state-trait anxiety and environmental
noise.
Th e review of literature prov id-
ed evidence tha t complementary
music therapy is eftective in reduc-
ing pos topera t ive anxie ty while
increasing pain control satisfaction.
According to the Joanna Briggs
Institute (2009), music therapy as a
non-pharmacologica l adjuvant to
opioid analgesia is best practice in
the management of pain and anxi-
ety. Unrelieved postoperative pain
can lead to complications, such as
ineftective breathing patterns and
delayed ambula t ion, resul t ing in
Tressa Comeaux A PRN FNP-C C EN is CICU Staff Nurse Our Lady of the Lake Regional
Medical Center Patient Care Services Baton Rouge LA.
Susan Steele-Moses DNS APRN-CNS AOCN® is Research Director Our Lady of the Lake
Regional Medical Center Academic Affairs Baton Rouge LA.
Acknowledgments: This study was funded by a non-restricted grant from the DAISY Fou ndation:
JPB-021-A. The authors wish to thank Angela Dykes BSN RN; Sandra Wade MN APRN-CNS;
and Yvette Robson RN-BC who conducted the ongoing study on the SURG unit at Our Lady of
the Lake Regional Medical Center Baton Rouge LA.
M S U R G
September October 2013
•
Vol. 22/No. 5
313
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Research or ractice
Introduction
Unrelieved postoperative pain remains
a
com mo n p roblem despite advances
in
pain management. Complementary music has been suggested as an adjuvant
to
the standard
of
care treatm ent fo r postoperative
pain.
Purpose
The purpose of this s tudy was to determine if music therapy was
an
effective
adjunct to decrease state anxiety, and increase pain m anagem ent and environ -
mental noise satisfaction
in
the postoperative patient.
Method
A quasi-experimental non-equivalent control group design was used
in
this study
with participants assigned based
on
room assignment rather than randomly. The
control group, which consisted of participants admitted to the A hallway, received
the standard of care.
The
intervention grou p, wh ich consisted of participants
admitted
to
the B hallway, received comp lemen tary music therapy
in
the form
of
pre-programmed MP3 players, in addition to the standard of care. Based on the
premise
of
a non-equivalent c ontrol design, neither analgesia ty pe
nor
route was
controlled. Each participant was enrolled
for
a total
of
3
days
or
until discharge,
whichever came first. Outcome measures were collected upon enrollment (Time
One) and for the next 2 consecutive days (Time Two and Time Three). Participants
in
the
intervention group were encouraged
to
listen
to a
selection
of
non-lyrical
low decibel (less than
60 db
pre-programmed music,
for at
least
30
minutes via
a
MP3
player after their prescribed analgesia was adm inistered . Non-lyrical
low
decibel m usic was chosen for this study because previous research supported its
effectiveness. State trait anxiety as well as pain and environmental noise satisfac-
tion were assessed using
the
State-Trait Anxiety Inventory and
two
standardized
questions f ro m the Press Ganey® survey.
Findings
Before the intervention was implemented, both groups were the same related
to
their average level
of
state and trait anxiety,
pain,
and noise perception. The
patient s state anxiety, pain perception ,
and
noise perception were measured
day after
the
intervention was
in
place.
A
significant difference was found from
Time One to Time Two in pain managem ent (t=3.938, p<0 001 ) and environmen-
tal noise satisfaction (t=3.457, p=0.001), while there was
no
change
in
state anx-
iety (t=0.373, p= 0 .7 n ). The intervention group experienced improved pain man-
agement (t=7.385, p<0.011)
and
environm ental noise satisfaction over tim e
(t=4.371; p<0.001); however, there was no improvement in state anxiety (t=1.47;
p=0.159). The findings suggest music therapy decreases pain and environmental
noise perception, although there was
no
effect on state anxiety.
Conclusions
Use of music therapy improves patients postoperative experience
by
increasing
their pain ma nagem ent and w hite noise satisfaction. Because the intervention w as
tested on a busy post-surgical unit with a short inpatient stay (mean=3.57), the
effect
of
music therapy over more than
2
days could not be m easured. This inter-
ventio n was inexpensive a nd easy
to
implement
in
the clinical setting, and the re-
fore recommended
to
improve postoperative outcom es in othe r facilities.
It
is rec-
om me nde d the study be replicated wit h a larger sample size and different p atient
populations
to
validate these findings .
increased postoperative morbidity,
delayed recovery and return
to
nor-
mal daily living, and reduced patient
satisfaction (Macintyre, Schug, Scort,
Visser,
Walker, 2010).
ffect
of
Music Therapy
Research indicates music therapy
provides distraction, promotes relax-
ation, and decreases anxiety (Engwall
Duppils, 2009). Music therapy has
a beneficial effect
on a
patient's per-
ceived pain, relaxation, respiratory
rate,
self-reported anxiety level,
and
the amount
of
analgesia required
for
eftective pain management (Ameri-
can Music Therapy Association,
2010). When used
in
conjunction
with pharmacologie pain manage-
ment strategies, music therapy pro-
motes
a
sense
of
well-being
and an
overall positive patient experience
(Walworth, Rumana, Nguyen,
Jarred, 2008). While music therapy
has
the
propensity
to
promote
dis-
traction
and
relaxation, limited
research has focused on the effective-
ness
of
music therapy
for
pain m an-
agement
in
postoperative patients
outside
a
controlled environmen t
Goanna Briggs Institute, 2009).
Relationship hetween Pain
and nxiety
Postoperative pain, while
an ex-
pected consequence
of a
surgical
procedure,
is
infiuenced
by
psycho-
logical factors, such as fear and anxi-
ety (Engwall
Duppils, 2009).
Be-
cause trait anxiety inherently is indi-
vidualized
and
aftects
the
ability
to
address
a
perceived threat, persons
wit
heightened anxiety may experi-
ence more postoperative pain than
those who are less prone
to
anxiety
(Lin, Lin, Huang, Hsu, Lin, 2011).
Conversely, patients with
low
trait
anxiety may
be
more pain tolerant
than those with high trait anxiety.
Researchers recommend interven-
tions should
be
stratified based
on
the participant's trait anxiety score
(Binns-Turner, 2008; Nilsson, 2008).
Contrary
to
trait anxiety, state anxi-
ety refers
to
feeling nervous
or
anx-
ious when faced
vnt an
imm ediate
danger
or
stressful situation.
It is
transient, fiuctuates over time,
and
varies in intensity (Lin et al., 2011).
3 4
September October 2013 • Vol
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M E D S U R G
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The Effect of Complem entary Music Therapy on the Patient's Postoperative State Anxiety, Pain C ontrol, and Environmental Noise Satisfaction
Environmental Noise
Reduction
Environmental noise is a signifi-
cant barrier to sleep for hospitalized
patients; research supports sleep
as
therapeutic
to
overall health, wound
heal ing, and recovery (Gardner,
Col l ins, Osborne, Henderson,
Eastwood, 2009). Noise in and
around
the
nurses' station
can be
especially problem atic (Haupt, 2012).
Music therapy functions as a dis-
tracter ftom hospital noise, thereby
reduc ing emot iona l anx ie ty and
pain (Gardner
et al.,
2009).
To pro-
m ote relaxation, music should: (a) be
non-lyrical, ti) have predom inant ly
low tones, (c) have m inima l brass
and percussion,
and (d)
have
a
max-
imum dec ibe l vo lume
of 60 db
(Nilsson, 2008).
Purpose and ypothesis
The purpose of this study was to
determine the eftect of music thera-
py on state anxiety, postoperative
pain, and environm ental noise per-
cep t ion . The hypo thes i s for this
study was as follows: Music therapy
will decrease state anxiety, increase
pain management eftectiveness,
and
increase environmental noise satis-
faction in postoperative patients.
Method
The first 41 data sets collected to
test the efficacy and feasibility of the
study methods are reported here.
The larger study, which is still o ngo -
ing, consists of three grou ps: (a) con-
trol, (b) music the rapy, and (c) wh ite
noise therapy. The pilot study and
the larger s tudy were provided
exempt status by bo th the Nursing
Research Council and Clinical Re-
search Steering Co mm ittee of OLOL-
RMC. An
implied con sent process
was used because a wriften consen t
would have t ied the participant to
the study, thereby precluding
exempt criteria definition. Providing
complementary music therapy
via
pre-programmed MP3 players was
an inexpensive intervent ion that
was implemented easily to enhance
the patient's postoperative experi-
ence.
TABLE 1
Demographic Data by Croup
Variable
Gender (A/=41)
Male n=27)
Female n=14)
Race (/V=41)
Caucasian n=25)
African American n=15)
Not disclosed n=1 )
Standard
of
Care
14 (34.2 )
8 (19.5 )
13 (31.7 )
8 (19.5 )
1 (2.4 )
Intervention
13 (31.7 )
6 (14.6 )
12 (29.3 )
7 (17.1 )
Sample and Setting
All patients adm itted to the surgi-
cal unit
who met the
following
inclusion criteria were asked
to par-
ticipate in the study: anticipated 3-
day hospital length of stay, alert and
oriented, age 18 or older, able to read
and write English, and hematology-
oncology diagnosis . Par t ic ipants
were not assigned randomly to the
in tervent ion but rather placed into
groups based on the hallway assign-
me nt. P articipants admifted to the A
hallway received the standard of care
(control group), while participants
admifted
to the B
hallway received
complementary music therapy (in-
terve ntion group) (see Table 1). Both
groups received the provider-ordered
analgesia. Participants in the inter-
vention group were encouraged to
listen to a selection of non-lyrical
p re -p rogrammed music via MP3
players for 30 minutes following the
administration
of
prescribed analge-
sia. Each participant was enrolled
in
the study for 3 consecutive days
(Time
One,
Time Two, Time Three)
or until discharge, whichever came
first.
e sures
The State-Trait Anxiety Inventory
(STAI)
was
used
to
evaluate anxiety.
The STAI is divid ed in to the two sub-
scales: STAI Form Y-1 and STAI F orm
Y-2. The 20-item STAI Form Y-1
(Chronb ach's a lpha = 0.62) was used
to m easure state anxiety (Spielberger,
Gorsuch, Luschene, 1970). The
STAI Form
Y-1
(range score 20-80)
measures the participant 's current
emotional feeling, such as calm or
nervous. Participants rated the de-
gree to which the item represented
how they currently felt using a 4-
po int Likert scale ranging ftom not at
all to very much so,
with
the
higher
score indicating greater state anxiety
(Spielberger et al., 1970).
The 20-item STAI Form Y-2
(Chronbach's alpha = 0.86) was used
to measure trait anxiety. The STAI
Form
Y-2
(range score
of
20-80) mea s-
ures participants' usual emotional
feelings, s uch as feelings of inadequa-
cy or happiness (Spielberger et al.,
1970). Parücipants rated the degree
to which
the
item represented
how
they generally felt using a 4-point
Likert scale with responses ranging
ftom almost never to almost always;
the higher score indicated higher
trait anxiety (Spielberger
et
al., 197 0).
Two standardized items concern-
ing patient satisfaction, which were
developed and used extensively by a
national vendor, measured the par-
ticipant's satisfaction with pain man-
agement and environm ental noise.
Participants were asked to rate each
item:
(a)
During
the
previous
24
hours, I am satisfied with my pain
control, (r2 = 0.72) (Press Ganey,
2010) and (b) Dur ing the previous
24 hours, I am satisfied with the
noise level in and a round my r o o m
(r̂ = 0.74) (Press Ganey, 2 010), on a
4-point Likert scale ranging ftom 1
no t t
all
to 4
{very
much so), with a
higher score indicating greater satis-
faction.
Data ollection Procedures
A m e m b e r
of the
clinical support
team, which consisted of a clinical
nurse specialist, clinical educator.
M S U R G
September October 2013 • Vol
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S
315
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Research for Practice
program direetor for nursing re-
seareh, and direet-eare nurse, ap-
proaehed eaeh patient on the first
postoperative day, explained the
purpose of the study, obtained verbal
eonsent, and provided data eollee-
tion paekets. Patients loeated on the
B hallway also reeeived the musie
intervention. The data eoUeefion
paeket eonsisted of a manila enve-
lope eontaining the initial survey
(Time One), two follow-up surveys
(Time Two and Time Three), and
three white envelopes. To proteef
patient anonj^nity and assure aeeu-
rate data analysis, surveys were
eoded based on the hallway assign-
ment, partieipant number, and day
of completion (e.g.: A-100-Time 1, A-
100-Time 2 , A-100-Time 3). The par-
fieipant s state anxiety, tra it anxiety,
and pain management and environ-
mental noise satisfaetion over the
previous 24-hour period were meas-
ured on enrollment (Time One).
State anxiety, t he patien t s pain
seore, and noise satisfaetion were
measured at Time Two and Time
Three or until diseharge, whiehever
eame first. The patient was instruet-
ed to plaee eaeh eompleted question-
naire in a white envelope, seal if, and
plaee fhe sealed envelope in the
manila envelope to maintain eonfi-
dentiality. Daily, the clinieal support
staft rounded, enrolled new patients,
distributed paekets, reminded pa-
tients to eomplete the questionnaire,
and eoUeeted eompleted paekets. In
the event the patient was diseharged
between rounding periods, a survey
eolleetion box was plaeed at the
nurses station for the patient to
deposit the MP3 players and eom-
pleted data eolleefion paekets. MP3
players were wiped with a germieid-
al disinfeetant between patients;
however, the ear buds were not
reused.
Data nalysis Procedure s
Deseriptive statisties were used to
summarize the sample démographie
eharaeteristies. eomparative analy-
sis of the mean difterenees within
groups was eompleted using a paired
t test. Analysis between groups was
eompleted using an independent t
test.
TABLE 2 .
Difference between Groups per Study Variable, Time One N=4^)
Variable
State Anxiety
Music
Control
Trait Anxiety
Music
Control
Pain Management Satisfaction
Music
Control
Environmental Noise Satisfaction
Music
Control
n
19
22
19
22
19
22
19
22
M
9.63
36.05
37.42
32.81
2.42
2.73
2.74
3.14
t
1.112
1.448
1.694
1.864
P
0.273
0.156
0.098
0.070
TABLE 3.
Difference betwe en C roups per Study Variable, Time Two /y/=41)
State Anxiety
Music
Control
Pain Management Satisfaction
Music
Control
Environmental Noise Satisfaction
Music
Control
19
22
19
22
19
22
37.11
35.68
3.47
2.77
3.53
3.05
0.373
3.938
3.457
0.711
<0.001
0.001
Findings
At Time One, no significant dif-
ferenee existed in state anxiety, trait
anxiety, or pain management or
environmental noise satisfaetion
between groups (see Table 2). The
partieipant s state anxiety, pain ma n-
agement satisfaetion, and noise satis-
faetion were measured again 1 day
after the intervenfion was in plaee
(Time Two). At Time Two, a signifi-
eant inerease was found in pain
management (t=3.938; p<0.001) and
environmental noise satisfaetion
(t=3.457; p=0.001), while n o ehange
was found in state anxiety (t=0.373;
p=0.711)(seeTable3).
The efteetiveness of the interven-
fion was analyzed over time. For the
eontrol group, no difterenee existed
in state anxiety (t=0.149; p=0.883),
pain m anagem ent (t=0.237;p=0.815),
or environmental noise (t=0.568;
p=0.576) satisfaetion ftom Time One
to Time Two (see Table 4). The inter-
vention group experieneed a signifi-
eant improvement in pain manage-
ment (t=7.385;p<0.001) and satisfae-
tion with environmental noise
(t=4.371; p<O OOiy however, no
ehange was found in the partieipant s
state anxiety (f=1.47; /7=0.159) ftom
Time O ne to Time Two (see Table 5).
Discussion
Both groups expressed average
levels of general anxiety (trait) and
situational anxiety (state) at the
3 6
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The Effect of Complementary Music Therapy on the Patient s Postoperative State Anxiety, Pain Control, and Environmental Noise Satisfaction
TABLE 4
Difference with in Group from Time One to Time Two, Co ntroi N=22)
State nxiety
Time One
Time Two
Pain Management Satisfaction
Time One
Time Two
Environmental Noise Satisfaction
Time One
Time Two
36.05
35.68
2.73
2.77
3.14
3.05
0.149
237
568
883
0.815
576
TABLE 5 .
Difference with in Group from Time One to Time Two , Music N=19)
State nxiety
Music
Control
Pain Management Satisfaction
Music
Control
Environmental Noise Satisfaction
Music
Control
39.63
37.11
2.42
3.47
2.74
3.53
1.47
7 385
4.371
0.159
<0.001
<0.001
completion of the Time One meas-
ure. The Time One measurement of
pain and environmental noise satis-
faction indicated participants gener-
ally were not satisfied with pain.
management or with noise levels in
and around their rooms. During the
Time One measurement, all partici-
pants reported being only somewhat
satisfied with pain m anagem ent over
the previous 24 hours (music group
li=2.42;
control group ]i=2.74), sug-
gesting participants were not satis-
fied with the standard of care alone.
At Time One, environmental noise
satisfaction was slightly higher in
the control group (p=3.14) than w ith
the music group (p=2.74). The differ-
ence in noise perception can be
attributed to renovations on the A
hallway, placing the bed behind a
double wall, further away from the
doorway, along with the installation
of acoustic tiles in each room .
The difference between groups at
Time Two revealed no significant
change in state anxiety (t=0.373,
p=0.711), suggesting music therapy
did not decrease situational anxiety
levels as previously predicted. Be-
cause the majority of the patients on
this un it had surgical oncology diag-
noses,
the lack of relationship bet-
ween music and state anxiety may
be understandable. Results of this
study partially supported the hypo-
thesis that music therapy is effecfive
as a non-pharmacological adjunct to
analgesia in increasing pain m anage-
ment and environmental noise satis-
faction; however, state anxiety re-
mained unchanged.
Nursing Implications
In th is study, use of musi therapy
improved pain management and
environmental noise satisfaction
when used as a com plementary ther-
apy. Therefore, distraction from neg-
ative experiences through use of
music therapy can increase satisfac-
tion in patients recovering from sur-
gery. This interv ention was inexpen-
sive and easy to implement in the
clinical setting, and therefore recom-
mended for use to improve postoper-
ative outcom es. MP3 player techno l-
ogy decreased in cost, providing a
viable option for hospitals. The play-
ers can be cleaned easily, patients
can be given their own ear buds to
keep,
and music discs are a one-time
purchase. Nurse leaders may consid-
er purchasing MP3 players inscribed
with their hospital logo for the
patients to keep, thus promoting the
intervention after discharge.
Findings ftom this study can be
incorporated easily in to the nurse s
practice. The medical-surgical nurse
could encourage family members to
bring the patient s favorite music
ftom home to augment analgesia.
Portable CD players, MP3 players,
and cell phones are all viable por-
table options to provide music.
Family members also should be
reminded to bring earphones or ear
buds to prevent disrupting other
patients. The nurse can encourage
the patient to listen to the music
immediately after analgesia adminis-
tration for a period of at least 30
minutes. Not only will the patient s
favorite music decrease anxiety, but
it also masks routine hospital noise
that patients often find annojáng.
Limitations and
Recommendations for
Future Research
Preliminary analysis identified
some limitations in the study. First,
patients were not assigned random-
ly to the intervention; although
room assignments were non-predic-
tive, they were not random . In addi-
tion, use of personal distraction may
have confounded the findings of
this study. Patients in the control
group also reported listening to
music. Patients may have brought
their own music with them or lis-
tened to music provided on the tel-
evision network. Because no manip-
ulation occurred to change usual
M S U R G
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Research
or
ractice
care, some unanticipated crossover
eftect m ay have o ccurred. While th e
sample size is small, the significant
difference observed may have
occurred by chance; however, find-
ings ftom the larger study support
the findings reported here. The
study should be replicated with a
larger sample size and w ith difterent
patient po pulations to validate these
findings. Data collected at Time
Three were limited due to the unit s
average length of stay or partici-
pants failure to complete the ques-
tionnaire on the day of discharge.
The
ST I
Qu estionnaire was tedious,
somewhat repetitive, and upsetting
for some, especially those with new
cancer diagnoses. Beginning the
intervention earlier in the preopera-
tive period also may be helpful so
the patient could benefit ftom the
intervention through the surgical
experience and hospitalization.
Conclusion
Findings of this study suggest
music therapy improves the postop-
erative experience through en-
hanced pain management and envi-
ronmental noise satisfaction. The
intervention was inexpensive and
easy to imp lement in the clinical set-
ting, and therefore is recommended
for use in improving postoperative
outcom es in other facilities.
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C o p y r i g h t o f M e d - S u r g M a t t e r s i s t h e p r o p e r t y o f J a n n e t t i P u b l i c a t i o n s , I n c . a n d i t s c o n t e n t
m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a l i s t s e r v w i t h o u t t h e c o p y r i g h t
h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t , d o w n l o a d , o r e m a i l a r t i c l e s f o r
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