NOVEMBER 1995, VOL 62, NO 5 Gaherson

The Effect of Humorous and Musical Distraction on Preoperative Anxiety

reoperative anxiety is a problem for most sur- gical patients. Excessive anxiety is thought to interfere with learning, affect the need for preanesthetic medication and anesthesia, and increase distress related to postoperative

pain.' A nursing intervention that reduces preopera- tive anxiety may reduce the incidence of complica- tions and shorten hospital stays, thereby reducing the cost of surgical patient care.

UrmATunEnEvIEw Few nursing research studies on the effective-

ness of nursing interventions to reduce preoperative anxiety have been reported. Studies investigating the effects of tranquil music on preoperative and postop- erative anxiety have demonstrated some reduction in anxiety, although the results cannot be generalized to all perioperative patients2

Humor has been studied as a means of manag- ing stress and relieving anxiety: but before a 1991 pilot study, no nursing research to study the effect of humorous distraction on preoperative anxiety had been reported. The following hypothesis was tested in the 1991 pilot study.

Among preoperative same day surgery patients who listen to a humorous audiotape, patients who listen to tranquil music, and patients who wait without auditory distraction for 20 minutes, there will he signijicant diger- ences in self-reported levels of preoperative anxiety. Those who listen to humorous audio- tapes will have the lowest anxiety levels, and those with no auditory distraction will have the highest level^.^

The pilot study was designed to test research pro- cedures and to determine the feasibility of conducting a larger test of the same hypothesis. The sample size of the pilot test w a intentionally small (n = 15), and the setting wa~ , limited to one hospital. Results of the pilot study showed that same day surgery patients who listened to humorous audiotapes reported lower levels of preoperative anxiety (mean [MI = 1.40) than patients who listened to tranquil music (M = 1.48) or who did not listen to tapes (M = 2.76). These differ- ences were not statistically significant (F = 1.48, P = .267), but a moderate effect size (ie, .496) suggested that statistical significance might be obtained with a

larger sample. A power analysis of the pilot study results revealed that a sample size of 45 patients would yield statistical significance if dif- ferences in anxiety levels do exist among treatment and control groups.

m o v DRSI~N I designed the study to deter-

mine if humorous distraction had a greater effect on preoperative anxiety than tranquil music or no intervention.

A B S T R A C T This study investigated the effect of humorous and musical dis-

traction on preoperative anxiety among 46 patients scheduled for same day, elective, nondiagnostic surgery. Preoperative anxiety was measured with a horizontal visual analog scale after treatment group subjects listened to either a humorous audiotape or a tranquil music audiotape for 20 minutes and control group subjects received no intervention. Results show no significant difference between the group anxiety means. This study provides no evidence that humor or music decreases preoperative anxiety, but it also shows no evi- dence that perioperative nurses should avoid using humor or music as nurslng Interventions. AORN J 62 (Nov 1995) 784-791.

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NOVEMBER 1995, VOL 62, NO 5 Gaherson

Purpose. The purpose of the study was to inves- tigate the effect of humorous distraction on preoper- ative anxiety. The study was a multisite project involving three same day surgery units in the Pits- burgh metropolitan area.

Hypothesis. The following research hypothesis was tested.

Among preoperative patients who listen to a humorous audiotape for 20 minutes, patients who listen to tranquil music for 20 minutes, and patients who wail without auditory dis- traction for 20 minutes, there will be differ- ences in self-reported levels of preoperative anxiety in the order of no auditory distraction (highest anxiety), music, and humor (lowest anxiety).

Variables. The dependent variable was preoper- ative anxiety. The independent variable was a 20- minute wait in the same day surgery waiting room, during which time treatment group subjects listened to audiotapes on a cassette tape player and control group subjects received no intervention.

Definitions. I used the following operational definitions in the study.

Preoperative anxiety. Feelings of apprehension, tension, nervousness, or wony in anticipation of surgery, as measured by scores on the visual analog scale (VAS) (Figure 1).

Humorous distraction. An audiotaped comedy routine (ie, selections from two Bill Cosby recordings).

Tranquil music. An audiotape of slow, quiet, in- strumental music (ie. Omni Suite by Steven Bergman).

Assumptions. Two assumptions influenced the development and implementation of this study.

Same day surgical patients admitted for nondiag- nostic elective procedures experience some de- gree of preoperative anxiety.

Random assignment of subjects to treatment or control groups would be an effective way of equalizing differences in the amount of preoper- ative anxiety experienced by subjects before treatment.s

Limitations. The study was limited to same day surgical patients who were scheduled for nondiag- nostic, elective procedures. The selection of subjects and settings was purposive; therefore, results cannot be generalized to all preoperative patients.

Conceptual framework. The Roy Adaptation Model provided the conceptual framework for this study.6 In this model, a person is seen as a biopsy- chosocial being who interacts constantly with a changing environment. Anxiety is a common re- sponse in preoperative patients as they attempt to adapt to the changing circumstances of the surgical experience. Humorous distraction was used as a nursing intervention with the goal of assisting the patients to adapt to preoperative anxiety.

MIIIIODOLOGY I used an experimental, three-group posttest

design in this study, assigning subjects randomly to treatment and control groups. In this research design, “NO pretest is given, but both groups are observed after treatment.”’ I manipulated the independent variable and observed the effects on the dependent variable.

Setting. The same day surgery units of three Pittsburgh-area hospitals served as settings for data collection. One site was a large, church-affiliated, health center hospital (450 beds), one was a large community hospital (450 beds), and one was a small community hospital (170 beds).

Sample. Subjects were men and women age 21 years or older who had been admitted to a same day surgery unit for elective surgical procedures. Surgeons gave consent for their patients to participate. Potential

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subjects were excluded if they did not speak, read, and understand English; if they had hearing loss; or if they had taken any medications with antianxiety effects within the past 24 hours. Patients undergoing diagnos- tic procedures were excluded from the sample, as they may have unusually high anxiety levels as compared to the general population of surgical patients.8 I antici- pated having a sample of 45 subjects (ie, 15 at each hospital), and I assigned subjects randomly to either the control group or to one of two treatment groups in each setting.

Intervention. The intervention consisted of lis- tening to an audiotape for 20 minutes after admission to the ambulatory surgery unit and before the sched- uled surgical procedure. A research assistant gave each subject in a treatment group an audiocassette tape player and a headset and asked the subject to listen to a humorous tape or a tranquil music tape for 20 minutes. Subjects in the control group received no auditory distraction during a 20-minute waiting period.

Instrument. I used a horizontal VAS to measure the dependent variable of preoperative anxiety. The VAS previously was reported to be a valid and reli- able measure of self-reported preoperative anxiety among a sample of 40 female ambulatory surgery patient^.^

This VAS consists of a 10-cm horizontal line with defined ends representing extreme limits of pre- operative anxiety. The left end of the line represents “no sensation” and the right end represents “as much as could possibly be.” Each subject self-reported the level of preoperative anxiety by making a vertical mark across the line at the point that represented his or her level of anxiety. The research assistant read the following directions to each subject.

This line represents the amount of woriy, anx- iety, concern, or fear which patients may feel before surgery. The left end of the line repre- sents no worry, anxiety, concern, or fear. The right end of the line represents as much worry, anxiety, concern, or fear as can be. Please make a vertical mark on this line to represent how much worry, anxiety, fear, or concern you feel right now.

I obtained the VAS score for each subject by measuring the distance in centimeters from the left end of the line to the subject’s mark. I scored all VAS instruments at the same time (ie, when data

Subjects were excluded if

they had taken any medica-

tions with antianxiety effects

within the past 24 hours.

collection was completed), using the same plastic ruler, to ensure reliability of measurement.

Protection of human subjects. The institutional review board of my university and of each hospital approved the study. There was a small risk of trans- mitting infectious organisms by way of the earpieces because the audiotape player headsets were to be used by multiple subjects. To prevent such transmis- sion, the research assistant cleaned the earpieces with alcohol wipes before each use, and I excluded from the sample potential subjects who presented with ear pathology. There were no other known risks to subjects.

To avoid contamination of the dependent vari- able (ie, preoperative anxiety), the research assistant informed subjects that the study concerned patients’ feelings before same day surgery. After participa- tion, the research assistant told the subjects that anxi- ety was the variable of interest.

Subjects gave their written consent to partici- pate. Information about subjects was kept confiden- tial. Subjects’ names did not appear on the data col- lection instruments. The consent forms, sealed in an envelope and locked in a file cabinet in my home, were the only documents that contained the names of subjects .

Data collection procedures. I obtained a list from the unit directors of surgeons who admitted patients to each of the same day surgery units. I sent these surgeons a letter describing the study and a con- sent form seeking their cooperation with the study. The surgeons’ consent forms were returned to me.

I trained three graduate nursing students to serve as research assistants for data collection. One assistant was assigned to each site. Each research assistant scheduled data collection days in coopera- tion with the same day surgery unit directors. We

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Table 1 varied data collection days within the week to con- trol for a possible “day” effect.

On data collection days, each research assistant checked the same day surgery schedule against the list of cooperating surgeons. The research assistant read the medical records of patients whose surgeons had consented to let their patients participate in the study to verify that the patients met inclusion criteria.

Patients who met inclusion criteria were given a brief oral explanation of the study and asked to par- ticipate in the study. The research assistant answered any questions regarding the study, consulting with me if necessary. Patients who agreed to participate as subjects signed the consent form. The subject retained one copy of the consent form, one copy was placed with the subject’s medical record, and I retained one copy.

Each research assistant randomly assigned sub- jects by lottery to one of three groups-the control group or one of the two treatment groups. The research assistant gave each subject in a treatment group an audiocassette tape player and a headset and asked the subject to listen to a humorous tape or a tranquil music tape (depending on his or her assigned group) for 20 minutes. Subjects in the con- trol group received no auditory distraction during the 20-minute waiting period.

During the 20-minute intervention period, the research assistant obtained necessary demographic data from subjects’ medical records (eg, age, gender, type of surgery). These data were used to describe the sample.

After the intervention, the research assistant measured the dependent variable (ie, preoperative anxiety) using the VAS. Each VAS was coded with the subject’s number. If a subject was called into the same day surgery unit before data collection was complete. that subject was dropped from the sample.

R W L T S There were 46 subjects enrolled in this study,

representing a 98% consent rate. The sample was composed of 27 women and 19 men. Ages of sub- jects ranged from 21 to 77 years, with a mean age of 47.35 years (standard deviation [SD] = 16.64) and a median age of 43.5 years. Mean ages of subjects in each group are shown in Table 1. Subjects in the music group tended to be older, and humor group subjects tended to be younger than the mean age of the entire sample.

The surgical procedures scheduled for these

standard GrOUD n mean deviation

Control 15 47.07 19.07

Music 16 51.75 17.18

Humor 15 42.93 12.92

Table 2

standard GrOUD n mean deviation

Control 15 3.92 2.89

Music 16 2.98 2.91

Humor 15 3.15 1.96

subjects included general, orthopedic, gynecologic, ophthalmic, otolaryngologic, and dental surgery. Random assignment of subjects to groups was intended to control for this variable.

Preoperative anxiety according to group. The mean preoperative anxiety score for the sample was 3.34 (SD = 2.60). Table 2 shows the means and stan- dard deviations for preoperative anxiety by group. The range of possible scores on the VAS was zero to 10; therefore, the mean anxiety scores of the entire sample and of all groups were fairly low. Subjects in the music group reported the lowest levels of anxi- ety, and the control group reported the highest levels. A one-way analysis of variance (ANOVA) (Table 3) revealed no significant difference between the group means; the F value (0.56) is not significant at the .05 level. The research hypothesis, therefore, was not supported.

I performed a two-way ANOVA to determine if anxiety scores varied according to age and group (Table 4) because the demographic data revealed dif- ferences in age among humor, music, and control groups. I used the median age (43.5 years) to divide the sample according to age, and the groups were humor, music, and control. The dependent variable was preopcrative anxiety. The two-way ANOVA result was not significant at the .05 level (F = 2.74, df = 2, P = .07); however, a larger sample might have yielded a significant result.

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Table 3 I performed an analysis of covariance to correct

for age differences across groups. The result (F = 0.58, df = 2 , P = .56) was not significant. Source df MS* F P

DISCUSSION Tn this study, subjects who listened to tranquil

music reported lower levels of preoperative anxiety than patients who listened to a comedy routine, and subjects who experienced no auditory distraction reported the highest levels of preoperative anxiety. These results are somewhat inconsistent with the pilot study finding that same day surgery patients who listened to humorous audiotapes reported lower levels of preoperative anxiety than patients who listened to tranquil music, although this difference was not statistically significant.I0

Although humorous distraction was not shown to reduce preoperative anxiety more than tranquil music, neither humor nor music increased anxiety in this sample. There is no evidence that perioperative nurses should avoid using humorous distraction with preoperative same day surgery patients.

Several methodological problems may have con- tributed to the nonsignificant findings. Although the intent was to collect data simultaneously at three sites, it took longer to recruit subjects into the study at one of the sites, and data collection at that site continued for some time after it was concluded at the other sites. A history effect cannot be ruled out (ie, the possibility that an event unrelated to the study occurred during the extended data collection period at one site that influenced the anxiety levels of subjects at that site).

This sample of same day surgery patients reported rather low levels of preoperative anxiety. Using the Roy Adaptation Model, I assumed that preoperative anxiety would be a common response of biopsychosocial beings who are attempting to adapt to the changing circumstances of the surgical experience. This assumption may be invalid; same day surgical patients may adapt to the experience of surgery in other ways. It also is possible that the effect of humorous distraction on preoperative anxi- ety cannot be detected at low levels of anxiety. Fur- ther investigation of the effect of humor on preopera- tive anxiety is recommended with subjects who are scheduled for diagnostic surgery because their state anxiety (ie, response to stressful situations) levels may be higher than those of subjects in this study.

Eleven of the 46 subjects in this study (ie, 24%) were age 65 years or older. The use of a VAS to measure preoperative anxiety may not have been appropriate for this age group. Previous studies have

~ ~~

Between groups 2 3 8 5 0 5 6 58

Within groups 43 6 91 Total 45

* mean square

Table 4

Source df MS* F P Group 2 1.67 0.26 .77

Age 1 5.14 0.80 .38

Group mean age 2 17.55 2.74 .07

Residual 40 6.40 * mean square

suggested that elderly subjects had difficulty using a VAS to measure perceived pain; this difficulty may be related to deficits in abstract reasoning ability.' In a more recent study, however, elderly subjects' inappropriate responses to a VAS did not differ sig- nificantly from those of the general population.'* Results of that study also indicated that elderly sub- jects preferred a verbal descriptor scale to a VAS and that they preferred a vertical VAS to a horizontal VAS. These findings suggest that further research into elderly patients' preference for and ability to use a VAS to measure preoperative anxiety is warranted.

Subjects in this study were assigned randomly to their groups. After participating in the study, sev- eral subjects commented that they would have pre- ferred a choice of music or humorous audiotapes. A preference for listening to music or a comedy routine may have affected some subjects' VAS scores, although that variable was not studied in this investi- gation. Future research studies should be designed to test the effect of choice of humorous or musical dis- traction on preoperative anxiety.

SUMMARY In this experimental study of 46 same day

surgery patients, no significant differences in self- reported preoperative anxiety were found among

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NOVEMBER 1995, VOL 62, NO 5 Gaberson

patients who listened to a humorous audiotape, lis- tened to a tranquil music audiotape, or received no intervention. No recommendations concerning pen- operative nurses’ use of humor or music can be made because this study provided no evidence that humor or music decreases preoperative anxiety. There is no evidence, however, that perioperative nurses should avoid using humor or music as nurs- ing interventions. Additional research on the effects of humor and music on perioperative patients is

Kathleen B. Gaberson, RN, PhD, is an associate professor of nursing at Duquesne University, Pittsburgh.

Editor‘s note: This SW was supported by an AORN Nurse Scientist Grant and a Duquesne University, Pitts-

recommended. A

NOTES

nursing research, Part I: Preoperative psychoeducational interventions,” AORN Journal 49 (February 1989) 597-619; M L Totas, “The emotional stress of the preoperative patient,” Journal of the American Association of Nurse Anesthetists 46 (February 1978) 27-30 US Department of Health and Human Services, Acute Pain Management: Operative or Medical Procedures and Trauma, AHCPR pub1 no 92-0032 (Rockville, MD: Agency for Health Care Policy and Research, 1992).

effect of music on anxiety: A research study,” AORN Journal 50

“The effect of music on anxiety in the surgical patient,” Perioperative Nursing Quarterly 3 (March 1987) 9- 16; V M Steelman, “Intraoperative music therapy: Effects on anxiety, blood pressure,” AORN Journal 52 (November 1990) 1026-1034.

1 . J C Rothrock, “Perioperative

2. G Kaempf, M E Amodei, ‘The

(July 1989) 112-1 18; V A MOSS,

burgh, Supplemental Faculty Development Grant.

3. N F Dixon, “Humor: A cogni- tive alternative to stress?” in Stress anddmiety, vol7, ed I G Sarason, C D Spielberger (Washington, DC: Hemisphere Publishing Corp, 1980) 281-289; R Safranek, T Schill, “Cop ing with stress: Does humor help?” Psychological Reports 5 1 (August 1982) 222.

4. K B Gaberson, “The effect of humorous distraction on preopera- tive anxiety: A pilot study,” AORN Journal 54 (December 1991) 1258- 1264.

5. N F Woods, M Catanzaro, Nursing Research: Theory andprac- tice (St Louis: The C V Mosby Co, 1988) 177.

6. C Roy, Introduction to Nurs- ing: An Adaptation Model, second ed (Englewood Cliffs, NJ: F’rentice- Hall, Inc, 1984).

7. Woods, Catanzaro, Nursing Research: Theory and Practice, 176.

8. D Scott, “Anxiety, critical thinking and information processing during and after breast biopsy,”

Nursing Research 32 (January/ February 1983) 24-28.

9. J Vogelsang, “The visual ana- log scale: An murate and sensitive method for self-reporting preoperative anxiety,” Journal of Post Anesthesia Nursing 3 (August 1988) 235-239.

10. Gaberson, ‘The effect of humorous distraction on preoperative anxiety: A pilot study,” 1258- 1264.

1 1. M P Jenson, P Karoly, S Braver, ‘The measurement of clinical pain intensity,” Pain 27 (October 1986) 117-126; E Kremer, J H Atkinson, R J Ignelzi, “Measurement of pain: Patient preference does not confound pain measurement,” Pain 10 (April 1981) 241-248; S I Revill et al, “The reliability of a linear ana- logue for evaluating pain,” Anaesthe- sia 3 1 (November/bxmber 1976) 1191-1 198.

12. K A Herr, P R Mobily, “Com- parison of selected pain assessment tools for use with the elderly,” Applied Nursing Research 6 (Febru- ary 1993) 39-46.

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