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O R I G I N A L A R T I C LE

The effect of music therapy on physiological signs of anxiety in patients


receiving mechanical ventilatory support
Esra Akin Korhan, Leyla Khorshid and Mehmet Uyar

Aims. The aim of this study was to investigate if relaxing music is an effective method of reducing the physiological signs of
anxiety in patients receiving mechanical ventilatory support.
Background. Few studies have focused on the effect of music on physiological signs of anxiety in patients receiving mechanical
ventilatory support.
Design. A studycasecontrol, experimental repeated measures design was used.
Method. Sixty patients aged 1870 years, receiving mechanical ventilatory support and hospitalised in the intensive care unit,
were taken as a convenience sample. Participants were randomised to a control group or intervention group, who received
60 minutes of music therapy. Classical music was played to patients using media player (MP3) and headphones. Subjects had
physiological signs taken immediately before the intervention and at the 30th, 60th and 90th minutes of the intervention.
Physiological signs of anxiety assessed in this study were mean systolic and diastolic blood pressure, pulse rate, respiratory rate
and oxygen saturation in blood measured by pulse oxymetry. Data were collected over eight months in 20062007.
Results. The music group had significantly lower respiratory rates, and systolic and diastolic blood pressure, than the control
group. This decrease improved progressively in the 30th, 60th and 90th minutes of the intervention, indicating a cumulative
dose effect.
Conclusion. Music can provide an effective method of reducing potentially harmful physiological responses arising from
anxiety.
Relevance to clinical practice. As indicated by the results of this study, music therapy can be supplied to allay anxiety in patients
receiving mechanical ventilation. Nurses may include music therapy in the routine care of patients receiving mechanical
ventilation.
Key words: anxiety, blood pressure, mechanical ventilatory support, music therapy, pulse rate, respiratory rate
Accepted for publication: 3 July 2010

Introduction
Intensive care treatment is a highly technological branch of
medicine. Even in what may appear to be hopeless cases, lives
can be saved through the application of this modern
technology (Aldridge et al. 1990). Intensive care units are
Authors: Esra Akin Korhan, MSc, RN, Research Assistant,
Department of Fundamentals of Nursing, School of Nursing, Ege
University; Leyla Khorshid, PhD, RN, Professor, Department of
Fundamentals of Nursing, School of Nursing, Ege University;
Mehmet Uyar, MD, Professor, Department of Anesthesia and
_
Reanimation, Ege University Medical Faculty, Izmir,
Turkey

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comparatively stressful environments (Almerud & Peterson


2003, Lee et al. 2005). Mechanical ventilation is commonly
used in critical care units to treat respiratory insufficiency
deriving from a variety of causes (Chlan 2003, 2004, Lee
et al. 2005). While mechanical ventilation itself is a lifesaving treatment, it induces a variety of experiences which are
Correspondence: Esra Akin Korhan, Research Assistant, Ege
_
University School of Nursing, 35100 Bornova/Izmir/Turkey.
Telephone: 0 232 3881103/147 (Office).
E-mail: akinesra80@hotmail.com

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 10261034


doi: 10.1111/j.1365-2702.2010.03434.x

Original article

physiologically and psychologically distressful for patients


(Chlan 2003, 2004, Lee et al. 2005). These distressful
experiences arise from the placement of the endotracheal
tube in the airway and from the ventilator itself delivering
oxygen gas to the patients (Chlan 2004). Having to depend
on a machine to breathe and being unable to speak cause
anxiety, which can result in sleep disturbances, increased
myocardial oxygen consumption and increased sympathetic
output. This last can lead to tachypnea, tachycardia or
hypertension and make weaning from the mechanical system
more difficult. The patients inability to speak may also make
it harder for nurses to meet their needs (Aldridge et al. 1990,
Lindgren & Ames 2005). Patients undergoing mechanical
ventilation are susceptible to numerous factors such as fear,
agitation, discomfort, thirst, immobility, dyspnoea, confusion, communication problems and inability to relax (Wong
et al. 2001, Chlan 2003, 2004, Lee et al. 2005). Anxiety is
also commonly found among ventilator-dependent patients
(Wong et al. 2001) and results from the numerous distressing
physiological and psychological sensations associated with
intubation and mechanical ventilation (Chlan 2004). Anxiety
can have harmful effects on the course of recovery and the
overall well-being of a person (Wong et al. 2001). It has been
estimated that great anxiety is provoked in approximately
7080% of intensive care patients, especially in ventilatordependent patients (Wong et al. 2001, Lee et al. 2005). If
anxiety is not managed well, it can result in the inability of
the patient to cope with the disease or to assist in the
treatment (Wong et al. 2001). Increased anxiety activates the
sympathetic nervous system, as manifested by increased heart
rate, blood pressure, respiratory rate and neurohumoral
responses (Lee et al. 2005). Management of symptoms,
including anxiety, with various pharmacological and nonpharmacological interventions is an important nursing
responsibility in the critical care unit (Chlan 2002, 2003).
To allay anxiety and promote relaxation, nurses frequently
administer a variety of intravenous sedative medications to
patients receiving mechanical ventilation. Sedatives have
several untoward side effects that include nausea and
vomiting, respiratory depression, decreased gut motility,
pruritis, urinary retention, hypotension, venous stasis,
pressure damage to soft tissue, respiratory and extremity
muscle weakness or atrophy, delayed weaning from mechanical ventilation, increased risk of infection, mental status
changes, central nervous system changes and even death
(Chlan 1998, 2002). Sedation by continuous IV infusion has
been associated with prolonged lengths of stay on the
ventilator (Lee et al. 2005, Lindgren & Ames 2005). Sedation
does not have to be the first choice in attempts to allay a
patients anxiety and the distress associated with mechanical

The effect of music in ventilated patients

ventilatory support (Chlan 2002). Music therapy can act as a


non-pharmacological nursing intervention to relieve signs of
anxiety of patients.

Background
Music therapy is a branch of health care dedicated to the use
of music for emotional, physical, functional and educational
improvement in a broad range of settings and conditions
(Esch et al. 2004). Paterson and Zderad described the arts
(e.g. music, painting) as an important part of the nursing
discipline. In previous studies, music has been shown to have
positive physiological and psychological effects on patients
(McCaffrey & Good 2000). Relaxing music has been shown
to influence a persons emotional feelings and physiological
responses. Calm and soothing music is found to be the most
appropriate in reducing anxiety (Wong et al. 2001).
Researchers have examined the effectiveness of music in
pain and stress management in women during labour and
birth (Komurcu 1999, Browning 2000) and caesarean delivery (Chang & Chen 2005), in patients undergoing bronchoscopy (Smolen et al. 2002), in patients undergoing medical/
dental treatment (Paul & Ramsey 2000), in patients undergoing hysterosalpingography (Agwu & Okoye 2006), in
patients experiencing an acute myocardial infarction (Elliott
1994, Byers & Smyth 1997, Barclay & Vega 2005), in
patients experiencing surgical anxiety (Murphy 1999, Brunges & Avigne 2003, Ikonomidou et al. 2004) and in patients
undergoing colonoscopy (Smolen et al. 2002, Ovayolu et al.
2006). In another study, it was found that when controlling
for ambient operation room noise, intraoperative music
decreased propofol requirements of both Lebanese and
American patients undergoing urological surgery under
spinal anaesthesia (Ayoub et al. 2005).
Minimal music therapy research has been conducted in
patients on mechanical ventilation. In a literature review, it
was reported that music therapy had been shown to reduce
anxiety and pain levels, heart and respiratory rates and blood
pressure in critical care and perioperative populations (Lindgren & Ames 2005). Music therapy has been found useful in
intensive care settings because of its anxiolytic effects in
reducing anxiety, heart rate, mean blood pressure and
respiratory rate (Chlan 1998, Wong et al. 2001, Angela
et al. 2005, Arnon et al. 2006). Almerud and Peterson (2003)
implemented a study with the aim of ascertaining whether
music therapy had a measurable relaxing effect on patients
(n:20) who were temporarily on a respirator in an intensive
care unit. The results showed a significant fall in systolic and
diastolic blood pressure during the music therapy and a
corresponding rise after cessation of treatment (Almerud &

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EA Korhan et al.

Peterson 2003). Chlan (1998) carried out a study in 20


ventilator-dependent patients. Subjects were randomised to
either a music or non-music group. The music group listened
to 30 minutes of classical music and had significantly reduced
respiratory rate, heart rate and mood disturbance. Chlan
extended her research with a second study involving 44
ventilator-dependent patients. Subjects were randomly assigned to a music group or a rest group. The music group had
significantly lower state anxiety, heart rate and respiratory
rate than the control group (Chlan 1998, Wong et al. 2001).
However most of these studies were conducted on a small
sample size, subjects were alert and mentally competent and
hospitalised in various intensive care units; also, the duration
of the music was generally 30 minutes, and the effects of the
music were not followed up after therapy.
The relaxation response is defined by a set of integrated
physiological changes that are elicited when a person
patiently engages in a repetitive mental or physical activity
and passively ignores distracting thoughts. This behaviour is
associated with instantly occurring physiological changes that
include decreased oxygen consumption or carbon dioxide
elimination, lowered heart rate, arterial blood pressure and
respiratory rate, accompanied by an overall decrease in brain
activity (Esch et al. 2004). There is a need for research related
to non-pharmacological relaxation interventions in patients
undergoing mechanical ventilation. No such studies have
previously been conducted among the Turkish population.

Aim
This study was implemented to evaluate the effect of music
therapy on a group of Turkish patients and the value of
including music therapy in nursing care in this country. The
aim of the study was to examine the effects of classical music
on physiological signs of anxiety (systolic blood pressure,
diastolic blood pressure, heart rate, respiratory rate and
oxygen saturation) in Turkish patients receiving mechanical
ventilatory support and to investigate the effects of sociodemographical characteristics on the variation in physiological signs of anxiety occurring as a result of music therapy in
the experimental group.

Methods
Design
Studycasecontrol design was used in this research. The
intensive care unit of a university hospital in Izmir was used
as the setting for the study. The research hypotheses for the
study were as follows:
1028

1 There are significant differences between a music intervention group and a control group in terms of the mean
systolic blood pressure, diastolic blood pressure, heart rate,
respiratory rate and oxygen saturation of patients receiving
mechanical ventilatory support.
2 There are significant differences between 0 and the 30th
minute, 0 and the 60th minute, 0 and the 90th minute, the
30th and 60th minutes and the 30th and 90th minutes in
the music intervention group in terms of mean systolic
blood pressure, diastolic blood pressure, heart rate, respiratory rate and oxygen saturation of patients receiving
mechanical ventilatory support.
3 There was an interaction between sociodemographical
variables and differences in physiological signs of anxiety
in the music intervention group of the patients receiving
mechanical ventilatory support.

Participants
Sample size was determined based on Repeated Measures
ANOVA Power Analysis to achieve a power of 081 and the
sample size was 60. The population for the research was
formed from patients who were hospitalised in the intensive
care unit of the hospital. A convenience sample was taken of
patients (n:60) who were hospitalised in the intensive care unit
between 1 July 20061 March 2007, who met the study
criteria and who were receiving mechanical ventilatory support. Subjects were of Turkish nationality, were aged 18
70 years (range 1870, mean 4531 SD 1473, 32 male), had
no psychiatric or neurological illnesses, were not receiving
inotropic support, had not taken any neuromuscular blocker
and antihypertensive drug, had haemodynamic stability, were
on pressure support ventilation mode, were able to hear and
had Glasgow Coma Scale Point 9 or above. Demographical
data were collected from the patients medical records on age,
sex, ethnicity, ventilator settings, current medications, medical
diagnosis and number of days receiving ventilatory support.

Intervention
Patients were randomised to a control group or an intervention group, who received 60 minutes of music therapy.
Sedation by intravenous propofol infusion at a dose of
13 mg/kg/h was stopped daily 30 minutes before the start of
the experiment in both groups. Propofol is the sedative of
choice in intensive care units because it has a relatively short
half-life when compared with other sedatives traditionally
used in critical care. Propofols short half-life and quick onset
of action allow the rapid awakening preferred for neurological examinations (Ho & Ng 2008). Stopping propofol

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 10261034

Original article

30 minutes before the intervention is long enough to prevent


an interaction between drug effect and patient response
(Beller et al. 1995).
Patients listened to relaxing music, consisting of classical
music with 6066 beats per minute, using media player and
headphones. Headphones used for music therapy were
disposable. Music with this beat was chosen because it has
a positive emotional effect on people (Chlan 1998, Chang &
Chen 2005), and classical music was chosen because it has
the most relaxing effect (Almerud & Peterson 2003). The
actual piece chosen was Bachs 19 trio sonatas played by
James Galway on flute. Bachs music has a unique polyphonic
harmony and balanced melody and is of a quality that
appeals to the emotions (Birkan 2006).

Data collection
The research nurse stayed with the patients during the whole
intervention period to collect physiological data. Subjects in
the two groups had physiological signs taken immediately
before the intervention, at 30 -minute intervals throughout
the intervention and 30 minutes after the intervention
finished. Pressure support ventilation is the most popular
made of ventilatory support in intensive care units internationally (Ala & Esteban 2000). In this mode, each breath is
triggered by an inspiratory effort on the part of the patient. In
pressure support ventilation, the patient determines the
frequency and cycle length, while the degree of pressure
support is preset (Pierce et al. 1993). In our study, all patients
were on pressure support mode with the inspiratory pressure
adjusted to provide a tidal volume of 68 ml/kg, with
FiO2 04 and PEEP 6 cmH2O. Data were collected over
eight months in 20062007.
Physiological measures
The physiological signs of anxiety assessed in this study were
systolic and diastolic blood pressure, pulse rate, respiratory
rate and oxygen saturation. Systolic and diastolic blood
pressure, pulse rate and respiratory rate values were obtained
by means of indwelling arterial lines, and oxygen saturation
in the blood was measured by pulse oxymetry.
Demographical descriptive data and clinical characteristics of
subjects
Data were collected from subjects relatives and from their
medical records to assess comparability between the experimental and control groups with respect to age, sex, educational level, marital status, primary medical diagnosis,
ventilator settings, number of days receiving mechanical
ventilation and Glasgow Coma Scale Point.

The effect of music in ventilated patients

Ethical considerations
The Ethic Committees of the School of Nursing and of the
Hospital approved the research. Patients relatives were
informed and their consent was taken verbally and in writing
after the first meeting with the researchers.

Data analysis
The data were analysed using SPSS version 13.0. Descriptive
analyses were used to summarise the data. Chi-Square tests
were used to detect any significant differences in the baseline
data of each intervention (age, sex, marital status, educational level, number of ventilator-dependent days) and
MannWhitney U-test was used for detect any significant
differences in the baseline data of the Glasgow Coma Scale.
Independent Sample t-tests were used to detect any significant differences in the baseline data of each intervention
(mean systolic blood pressure value, mean diastolic blood
pressure value, respiratory rate and pulse rate and oxygen
saturation).
The KolmogorovSmirnov test was used for accordance of
dependent variables and to provide their normal distribution
(p > 005). Then, because there were no variables which
deviated from normal distribution, five different repeated
measures analyses of variance (R_ANOVA ) were used for every
variable. Repeated measures analysis of variance (R_ANOVA )
was also used to examine mean systolic and diastolic blood
pressure, respiratory rate, pulse rate and oxygen saturation
across the intervention period, measured at 30-minute
intervals within groups and between groups. Therefore, the
Bonferroni test was used to examine the difference between
the intervals within each group and to examine the interaction between group and interval. The Bonferroni test was
carried out in the periods between 0 and the 30th, 0 and the
60th, 0 and the 90th, the 30th and 60th and the 30th and
90th minutes. Repeated measures analysis of variance
(R_ANOVA ) was used to examine the effects of sociodemographical characteristics on the difference in physiological signs of anxiety occurring during the music therapy in the
experimental group.

Results
Demographical characteristics
The study participants ranged in age from 1870 years (mean
4531 SD 1473). The sample consisted of 60 Turkish subjects
32 men and 28 women. Most of them were educated to
primary school level (n = 33), 16 to secondary school level

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EA Korhan et al.

and 11 to high/undergraduate school level. Age, sex and


educational level had no effect on systolic blood pressure,
diastolic blood pressure, heart rate, pulse rate and oxygen
saturation.
Most subjects medical diagnoses were pulmonary
(n = 25), heart failure (n = 21), chronic kidney failure
(n = 5), pancreatitis (n = 4) and liver failure (n = 5). Subjects
had been receiving mechanical ventilatory support for an
average of 832 (SD 137) days within a range of 130 days at
study entry. All patients were receiving positive end-expiratory pressure. There were no statistically significant differences in the baseline data of days of ventilator dependency,
points from the Glasgow Coma Scale, systolic blood pressure,
diastolic blood pressure, pulse rate, respiratory rate or
oxygen saturation in the two groups (p > 005). It was
found that there was a relationship between the number of
ventilator-dependent days and systolic blood pressure
(p = 0045) and diastolic blood pressure (p = 0003) in the
experimental group.

60th minutes (p = 0001), 30th and 90th minutes (p = 0001)


and the 60th and 90th minutes (p = 0001) in the music
intervention group (Fig. 1). There was a statistically significant difference in diastolic blood pressure over time
(p = 0001, Fig. 2). There was a significant difference in
mean diastolic blood pressure between 0 and the 30th minute
(p = 0001), 0 and the 60th minute (p = 0001), 0 and the
90th minute (p = 0001), the 30th and 60th minutes
(p = 0021), 30th and 90th minutes (p = 0001) and the
60th and 90th minutes (p = 0042) in the music intervention
group (Fig. 2). There was a statistically significant difference
in respiratory rate in over time (p = 0001, Fig. 3). There
were significant differences in mean respiratory rate between
0 and the 30th minutes (p = 0001), 0 and the 60th minutes
(p = 0001), 0 and the 90th minutes (p = 0001), the 30th and
60th minutes (p = 0001), 30th and 90th minutes (p = 0001)

Experimental group
Control group

The effects of music therapy


There was a statistically significant difference in mean systolic
(p = 0024) and diastolic (p = 0016) blood pressure both
groups. There was a statistically significant difference in
mean respiratory rate both groups (p = 0043). There was
no statistically significant difference in heart rate (p = 0170)
and in oxygen saturation (p = 0859) both groups.
There was a statistically significant difference in systolic
blood pressure over time (p = 0001, Fig. 1). There was a
significant difference in mean systolic blood pressure between
0 and the 30th minute (p = 0001), 0 and the 60th minute
(p = 0001), 0 and the 90th minute (p = 0001), the 30th and

Diastolic blood pressure

7500

7000

6500

6000

5500
0

30

60

90

Time (min)

Figure 2 Mean diastolic blood pressure over time.

Experimental group

2300

Experimenal group
Control group

Control group

14000

Respiratory rate

Systolic blood pressure

2200

13000

12000

2100

2000
1900
1800

11000

1700

30
60
Time (min)

Figure 1 Mean systolic blood pressure over time.

1030

90

30

60

90

Time (min)

Figure 3 Mean respiratory rate over time.

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 10261034

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The effect of music in ventilated patients

and the 60th and 90th minutes (p = 0001) in the music


intervention group (Fig. 3). There was a statistically significant difference in heart rate over time (p = 0024, Fig. 4).
There was a significant difference in mean heart rate between
0 and the 30th minute (p = 0001) and the 30th and 90th
minutes (p = 0044) in the music intervention (Fig. 4). There
was no statistically significant difference in oxygen saturation
over time (p = 0418, Fig. 5). There were no significant
differences in mean oxygen saturation between 0 and the
30th minute (p = 1000), 0 and the 60th minute (p = 1000),
0 and the 90th minute (p = 1000), the 30th and 60th minutes
(p = 1000) and the 30th and 90th minutes (p = 1000) and
the 60th and 90th minutes (p = 0001) in the music intervention group (Fig. 5).

Experimental group

10500

Every group shows different reactions over time. The


systolic blood pressure goes up in the control group, but
down in the experimental group (p = 0001, Fig. 1). The
diastolic blood pressure goes up in the control group, but
down in the experimental group (p = 0001, Fig. 2). The
respiratory rate goes up in the control group, but down in the
experimental group (p = 0001, Fig. 3). The heart rate goes
up both in the control group and experimental group
(p = 0064, Fig. 4). The oxygen saturation goes up both in
the control group and experimental group (p = 0428,
Fig. 5).
The figures indicate that interaction effects in the control
group increased and those in the experimental group
decreased over time and that the differences were significant
(p = 0001). An interaction was found between group and
interval (time) (p = 0001), and it was shown that the effect of
the interval was not the same in the two groups.

Control group

Discussion

Heart rate

10250

10000

9750

9500

9250
0

30
60
Time (min)

90

Figure 4 Mean heart rate over time.

Experimental group
Control group

Oxygen saturation

9700

9680

9660

9640
0

30

60
Time (min)

Figure 5 Mean oxygen saturation over time.

90

Music has been recognised and specifically used as a


therapeutic intervention from the mid-20th century; however,
it has existed in various forms in most cultures for many
centuries. In recent years, the use of music as an intervention
has increased and this, to some extent, may reflect the
growing interest in complementary therapies.
Music was used in this study as a non-pharmacological
nursing intervention to facilitate relaxation and reduce the
physiological signs of anxiety. Music therapy reduced the
physiological signs of anxiety among mechanically ventilated
patients in this study. Systolic blood pressure, diastolic blood
pressure and respiratory rate decreased over time for those
subjects in the music therapy intervention group, whereas the
control group displayed a varying pattern of decreases over
the rest period. Decreases in these variables could indicate a
relaxation response. These findings in the physiological
measurements are supportive of the hypothesis that there
are significant differences between a music intervention group
and a control group in terms of the mean systolic blood
pressure, diastolic blood pressure, heart rate, respiratory rate
and oxygen saturation of patients receiving mechanical
ventilatory support.
Findings from this study on physiological measurements
are congruent with other studies for decreased systolic
blood pressure, decreased diastolic blood pressure (Wong
et al. 2001, Chlan et al. 2001, Almerud & Peterson 2003,
Angela et al. 2006, Chlan et al. 2007) and decreased
respiratory rate (Chlan 1998, 1999, Chlan et al. 2001,
Wong et al. 2001, Angela et al. 2005) in response to music
therapy intervention with critically ill patients. In a study by

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EA Korhan et al.

Almerud and Peterson (2003), a significant fall in systolic


and diastolic blood pressure was found during the music
therapy session and a corresponding rise was found after
cessation of treatment. Sixty minutes after completion of
treatment, systolic blood pressure had risen from 124
131 mmHg. (Almerud & Peterson 2003). In a study with
patients recovering from cardiac surgery by Byers & Smyth
(1997), it was shown that heart rate and systolic blood
pressure decreased during the music intervention compared
with the baseline. Also, diastolic blood pressure decreased
from the baseline during the music intervention at time 2,
but not at time 1 (Barclay & Vega 2005). The pulse rate
and oxygen saturation did not decrease over time for those
subjects in the treatment group of music therapy. In another
study, no effect of musical therapy was found on oxygen
saturation. In systematic reviews on music therapy effectiveness in ventilator-dependent patients, it was concluded
that vital signs did not show a significant difference
between the two groups, but the oxygen saturation of the
experimental group was significantly elevated after 60 minutes (Roteta 2003). Findings relating to oxygen saturation
in that study are not consistent with other studies.
It was found that by the 30th minute, music therapy began
to affect some physiological signs (systolic and diastolic
blood pressure and respiratory rate) of anxiety. This effect
had increased by the 60th minute and was still present at the
90th minute (Figs 13). These findings on the physiological
measurements are supportive of the hypothesis that there will
be significant differences between 0 and the 30th minute, 0
and the 60th minute, 0 and the 90th minute, the 30th and
60th minutes, the 30th and 90th minutes and between the
60th and 90th minutes in the music intervention group in
terms of mean systolic blood pressure, diastolic blood
pressure and respiratory rate. While some physiological signs
of anxiety showed a decrease in the intervention group, they
increased in the control group. This result may be because of
the fact that music therapy was discontinued after 60 minutes. This result shows that music therapy decreases some
physiological signs of anxiety. This decreasing trend continued in the 30th, 60th and 90th minutes of the intervention,
indicating a cumulative dose effect. This suggests that music
therapy should be used over periods of at least 60 minutes.
Age, sex and educational level had no effect on systolic
blood pressure, diastolic blood pressure or pulse rate (Angela
et al. 2005). Also, there was no statistically meaningful
relationship between sex, age groups and physiological
parameters. It was found that there was no relationship
between educational level and systolic blood pressure,
diastolic blood pressure, pulse rate, respiratory rate and
oxygen saturation, in the experimental group (Angela et al.
1032

2005). There was no statistically meaningful relationship


between educational level and oxygen saturation. Also, days
of ventilator dependency did not affect the results of musical
therapy on pulse rate, respiratory rate or oxygen saturation.
These findings are not supportive of the hypothesis that there
was an interaction between sociodemographical variables
and differences in physiological signs of anxiety in patients in
the music intervention group. However, a relationship was
found between the number of ventilator days and systolic and
diastolic blood pressure in the experimental group;as the
number of ventilator days increased, the effectiveness of the
intervention on systolic and diastolic blood pressure increased. This result shows that those who have been
ventilated for longer are relatively more easily calmed.
Patients may need time to accustom themselves to the
music. It is reported that subjects became more relaxed as
they listened to the music more frequently (Angela et al.
2005). Therefore, the fact that patients listened to a single
music intervention session and the duration of the music
session was limited might have influenced the results of this
study.
Sedation by continuous intravenous infusion has been
associated with prolonged lengths of stay on the ventilator
(Lindgren & Ames 2005). A decrease in physiological signs
of anxiety in patients receiving music therapy could indicate
a relaxation response and may reduce both the necessity
for sedation and the length of stay on the ventilator.

Conclusion
Respiratory rate and systolic and diastolic blood pressure
were reduced significantly after completion of music therapy.
Findings support the benefits of music therapy for ventilatordependent patients. Music has the ability to be used as a
therapeutic tool for lowering respiratory rate and systolic and
diastolic blood pressure in mechanically ventilated patients.
Music is a safe intervention that is not detrimental to
patients. Music therapy can be applied with advantage for
managing anxiety in ventilator-dependent patients without
risking unwanted side effects. Nurses can implement music
intervention using music with a tempo of 6080 beats per
minute to induce relaxation for short-term benefit.
Music therapy is a non-invasive, inexpensive and non-timeconsuming nursing intervention. It is recommended that
studies be conducted to explore the optimal time, duration,
or number of music sessions to be used when implementing
music therapy. Intensive care nurses can apply music therapy
as a non-pharmacological intervention to decrease signs of
anxiety in critically ill patients receiving mechanical ventilatory support.

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 10261034

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The effect of music in ventilated patients

Study limitations
Each subject undertook the music session at different times
during the day. Anxiety might be affected by the time of
the day at which the data were collected. The choice of
musical selection might present another limitation. Music
that is relaxing for one person might not be relaxing for
another. The efficiency of music to act as an anxietyreducing agent is dependent on the type of music used, the
preferences of the patient and the patients interest in
music. This could be a threat to the external validity of the
study, thereby affecting the generalisability of the findings
to other settings or samples. In this study, the preferences
of the patient were not considered, because some of the
patients were conscious, but others were unconscious or
semi-conscious. This is the first study implemented in
patients at mixed conscious levels. However, this may have
had an effect on the results. Because of cultural diversity
among the patients, their choices might differ. To provide
standards in the research, the choice of music was not left
to patients and classical music, which is known to have a
therapeutic effect (Almerud & Peterson 2003), was used in
the study.
The research nurse was not blinded as to the allocation of
each group. This is a limitation of the study. Because heart
rate, respiratory rate, systolic blood pressure, diastolic blood
pressure, oxygen saturation of patients were recorded from a
monitoring device which recorded all the results, no kind of

blinding technique was used and the investigator was not


blinded.

Relevance to clinical practice


Music should be considered as a first-line therapy to allay
anxiety in patients receiving mechanical ventilation.
Nurses should include music therapy in the routine care of
patients receiving mechanical ventilation.
Further research is needed to explore the effect of the
duration and kind of music sessions to be used on patients
receiving mechanical ventilation.

Acknowledgement
We thank all the people who so willingly participated in this
study.

Contributions
Study design: EK, LK, MU; data collection and analysis: EK
and manuscript preparation: EK, LK, MU.

Conflict of interest
This research was funded by Ege University Research
Foundation.

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