Pages 396-410 (February 2003)

Effects of Music on Patient Anxiety

Esther Mok, RN, Kwai-Yiu Wong, RN
ABSTRACT

Undergoing surgery with local anesthesia is stressful because patients often are aware of their
surroundings. This study investigated music as a method of reducing patients' anxiety during
minor surgery with local anesthesia. For this study, researchers assessed the effectiveness of
music as a relaxation modality by measuring patients' vital signs and self-reported anxiety before
and after surgery. Study results indicate 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. AORN J 77 (Feb 2003) 396-410.

Effects of Patient-Controlled Music Therapy

During Coronary Angiography on
Procedural Pain and Anxiety Distress
Syndrome
Kathy Bally, RN, BNSc, CCN(C)
Debbie Campbell, RN, CCN(C)
Kathy Chesnick, RN, MSc
Joan E. Tranmer, RN, PhD
All authors are employed at the Kingston General Hospital in Kingston, Ontario. Kathy Bally is
a clinical instructor for the coronary care unit, cardiovascular laboratory, cardiology unit, and
the cardiac devices clinic. Debbie Campbell is the regional cardiac care coordinator with the
Cardiac Care Network and is project leader of multicenter trials in critical care. Kathy Chesnick
is the professional practice leader in nursing at Kingston General Hospital and Hotel Dieu
Hospital. Joan E. Tranmer is director of nursing research at Kingston General Hospital and an
assistant professor in the school of nursing at Queen’s University, Kingston, Ontario.

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Undergoing invasive procedures, such as coronary angiography, can be acutely stressful for
many patients. Many factors contribute to patients’ level of stress: previous experience, pain,
anxiety, unfamiliar environment, and fear. Stress produces a physiological and biochemical
response that is unique for each person with respect to duration, intensity, and overall impact.
This response is elicited when stressors, such as pain or anxiety or a combination thereof, are
physically and psychologically demanding for the patient. The psychophysiological stress
response involves activation of the hypothalamic-pituitary-adrenal axis and the sympathetic
nervous system and is characterized by increased heart rate, blood pressure, and cardiac output.
The degree of the physiological stress response reflects the stress perceived and experienced.
Obviously, this response increases the workload on a cardiovascular system that may already be
compromised.

Stress can be reduced by either removing the source of the stress or by mediating its effect
through supportive interventions. Pain and anxiety are 2 common stressors in patients with
cardiovascular conditions. Anxiety is an emotional state characterized by feelings of tension,
nervousness, worry, apprehension, and heightened activity of the autonomic nervous system.
Spielberger1 differentiates between state anxiety as a transitory emotional condition and trait
anxiety as a stable predisposition to anxiety. Anxiety may bring about coping mechanisms to
reduce the impact of the stress; but too much anxiety may interfere with cognitive ability to cope
and lead to feelings of helplessness. Some anxiety is expected and may be beneficial during
coronary angiography procedures, because it indicates that the patient is confronting and attuned
to the demands of the procedure and event. However, high anxiety may cause or potentiate an
imbalance and create an unhealthy stress response. High anxiety, measured physiologically and
with the State-Trait Anxiety Inventory (STAI), has been reported in cardiac patients in coronary
care units2–5 and after surgery.6,7 Most nurses have observed that pain can cause or potentiate the
level of anxiety. Pain during angiographic procedures may be associated with sheath insertion,
immobilization, injection of contrast material, and balloon inflation. At Kingston General
Hospital, Kingston, Ontario, patients are routinely administered an anxiolytic agent (ie,
lorazepam) to help alleviate anxiety during the procedure and a local anesthetic at the time of
sheath insertion to alleviate pain. Despite these pharmacological measures and the usual
supportive care provided by the nurses, indications of anxiety often occur in patients even during
the procedure. Nonpharmacological interventions, such as music therapy, have not yet been
incorporated into usual care.

Ideally, supportive care interventions should enhance patients’ ability to physically and
cognitively (behaviorally) cope with the stress. Although the evidence is varied, the available
research suggests that music therapy is an intervention that may be effective in mediating or
reducing pain and anxiety. Music therapy is a nonpharmacological intervention that purportedly
improves level of comfort and enhances well-being in patients by engaging the affective,
cognitive, and sensory mechanisms.8,9

Studies exploring the effectiveness of music therapy have produced mixed results. Stevens10
examined patients’ response to music during operative procedures involving spinal, epidural, or
local infiltration anesthesia: 75% of the patients rated the music as helpful, relaxing, and
supportive. Participants stated that listening to music helped counterbalance the feeling of
depersonalization associated with being in the hospital environment. Palakanis et al11 reported
the effect of music on patients’ anxiety during flexible sigmoidoscopy. They found that music
was an effective anxiolytic; state anxiety scores were significantly less in the group of patients
who listened to self-selected tapes during procedures than in patients who received the standard
protocol. Conversely, music in combination with muscle relaxation was ineffective in reducing
anxiety in patients admitted to a coronary care unit with unstable angina or acute myocardial
infarction.6 Good12 reviewed the effects of music and relaxation on postoperative pain and
concluded that relaxation and music were effective in reducing affective and observed pain in
most studies but were less effective in reducing opioid intake and sensory pain. Methodological
problems, such as inadequate sample size, poor measurement of pain, and no assurance of pretest
equivalence reduced the validity of the study results reviewed by Good. Good recommended that
randomized controlled trials be conducted within various clinical contexts to determine the
effectiveness of music therapies on relevant outcomes for patients.

Article: Effects of music on patient anxiety.

(Research).
Article from:
AORN Journal
Article date:
February 1, 2003
Author:
Mok, Esther; Wong, Kwai-Yiu

Patients undergoing surgical procedures often experience anxiety in anticipation of events that
will be unfamiliar, uncomfortable, or have undesirable results. Even minor surgical procedures
can produce anxiety in patients, which can affect their postoperative recovery and risk for
physiological complications. Music is an easily administered, nonthreatening, noninvasive, and
inexpensive tool to calm preoperative anxiety.

The effect on patients of listening to music before and during surgery has been the subject of a
number of studies. Some indicate that music is effective in reducing anxiety before and during
surgery. (1) There also are studies, however, that report insignificant results from music
intervention. (2) Additional research with rigorous design is needed.

Other than studies with inconclusive findings about the effect music has on reducing
preoperative and intraoperative anxiety, music intervention during minor surgery with local
anesthesia in a Chinese population has not been tested previously. For this study, researchers
assessed the effectiveness of music as a relaxation modality by measuring patients' vital signs
and self-reported anxiety before and after surgery. The study design required the use of the
Chinese State-Trait Anxiety Inventory (C-STAI) as a principle measure and a physiological
measure of procedure-related anxiety. This study also was designed to learn about the broader
effects of music by asking patients their perception of listening to music during surgery. The
goals of this study are to examine whether music can reduce patients' intraoperative anxiety and
sense of isolation effectively and be considered an alternative nursing intervention when
planning patient care in the OR.

LITERATURE REVIEW

Music is thought to have many effects on an individual. One researcher believes that music may
relieve stress by diverting attention away from or masking annoying noise? One author reveals
that music can help achieve a deep state of relaxation, relieve insomnia, enable patients to recall
suppressed memories, lower blood pressure, and normalize cardiac arrhythmia. (4) Another
author says that music enables the body to synchronize its rhythms with the rhythms of vibrating
bodies around it. (5) For example, if an anxious patient with a racing heartbeat listens to slow
music, his or her heart rate will slow down and synchronize with the music's rhythm.

Other researchers looked at the lived experience of listening to music during postoperative
recovery and evaluated findings from a phenomenological perspective. Three themes emerged
from the interview data, including

* comfort from a discomforting condition;

* familiarity in a strange environment; and

* distraction from fear, pain, and anxiety. (6)

Another group of researchers also found that music in combination with relaxation reduces
postoperative pain during both ambulation and rest. (7)

Many scientists and researchers have examined music and its ability to reduce anxiety in a
variety of health care settings and patients. Music's soothing effects have been demonstrated in
patients undergoing chemotherapy or elective surgery under local or regional anesthesia. These
effects also have been noted in preoperative and postoperative patients, patients receiving
assistance from a ventilator or undergoing flexible sigmoidoscopy, and women in labor. (8)

In the literature, there is some discrepancy about the efficacy of listening to music on patients'
anxiety during surgery. One researcher investigated the effect of humorous and musical
distraction on preoperative anxiety among patients scheduled for elective nondiagnostic surgery.
The results showed no significant differences in self-reported preoperative anxiety among
patients who listened to a humorous audiotape, listened to a tranquil music audiotape, or received
no intervention. (9) These results were somewhat inconsistent with an earlier pilot study that
found same-day-surgery patients who listened to humorous audiotapes reported lower levels of
preoperative anxiety than patients who listened to tranquil music, although the difference was not
statistically significant. (10) The researcher acknowledged that a preference for listening to
music or a comedy routine may have affected some participants' anxiety scores. Several
methodological problems also might have contributed to the insignificant results.

Another group of researchers recruited 96 patients undergoing heart surgery and randomly
assigned them to one of three groups (ie, music therapy, music-videotape therapy, scheduled
rest). Participants in the groups received their assigned 30-minute intervention at two times on
postoperative days two and three. The results showed significant improvement in mood among
participants in the music intervention group; however, no significant differences were reported
for anxiety ratings. There were significant effects over time on heart rate and systolic and
diastolic blood pressure, which indicates a generalized relaxation response. (11)

In a carefully designed study on the effects of music, 121 patients undergoing cataract surgery as
outpatients were allocated randomly into three groups. Patients in the first group heard relaxing
suggestions, patients in the second group heard white noise and OR noise, and patients in the
third group heard relaxing music. Patients in the group listening to relaxing music were found to
be more satisfied than patients in the group listening to relaxing suggestions. Patients in the
group who heard the white noise and OR noise were found to be the least satisfied, but there was
no concomitant reduction in levels of anxiety among members of the three groups.

Effect of music therapy on stress response to

day surgery
AORN Journal, Oct, 2007 by George Allen

British Journal of Surgery August 2007

Surgery, regardless of whether it is performed in a hospital or day surgery setting, is a well-

recognized cause of stress. Anxiety; metabolic, neurohormonal, and immune system changes;
cardiovascular alterations; and increased levels of cortisol and natural killer lymphocytes are all
associated with stress.

Numerous studies have shown that music therapy can inhibit stress, reducing the neurohormonal
responses to psychological stress as well as preoperative anxiety and postoperative pain. The
most suitable type of music to use for music therapy, however, is still a matter of debate. The
primary purpose of this randomized study was to examine the role of music therapy in reducing
stress associated with day surgery by evaluating changes in plasma levels of cortisol and natural
killer lymphocytes, both of which are known to increase during stress. A secondary objective
was to determine the effect of different types of music (ie, new age, patient selected).

Between January and December 2005, 60 patients undergoing surgery at a day surgery unit of a
university hospital in Italy were randomly assigned to one of three groups, with 20 patients in
each group. Patients in group I listened to a compilation of relaxing new age music via
headphones before and during surgery. On the morning of admission for day surgery, patients in
group II chose the type of music they would listen to from a selection of classical, country, pop,
and dance music compilations, and listened to their musical choice via headphones before and
during surgery. Patients in group III (ie, the control group) did not listen to music before or
during surgery.
Patients in the music therapy groups listened to music from one hour before surgery until the end
of the surgical procedure. All of the surgical procedures were performed without general
anesthetics or analgesics and were performed between 9 AM and 1 PM. The preoperative anxiety
level of all patients was evaluated on admission using the Hamilton Anxiety Scale. A sample of
blood was collected immediately before, during, and three hours after surgery and tested for
cortisol levels and lymphocyte counts, including natural killer lymphocyte cell counts. The blood
pressure, heart rate, and respiratory rate of all patients were recorded at the same times.
Postoperatively, pain was assessed using a visual analogue scale and by noting the doses of
analgesic required. Common statistical techniques, including analysis of variance and the
Duncan multiple range test, were used to analyze differences between the groups.

FINDINGS. Plasma levels of cortisol and natural killer lymphocytes decreased during surgery in
the groups that listened to music but increased during surgery in the control group. Intraoperative
levels of natural killer lymphocytes were significantly lower in group I than in group III (mean
[M] 212.2 cells/mcL versus 329.1 cells/mcL, P < .05). Postoperatively, cortisol levels were
significantly higher in group I than in group II (M 14.21 nanograms [ng]/mL versus 8.63 ng/mL,
respectively; P < .05).

The effect of music listening on older adults

undergoing cardiovascular surgery
1. Elizabeth Twiss1,
2. Jean Seaver2,
3. Ruth McCaffrey3,*

The purpose of this study was to determine the effect of music listening on
postoperative anxiety and intubation time in patients undergoing cardiovascular
surgery. Coronary artery disease and valvular heart disease affect approximately 15
million Americans and 5 million persons in the UK annually, with the majority of
these patients being older adults. The anxiety experienced before, during and after
surgery increases cardiovascular workload, thereby prolonging recovery time. Music
listening as a nursing intervention has shown an ability to reduce anxiety. The study
used a randomized control trial design. Sixty adults older than 65 years were
randomly assigned to the control and the experimental groups. The experimental
group listened to music during and after surgery, while the control group received
standard postoperative care. The Spielberger State Trait Anxiety Inventory was
administered to both groups before surgery and 3 days postoperatively. The mean
of the differences between scores was compared using analysis of variance.
Differences in mean intubation time were measured in both groups. Older adults
who listened to music had lower scores on the state anxiety test (F= 5·57, p = ·022)
and had significantly fewer minutes of postoperative intubation (F = 5·45, p = ·031)
after cardiovascular surgery. Older adults undergoing cardiovascular surgery who
listen to music had less anxiety and reduced intubation time than those who did no