Evaluating the effect of music on patient anxiety during minor plastic surgery.
Article Type: Report
Subject: Anxiety (Care and treatment)
Anxiety (Research)
Surgery, Plastic (Health aspects)
Music therapy (Health aspects)
Author: McLeod, Roddy
Pub Date: 01/01/2012
Publication: Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589
Issue: Date: Jan, 2012 Source Volume: 22 Source Issue: 1
Topic: Event Code: 310 Science & research
Product: Product Code: 8000418 Cosmetic Surgery NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 280303364
Full Text: Aim: The study sought to assess the effectiveness of music on patient anxiety levels during minor surgery. Methods: Eighty patients attending a minor plastic surgery outpatient department were assessed using the Spielberger State-Trait Anxiety Inventory Questionnaire. Forty participants in the experimental group listened to music which was self selected and played during their operation. Forty participants in the control group received the standard care during their operation but with no music. The questionnaire was used to collect data pre and postoperatively. During the recovery period all participants were asked to reflect on their level of anxiety during surgery while completing the questionnaire. Analysis was carried out using Statistical Package for Social Sciences (SPSS) version 12. Results: The postoperative mean anxiety score of the control group was 33.5 (SD 10.6). The mean anxiety score for the experimental group was 30.52 (SD 9.82). Statistical analysis revealed that there was no significant difference among those who did and did not listen to music during their procedure. Conclusion: Although the researcher did not find statistically significant differences in the selected outcome measures, the intervention seemed to be enjoyed by the patients in the experimental group. Minimising anxiety prior to and during a minor operation may help promote relaxation and enhance patient comfort.

Introduction

Anxiety is a common phenomenon in hospitalised patients (Shuldham et al 1995) and may be triggered by a variety of factors including impending surgery and potential post-operative consequences (Mitchell 1997). Patients undergoing surgery may also experience preoperative anxiety (Shuldham et al 1995). According to Salmon (1993) it has become normal to consider anxiety as an undesirable patient problem despite the recognition that it is a necessary human behaviour which prepares the body both psychologically and physically for the anticipated stressor. Salmon (1993) also states that patients need to have some degree of anxiety to enable them to respond to stressful situations and suggests that nurses may be doing more harm than good when attempting to reduce anxiety.

The purpose of this research was to evaluate the effect of music on patient anxiety during minor plastic surgery. Medical and nursing literature substantiates the relationship between music and the reduction of surgery-related anxiety (Standley 1986, Thompson & Kam 1995, Evans 2002). It has also been suggested that giving patients a choice of music lowers anxiety and promotes relaxation (Fischer 1990, Stevens 1990). However, despite a wealth of research into the assessment and treatment of anxiety before surgery (Miluk-Kolasa 1996, Yung et al 2002) there is less work that explores approaches to decreasing the anxiety of patients undergoing surgical procedures during local anaesthesia.

Background

The therapeutic value of music has been ascertained through a number of studies involving hospitalised patients. For example, music is reported to distract patients in a strange environment and to provide a comforting and familiar effect in discomforting conditions (Wong et al 2001, Evans 2002, Mok & Wong 2003).

McCaffery (1990) suggested that listening to music was an effective sensory distraction and was useful in minimising discomfort associated with short medical procedures. In surgical settings, use of music has been shown to decrease patient anxiety preoperatively (Augustin & Hains 1996) and intraoperatively (Naidu 1982). These benefits have been attributed to the reduction of unfamiliar and loud auditory stimuli that occur during surgery. Use of music in the operating environment has also been long-standing because of the tranquilising effect (Knight & Rickard 2001). It would therefore appear that appropriate use of music, particularly if selected by patients, can be an intervention which reduces anxiety and promotes feelings of well being. Despite the evidence in support of music improving patient wellbeing, nurses have been slow to embrace this as a therapeutic approach to reducing anxiety (Watkins 1997).

Music as an intervention to decrease anxiety

Watkins (1997) stated that sensory inputs such as music can be pathways for pleasure and can be positively developed within the theatre environment to reduce heart rate, blood pressure, pain and anxiety. He also indicated that the scientific evidence has shown that music reduces not only blood pressure, heart rate and respiration, but also insomnia and anxiety levels.

A more recent systematic review by Evans (2002) investigated the effectiveness of music as an intervention for hospital patients. Twenty nine studies were identified and the review concluded that music was effective in reducing anxiety during normal care delivery but also highlighted the need for further research. The author anticipated that many uses for music have yet to be fully explored.

Research into the effects of music (as a distraction) played pre-, intra- or postoperatively (Miluk-Kolasa 1996, Cooke et al 2005) has been conducted, but few studies have shown significant benefits in terms of anxiety reduction. Other studies have indicated positive support for the use of music both before (Moss 1987, Updike & Charles 1987) and during surgery (Steelman 1990, Stevens 1990).

Playing music during the pre- and postoperative phases

The effects of music on critically ill patients have included reported improvements in emotional status, decreases in levels of anxiety and in haemodynamic parameters (Guzzetta 1989, Updike 1990, White 1992). This research has shown that music, as a therapeutic modality, relieves anxiety and pain in patients before and after surgery (Augustin & Hains 1996).

Music during surgery

Music listening has also been studied with patients undergoing elective procedures using regional anaesthesia to determine its effect on anxiety levels during surgery. Eisenman and Cohen (1995) studied patients undergoing orthopaedic surgery who reported that listening to music helped to make the time to pass more quickly, masked background noises and diverted their attention away from the surgical procedure. The data also indicated that study patients required less anaesthesia, were calmer and maintained more stable pulse rates and blood pressures. Palakanis et al (1994) studied the effects of music on anxiety levels in patients who were having a flexible sigmoidoscopy. Results demonstrated that music led to a significant decrease in blood pressure, heart rate and self-reported anxiety score from subjects in the experimental group.

Cruise et al (1997) assessed the effect of music on elderly patients undergoing cataract surgery. Patients reported being more satisfied with the 'whole operative experience' if they heard music rather than relaxing suggestions, white noise, or operating theatre noise. However, the researchers did not find that music influenced the state of anxiety in those patients.

Music can also be used in conjunction with pharmacological interventions and could promote comfort to patients undergoing minor plastic surgery. The study by Mok and Wong (2003) found that there appear to be positive changes in physiological variables measured, although these changes are not consistent nor are they always significant. One of the problems frequently mentioned by researchers when testing the effects of music relates to type and choice. A number of studies suggest that the therapeutic effects of music are enhanced when patients actually choose their own musical selections (Winter et al 1994). By providing patients with a choice, patients retain a sense of control over their treatment.

Methods

A quasi-experimental quantitative study design was used to compare the effects of an intervention on self-reported anxiety levels among experimental (standard care plus listening to music preferences) and control (standard care) groups attending a plastic surgery outpatient department within a major teaching hospital in the East of Scotland. For this study, minor surgery involved the use of minimally invasive techniques which were performed using local anaesthetic, and where each procedure was not longer than 45 minutes. Ethical approval was sought and granted by the local Medical Research Ethics Committee. Ethical approval was also secured by the University Ethics Committee.

Sample

All patients at one trust in Scotland, who were scheduled for minor plastic surgery under local anaesthetic who met the following criteria were eligible to participate in the study:

* Aged 18 years or older

* Willing to volunteer and consent to participate

* Able to comprehend written and oral instruction

* Have no hearing impairment.

Participants were excluded if they did not like music, had hearing impairments or were undergoing ear surgery.

A total of 100 participants scheduled for plastic surgery were contacted by the consultant surgeon's secretary. A participant information sheet was sent which explained the details of the study along with a covering letter from the consultant stating that the research would be conducted with the knowledge and support of senior clinicians in plastic surgery.

Eighty patients agreed to participate. Reasons for refusal varied: some patients discovered that they did not require surgery and therefore were ineligible to participate, others did not like listening to music or the choice of music available was not to their liking. Those who volunteered were assigned to the experimental or control group according to a six week schedule. For example, patients who came in the first week were assigned to the experimental group and patients who attended the following week were assigned to the control group which received the standard care reflective of current practice (see Table 1). This arrangement helped to minimise the threat of diffusion of intervention, thereby avoiding subject interaction that would happen if random assignment to groups was done on the same day. This assigning process continued until each group had 40 patients.

Data collection

The study was conducted over a 6-week period with patients requiring plastic surgery for conditions such as scar revision, excision of benign skin lesions, excision of moles, skin grafting and hand surgery. Participants were invited to answer the 20 questions within the Spielberger State-Trait Anxiety Inventory Questionnaire (Spielberger 1983). This provided the situational and baseline anxiety levels.

Before surgical preparation, patients in the experimental group were offered a choice of music from a wide range of styles. Participants in the experimental group chose a style of music from those presented by the nurse researcher, which they found to be the most agreeable. In the experimental group (15%) patients had easy listening music, (70%) listened to classical music, (5%) listened to relaxation music and (10%) had contemporary music. Once a preference was indicated, patients were instructed to close their eyes and concentrate on the sound of the music. The volume was adjusted accordingly by the circulating nurse and the music played openly in the operating theatre. Participants in the control group received standard care but without the opportunity to listen to music.

Immediately after surgery in the recovery waiting area, all participants were instructed to reflect on their level of anxiety during the surgery while completing the second state anxiety questionnaire. This score was taken to represent the intra-operative state anxiety score.

The 'State' part of the questionnaire reports how a person feels when they have completed the questionnaire and also evaluates their temporary condition which responds to physical danger and psychological stress. Only the State anxiety portion of the questionnaire was used as opposed to the 'Trait' portion which deals with the more general and longstanding qualities of anxiety.

The essential qualities evaluated by the anxiety questionnaire are feelings of apprehension, tension, nervousness and worry, as well as assessing how people feel 'right now'. This scale may also be used to evaluate how the patient felt at a particular time in the recent past and how they will feel either in a specific situation that is likely to be encountered in the future or in a variety of hypothetical situations.

The questionnaire consisted of 20 items arranged on a four point Likert scale (1 = absence of anxiety and 4 = high anxiety). The total score is the weighted sum of all 20 responses ranging from 20-80: low anxiety (20-30), moderate anxiety (40-59), and high anxiety (60-80).

Data analysis

Analysis of data was carried out using Statistical Package for Social Science (SPSS version 12). Descriptive statistics included mean values and standard deviation. All data were tested for normality by using a one sample KS TEST. This would compare the experimental distribution against the hypothetical ideal. Demographics and comparability of the experimental and control groups were assessed using the t test for continuous variables and chisquared test for categorical variables.

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A t-test was used to compare differences between the experimental and control groups. A t-test for the independent groups detected baseline differences in each of the pre-test variables. A t-test for independent groups detected differences in the identified variables during surgical procedures. This revealed the values of the patients receiving the music intervention and compared against patients in the control group. T-test paired samples compared pre-test and post-test variables for both groups.

Results

Preoperative anxiety

Baseline mean anxiety score for the experimental group was M = 38.50 (SD 15.60) with a range of 20 to 76. The control group mean anxiety score was M = 38.45 (SD 11.50). The t-test revealed no significant difference between the groups (Table 2).

Postoperative anxiety

Anxiety scores postoperatively detected differences in the identified variables during surgical procedures by immediate retrospective rating. They showed a mean anxiety score for the experimental group of 30.52 (SD 9.82) with a range of 20 to 56. The mean anxiety score of the control group was 33.15 (SD 10.60). The difference in postoperative anxiety scores was examined by a t-test which revealed no significant difference (Table 3).

Comparisons between pre-test and post test variables for both groups were also undertaken and there was a decrease in anxiety levels after surgery. There were no statistically significant differences among those who did and did not listen to music (Table 4).

The mean anxiety score for the experimental group was 34.51 (SD 10.58). The mean anxiety score for the control group was 35.80 (SD 9.82). Changes between pre and postoperative anxiety scores were tested by a paired t-test:

t (39) = 19.21; p<0.001 (Experimental)

t (39) = 18.37; p<0.001 (Control)

After the procedures, no significant differences were found. The experimental group consistently reported decreased levels of negative reactions and increased levels of positive reactions from pre to post test.

Conclusions

This study was performed in order to test a hypothesis from clinical experience that many patients undergoing minor plastic surgery under local anaesthetic, for example, for benign skin lesions or excision of moles, show signs of stress. Although this kind of surgery is minor, many patients do feel insecure and afraid of the procedure. Because the study was based on the use of a questionnaire, the researcher did not attempt to measure levels of anxiety during the surgical procedures. Spielberger (1983) recommended that, in circumstances in which it was not possible to measure anxiety at the time it was experienced, that it was valid for patients to be instructed to retrospectively reflect on how they felt during the particular occasion provided the feelings were recently experienced. The researcher therefore assessed the 'intra-operative' state anxiety retrospectively but immediately after the patient had been admitted to the recovery area as it would have been difficult and inappropriate to subject the patient to complex STAI assessment intra-operatively.

The main objective of this research was to determine whether music as an intervention was effective in reducing levels of anxiety among 80 patients who were undergoing minor plastic surgery. Before the surgical operations in question commenced, patients reported various levels of anxiety with scores ranging from 23 to 76 on the STAI anxiety scale. The experimental group consistently reported decreased levels of positive reactions from pre to post test. After the procedures, no significant differences were found. The experimental group consistently reported decreased levels of negative reactions and increased levels of positive reactions from pre to post test.

This study presented the practice of listening to music as a non-invasive intervention designed to assist perioperative nurses in creating a stress-free environment to promote health and well-being to surgical patients. The results lend further support to a recent review suggesting that music can be an effective tool in reducing anxiety and should be offered to patients pre-, intra- and postoperatively (Evans 2002).

Limitations

The generalisability of this study is limited because all data were collected in one hospital. Any conclusions and generalisations reached may be applicable only to this particular population. Patients in this study were required by the postoperative questionnaire to recall how anxious they felt during their operation. Participants might not have been able to accurately report how anxious they felt during surgery due to memory lapses and possible influence of local anaesthetic. The presence of the researcher throughout the procedure also might have influenced the subjects to provide a more positive response. These points have implications regarding the generalisation of the findings.

Recommendations

Relaxing music, carefully chosen, should be offered to all patients undergoing minor plastic surgery. Music listening can produce positive effects in this patient group, for example by promoting relaxation and reducing anxiety by a non-pharmacological means. Although results in this study were largely not significant, music is a simple, inexpensive and reliable tool which can be applied with advantage in the nursing of plastic surgery patients without risking unwanted side-effects.

Additional research is needed to better define the optimal role for music in comprehensive, cost-effective patient care. Similar studies could follow the above procedure and extend the present findings by using a larger sample size and measuring physiological parameters such as blood pressure, heart rate, respiration rate and cortisol levels. They might also include patients from a variety of surgical specialties. Also, patients with and without prior experience of minor plastic surgery under local anaesthetic could be included in the sample and could then be compared to examine whether there is any difference when exposed to music therapy.

References

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Cooke M, Chaboyer W, Hiratos M A 2005 Music and its effects on anxiety in short waiting periods: a critical appraisal Journal of Clinical Nursing 14 145-55

Cruise C J, Chung F, Yogendrans S, Little D 1997 Music increases satisfaction in elderly outpatients undergoing cataract surgery Canadian Journal of Anaesthesia 44 (1) 43-48

Eisenman A, Cohen B 1995 Music therapy for patients undergoing regional anesthesia AORN Journal 62 (6) 947-50

Evans D 2002 The effectiveness of music as an intervention for hospital patients: a systematic review Journal of Advanced Nursing 37 8-18

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Knight WE, Rickard NS 2001 Relaxing music prevents stress-induced increases in subjective anxiety, systolic blood pressure, and heart rate in healthy males and females Journal of Music Therapy 38 (4) 254-272

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Moss VA 1987 The effects of music on anxiety in the surgical patient Perioperative Nursing 3 9-16

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Clinical Nurse Specialist 11 43-50

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by Roddy McLeod

Correspondence address: Clinical Skills Centre, Ninewells Hospital, Dundee, DD1 9SY. Email: r.mcleod@dundee.ac.uk

About the author

Roddy McLeod

MSc, BN, RGN, Adult Nursing Pg Cert Teaching

Higher Ed, FHEA

Senior Clinical Skills Tutor, Ninewells Hospital,

Dundee

No competing interests declared
Group          N     Mean        Std      Std
                                    deviation    error
                                                  mean

Anxiety  experimental  40  38.5000   15.59421  2.46566
score
pre-op
         control       40  38.4500   11.49794  1.81798

Table 2 Preoperative anxiety scores


Group          N     Mean        Std      Std
                                    deviation    error
                                                  mean

Anxiety  experimental  40  30.5250    9.82145  1.55291
score
post-op
         control       40  33.1500   10.58191  1.67351

Table 3 Postoperative anxiety scores


Group          N     Mean        Std      Std
                                    deviation    error
                                                  mean

Anxiety  experimental  40  38.5000   15.59421  2.46566
score
pre op
         control       40  38.4500   11.49794  1.81798
Anxiety  experimental  40  30.5250    9.82145  1.55291
score
post op
         control       40  33.1500   10.58191  1.67315

Table 4 Pre and post test comparison
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