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Minimising preoperative anxiety with music for day surgery patients a randomised clinical trial
Cheng-Hua Ni, Wei-Her Tsai, Liang-Ming Lee, Ching-Chiu Kao and Yi-Chung Chen

Aims and objectives. The objective of this study was to evaluate the effects of musical intervention on preoperative anxiety and vital signs in patients undergoing day surgery. Background. Studies and systematic meta-analyses have shown inconclusive results of the efcacy of music in reducing preoperative anxiety. We designed a study to provide additional evidence for its use in preoperative nursing care. Design. Randomised, controlled study. Method. Patients (n = 183) aged 1865 admitted to our outpatient surgery department were randomly assigned to either the experimental group (music delivered by earphones) or control group (no music) for 20 minutes before surgery. Anxiety, measured by the State-Trait Anxiety Inventory, and vital signs were measured before and after the experimental protocol. Results. A total of 172 patients (60 men and 112 women) with a mean age of 4090 (SD 1180) completed the study. The largest number (357%) was undergoing elective plastic surgery and 767% of the total reported previous experience with surgery. Even though there was only a low-moderate level of anxiety at the beginning of the study, both groups showed reduced anxiety and improved vital signs compared with baseline values; however, the intervention group reported signicantly lower anxiety [mean change: 583 (SD 075) vs. 172 (SD 065), p < 0001] on the State-Trait Anxiety Inventory compared with the control group. Conclusions. Patients undergoing day surgery may benet signicantly from musical intervention to reduce preoperative anxiety and improve physiological parameters. Relevance to clinical practice. Finding multimodal approaches to ease discomfort and anxiety from unfamiliar unit surroundings and perceived risks of morbidity (e.g. disgurement and long-term sequelae) is necessary to reduce preoperative anxiety and subsequent physiological complications. This is especially true in the day surgery setting, where surgical admission times are often subject to change and patients may have to accommodate on short notice or too long a wait that may provoke anxiety. Our results provide additional evidence that musical intervention may be incorporated into routine nursing care for patients undergoing minor surgery. Key words: CAM, musical intervention, nurses, nursing, preoperative anxiety, State-Trait Anxiety Inventory, Taiwan
Accepted for publication: 20 July 2010

Introduction
A high level of preoperative anxiety is common among patients undergoing surgery (Augustin & Hains 1996).
Authors: Cheng-Hua Ni, MSc, Instructor, School of Nursing, College of Nursing, Taipei Medical University and Head Nurse of Operating Room, Department of Nursing, Taipei Medical University, Wan Fang Hospital; Wei-Her Tsai, PhD, Assistant Professor, Department of Health Care Management, National Taipei University and Health Science; Liang-Ming Lee, MD, Assistant Professor and Chief of Urology Department, School of Medicine, College of Medicine, Taipei Medical University, Wan Fang Hospital; Ching-Chiu Kao, MSc, Instructor,

Anxiety over loss of control, unfamiliarity with hospital or unit settings and perceived morbidity and mortality contribute to increased intra-operative anaesthetic requirements and postoperative complications (Maraneta & Kain 1999, Kain
School of Nursing, College of Nursing, Taipei Medical University and Director, Nursing Department, Taipei Medical University Hospital, Taipei; Yi-Chung Chen, MSc, Attending Physician, Internal Medical Department, Da-Chien General Hospital, Miaoli, Taiwan Correspondence: Yi-Chung Chen, Attending Physician, Taipei Medical University, Wan Fang Hospital, No. 111. Section 3, Hsing-Long Rd, Taipei 116, Taiwan. Telephone: +886 2 27296603. E-mail: m600105@yahoo.com.tw

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2011 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 620625, doi: 10.1111/j.1365-2702.2010.03466.x

Original article

Music effect on anxiety in preoperative patients

et al. 2000, Ozalp et al. 2003). Even patients with a low predisposition to anxiety may become apprehensive in the anticipation of surgery and show physical and psychological changes, including increased heart rate (HR), blood pressure, palpitations, vasoconstriction, nausea, vomiting and gastric stasis (Simpson & Stakes 1987, Jacquet et al. 2006). In day surgery, where preoperative nursing care is limited and waiting times for surgery are unnervingly long and subject to change, traditional pharmacological anxiolysis may fail to reduce preoperative anxiety (Gilmartin 2004). Nursing interventions including preoperative psychological preparation, timely provision of information and symptom management are necessary to limit anxiety and stress and to facilitate a fast and painless discharge and aftercare. The therapeutic value of music in various clinical settings has been recognised for its ability to modify the limbic system to provide pain relief, relaxation and reduction in psychophysiological stress. This depends on the nature and rhythm of the music and the personal associations generated while listening (Thaut 1990). Increases in HR and vasoconstriction because of stress are modulated by the autonomic nervous system; music acts on the autonomic nervous system by occupying several neurotransmitters from the auditory centre of the temporal lobe, which then signals the hypothalamus, medulla, amygdala, pons, midbrain and thalamus (Thaut 1990). The result is an anxiolytic diversion from negative stimuli and an integrated hypothalamic relaxation response resulting in reduced HR and blood pressure. These benets have led to considerable research on the effect of music on preoperative anxiety for minor surgery, bronchoscopy, colonoscopy, cardiac catheterisation and transurethral resection of the prostate (Nilsson 2008), mostly with mixed results. The object of this study was to evaluate the effectiveness of musical intervention in reducing preoperative anxiety in patients undergoing day surgery as measured by the StateTrait Anxiety Inventory (STAI). We also assessed the effect of music on the physiological parameters of anxiety, including HR and systolic and diastolic blood pressures (SBP and DBP).

Good & Chin 1998, Huang 2003, 2005, Wu & Chou 2008) and none reported internationally. Systematic meta-analysis conducted by Nilsson (2008) revealed that 50% of studies (12 of 24) published between January 1995January 2007 found signicant reductions in anxiety scores as measured by STAI. Others have reported minor but insignicant reductions in physiological indices. These mixed results have been attributed to small sample size, lack of a control group, lack of randomisation, selection bias, previous surgical experience, non-objective outcome measures, inconsistent duration of musical intervention and non-standardised protocols. In this study, we sought to overcome these limitations with a randomised, controlled study design.

The importance of the type of music


Cooke et al.s (2005a) of 12 studies found that the effectiveness of musical intervention did not appear to be inuenced by genre or type of soothing music selected, although slow rhythm and other descriptions of the music were often undened. All Chinese studies conducted thus far have included a choice of soothing Western or Eastern music provided by the investigators (Szeto & Yung 1999, TaylorPiliae & Chair 2002, Yung et al. 2002, Mok & Wong 2003, Lee et al. 2004); Szeto and Yung (1999) and Yung et al. (2002) reported a lack of difference in musical preference among patients but mentioned that patients preferred their own personal selections. Cooke et al. (2005b) also found that patients had specic musical preferences. In all cases, soothing, non-lyrical music with a tempo of 6080 beats, delivered at a maximum volume level of 60 dB, has been recommended (Staum & Brotons 2000). Musical intervention generally lasts 1530 minutes.

Methods
Design
This randomised, controlled study was conducted with patients aged 1865 admitted to our outpatient surgery department from 20042007. The exclusion criteria were (i) patients with cognitive decits or who were illiterate in Chinese; (ii) patients with hearing impairments or who had difculty wearing earphones; (iii) patients who received preoperative sedatives; (iv) patients who did not have sufcient time to participate in the study waiting time of <3045 minutes; (v) patients who were undergoing ophthalmic surgery or major surgery; and (vi) patients with psychological illnesses or life-threatening diseases. Permutedblock randomisation was used to assign participants to either

Background
The effects of music on preoperative anxiety
The effect of music on preoperative anxiety has been a subject of ongoing investigation in Western/European countries (Evans 2002, Nilsson 2008) and, to a lesser extent, in Eastern countries: (Szeto & Yung 1999, Taylor-Piliae & Chair 2002, Yung et al. 2002, Mok & Wong 2003, Lee et al. 2004). Research on musical intervention in Taiwan is limited, with only a few studies reported domestically (Hwang et al. 1996,
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experimental (music delivered by earphones) or control group (no music); routine nursing care was performed for both groups. The primary outcome was anxiety level as measured by STAI. Vital signs (blood pressure and HR) were also measured before and after musical intervention. This study was approved by the institutional review board, and informed consent was obtained from all participants. The STAI is a two-part 20-item self-report measure developed by Spielberger (1983). It contains 40 items rated on a Likert scale (one being not at all and four being very much so) measuring feelings of apprehension, tension, nervousness and worry. Total scores range from 2080, with higher scores indicating greater anxiety (low anxiety: 2039; moderate anxiety: 4059; and high anxiety: 6080). The Chinese STAI (Shek 1993) used in this study has been previously validated and exhibited high internal consistency (090094) (Taylor & Deane 2002). The STAI takes fewer than ve minutes to complete and can be scored quickly.

Statistical analyses were performed using software (SPSS Inc., Chicago, IL, USA).

SPSS

15.0 statistics

Results
One hundred and eighty-three patients were selected for our study between 20042007 in the Taipei Municipal Wan Fang hospital (Taipei, Taiwan); however, three failed to meet inclusion criteria and six did not complete the questionnaire. The remaining 174 patients were randomly assigned, with 87 in the music group and 87 in the control group. Of these patients, 112 (651%) were women. One patient in the music group and one patient in the control group did not complete the study. Figure 1 is a ow chart of the trial that presents the reasons for early patient termination. The groups were comparable in baseline characteristics (Table 1). The STAI scores and vital signs did not show signicant differences between the two groups (p > 005). The primary endpoint, the mean change in STAI score from baseline after intervention, is shown in Table 2. Signicant decreases in STAI scores from baseline were observed in both groups (both p < 0001). In addition, there was a statistically signicant difference between the music and control groups (p < 0001). The STAI score decreased by means of 583 and 172 in the music and control groups, respectively. The secondary endpoints, the mean changes in vital signs from baseline after intervention, are also shown in Table 2. Decreases in HR, systolic and diastolic blood pressures from baseline were observed in both groups.

Data collection
Patients who were admitted to the hospital 3045 minutes prior to surgery received the same procedural instructions from an investigator. Consent to participate and detailed demographic information were obtained at that time. After preoperative registration, a registered nurse took vital signs and administered the STAI following standardised instructions. A computer-generated list then randomised the patients to receive either musical intervention or control. Music consisted of an investigator-selected mini library that included soothing popular Chinese and Minan Taiwanese Pop songs (low-tone, slow-rhythm ballads only) in compact disc format delivered by headphones and a compact disc player. The patients were free to select from the musical menu. Control patients engaged in relaxing activities in the waiting room. After 20 minutes, anxiety and vital signs were measured again. Patients then underwent standard preoperative anaesthetic and surgical management.

Discussion
Although Lee et al. (2004) found signicant changes in selfreported anxiety but no signicant changes in physiological indices postintervention, four other Chinese studies on the effect of music on preoperative anxiety found changes in both (Szeto & Yung 1999, Taylor-Piliae & Chair 2002, Yung

Statistical analysis
Categorical variables were analysed by the use of Chi-square analysis/Fishers exact test. Paired t-tests in both groups were employed to analyse the results of differences in improvement after intervention. Independent two-sample t-tests were used to detect group differences in baseline-to-postintervention changes. Continuous data were presented as mean standard deviation, while categorical data were represented by a number and a percentage. All statistical assessments were two-tailed and considered signicant at the 005 level.

Patients screened n = 183 Patients randomised n = 174

Screening failures: - Criteria (3) - Time is not enough to complete questionnaire (6)

Music group n = 87

Control group n = 87 Completed n = 86 Withdrawn n=1

Completed n = 86

Withdrawn n=1

Figure 1 Patient ow chart.

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Original article Table 1 Basic demographic parameters and baseline characteristics of study population (n = 172)* Age (years) Gender Male Female Education Elementary school High school University Surgery Neurosurgery Obstetrics & Gynaecology General Clinic ENT Department Urology Plastic Surgery Cardiovascular Experience of surgery Smoking Drinking Heart rate (beat/min) Systolic pressure (mmHg) Diastolic pressure (mmHg) STAI

Music effect on anxiety in preoperative patients

Total (n = 172) 4090 1180 60 (349%) 112 (651%) 18 (105%) 102 (593%) 52 (302%)

Music group (n = 86) 4159 1097 31 (360%) 55 (640%) 8 (93%) 51 (593%) 27 (314%)

Control group (n = 86) 4021 1260 29 (337%) 57 (663%) 10 (116%) 51 (593%) 25 (291%)

p-value 0444 0749

0861

29 (170%) 12 (140%) 17 (200%) 32 (187%) 13 (151%) 19 (224%) 19 (111%) 9 (105%) 10 (118%) 13 (76%) 8 (93%) 5 (59%) 14 (82%) 5 (58%) 9 (106%) 61 (357%) 38 (442%) 23 (271%) 3 (18%) 1 (12%) 2 (24%) 132 (767%) 70 (814%) 62 (721) 37 (216%) 16 (188%) 21 (244%) 25 (146%) 14 (163%) 11 (129%) 7997 1252 8124 1241 7869 1258 13161 2059 12921 1948 13404 2151 8374 1191 8336 1196 8412 1193 4392 933 4283 999 4502 854

0225

0149 0694 0424 0187 0128 0682 0124

*Data are presented as mean SD and ,number (percentage). STAI, State-Trait Anxiety Inventory. p-values based independent two-sample t-test (), p-values based independent chi-square test (), p-values based independent Fishers exact test ().

Table 2 Comparative primary endpoint (mean change of anxiety score from baseline) and secondary endpoints (mean change in vital signs from baseline) between the two groups (n = 172)* Mean change from baseline Primary endpoint STAI Secondary endpoints Heart rate (beat/min) Systolic pressure (mmHg) Diastolic pressure (mmHg) Music group (n = 86) 583 075 Control group (n = 86)

p-value

172 065 <0001 0216 0002 0976

501 079 376 063 772 116 1289 116 426 087 423 078

*Data are presented as mean SE. Signicant difference between pre- and postintervention using paired t-test, p < 005. Signicant difference between two groups using independent twosample t-test, p < 005. STAI, State-Trait Anxiety Inventory.

et al. 2002, Mok & Wong 2003). In their study, Cooke et al. (2005b) found a signicant reduction in state anxiety level but did not measure physiological changes. The design and
2011 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 620625

sample size of this study afrm both the anxiolytic effects of music on preoperative anxiety and its ability to reduce physiological indices. Patients in both the intervention and control groups showed a reduction in HR, SBP and DBP, but the differences were not signicant except for SBP that was actually lower in the control group. Variable changes in physiological outcome measurements are common (Davis & Thaut 1989, Strauser 1997, Taylor-Piliae & Chair 2002, Wang et al. 2002) and have been explained by trait-related differences in sympathetic system response to stress (Wang et al. 2002), cultural expectations regarding the public display of emotion (Taylor-Piliae & Chair 2002) and previous experience with the stressor. The latter may have also been a confounding factor in our study, as a majority (767%) had had previous experience with surgery and many were undergoing elective plastic surgery (357%) that they felt positive about. While this study demonstrated positive results, there are also several limitations to the research. It is possible that a 20-minute musical intervention may have been insufcient to produce physiologically measurable effects, and the relaxing

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effect of the investigators selections may not have been as great as it might have been if the patient had brought his own music from home. The use of an interviewer to administer the questionnaire may have introduced a positive bias in scores (more data about anxiety), but that bias would have been the same for both groups. The individuals who collected postintervention data were aware of who was in each group and this may have biased the results. We did not gather information about preoperative pain or other adverse events and did not examine other potential determinants of preoperative anxiety such as bedside manner, responsiveness to patient needs or adequacy of information. Finally, the ndings may not be generalised beyond a day surgery setting in a medical centre. Future studies might incorporate more sophisticated outcome measurements such as galvanic skin response, epinephrine, norepinephrine, cortisol and prolactin levels in urine and blood before and after musical intervention. Another meaningful area of study would be the association between preoperative anxiety and postoperative patient satisfaction to see whether reduction in the former produced an increase in the latter.

Relevance to clinical practice


Finding multimodal approaches to ease discomfort and anxiety from unfamiliar unit surroundings and perceived risks of morbidity (e.g. disgurement and long-term sequelae) is necessary to reduce preoperative anxiety and subsequent physiological complications. This is especially true in the day surgery setting, where surgical admission times are often subject to change and patients may have to accommodate on short notice or too long a wait that may provoke anxiety. Our results provide additional evidence that musical intervention may be incorporated into routine nursing care for patients undergoing minor surgery.

Acknowledgements
We acknowledge all staff members in the Departments of Nursing Service and Surgery, Taipei Medical University, Wan Fang Hospital, for their assistance in the smooth completion of this study. The study was supported by grants from Taipei Medical University, Wan Fang Hospital, 96wf-eva20.

Contributions Conclusions
The results of this study indicate that patients scheduled to undergo elective day surgery may benet from musical intervention in terms of reduced preoperative anxiety levels and physiological indicators of anxiety. The ndings suggest that nurses can make a positive contribution to quality of care through such an intervention. Study design: C-HN, Y-CC; data collection and analysis: C-HN, W-HT, L-ML, C-CK, Y-CC and manuscript preparation: C-HN, W-HT, L-ML, C-CK, Y-CC.

Conict of interest
None.

References
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Music effect on anxiety in preoperative patients Taylor-Piliae RE & Chair SY (2002) The effect of nursing interventions using music therapy or sensory information on Chinese patients anxiety prior to cardiac catheterization: a pilot study. European Journal of Cardiovascular Nursing 1, 203211. Thaut MH (1990) Neurophysical processes in music perception and their relevance in music therapy. In: Music Therapy in the Treatment of Adults With Mental Disorders: Theoretical Bases and Clinical Interventions (Unkefer RF ed.). Schirmer Books, New York, NY, pp. 332. Wang SM, Kulkarni L, Dolev J & Kain ZN (2002) Music and preoperative anxiety: a randomized, controlled study. Anesthesia and Analgesia 94, 1489 1494. Wu SJ & Chou FH (2008) The effectiveness of music therapy in reducing physiological and psychological anxiety in mechanically ventilated patients. The Journal of Nursing 55, 3544. Yung PM, Chui-Kam S, French P & Chan TM (2002) A controlled trial of music and pre-operative anxiety in Chinese men undergoing transurethral resection of the prostate. Journal of Advanced Nursing 39, 352359.

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