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

Effect of sleep-inducing music on sleep in persons with percutaneous transluminal coronary angiography in the cardiac care unit
Min-Jung Ryu, Jeong Sook Park and Heeok Park

Aim and objective. The study compared the effect of earplug-delivered sleep-inducing music on sleep in persons with percutaneous transluminal coronary angiography in the cardiac care unit. Background. Diverse types of music have been claimed to improve sleeping elsewhere, but relatively little is known in South Korea. Most studies investigating the effect of sleep-inducing music on sleep have involved persons with insomnia, even though many persons with cardiovascular disease in the intensive care unit suffer from sleeping problems. There is a need to investigate the effect of sleep-inducing music on sleep disorders in persons with percutaneous transluminal coronary angiography in the cardiac care unit. Design. An experimental research design was used. Methods. Data collection was conducted in the cardiac care unit of K University Hospital in D city, from 3 September– 4 October 2010. Fifty-eight subjects participated and were randomly assigned to the experimental group (earplug-delivered sleep-inducing music for 52 min beginning at 10:00 PM , while wearing an eyeshield, n = 29) and the control group (no music, but earplugs and eyeshield worn, n = 29). The quantity and quality of sleep were measured using questionnaires at 7 AM the next morning for each group. Results. Participants in the experimental group reported that the sleeping quantity and quality were significantly higher than control group (t = 3Æ181, p = 0Æ002, t = 5Æ269, p < 0Æ001, respectively). Conclusion. Sleep-inducing music significantly improved sleep in patients with percutaneous transluminal coronary angiography at a cardiac care unit. Offering earplugs and playing sleep-inducing music may be a meaningful and easily enacted nursing intervention to improve sleep for intensive care unit patients. Relevance to clinical practice. Nurses working at cardiac care unit can use music to improve sleeping in clients with percutaneous transluminal coronary angiography. Key words: cardiac care unit, cardiovascular disease, earplugs and eyeshield, insomnia, nurses, nursing, percutaneous transluminal coronary angiography, sleeping, South Korea
Accepted for publication: 21 June 2011

Introduction
The prevalence of cardiovascular disease (CVD) is increasing because of increased life expectancy, obesity and lack of exercise. CVD has been significantly related with high mortality in South Korea (Statistics Korea, 2010). Most

persons with CVD require coronary angiography as one of the treatments and are supposed to be admitted to the intensive care unit (ICU) for close observation. The environment of a typical ICU is not conducive to sleep. Sleepdepriving influences include continuous bright light, extreme noises, discomforting smells and frequent medical/nursing

Authors: Min-Jung Ryu, MSN, RN, Nurse, Keimyung University, DongSan Hospital; Jeong Sook Park, PhD, RN, Professor, Keimyung University, College of Nursing; Heeok Park, PhD, RN, Tenure Track - Lecturer, Keimyung University, College of Nursing, Daegu, South Korea

Correspondence: Heeok Park, Tenure Track - Lecturer, Keimyung University, College of Nursing, Deagu, South Korea. Telephone: +82 53 580 3924. E-mail: hopark@kmu.ac.kr

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Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 728–735, doi: 10.1111/j.1365-2702.2011.03876.x

the result is increased quantity and quality of sleep. massage and music have been applied (Zimmerman et al. emotional discomfort and mortality. 728–735 Background ICU sleep Sleep disturbances increase neurosis. Kahn et al. 2006. Seoul. Patients with coronary vascular disease are often admitted to the ICU. Levin (1998) applied the term ‘brain music’ to describe the change in brain wave patterns observed in sleep-deprived subjects during periods of increased musicassisted sleep. MH Lee. which includes a 24-hour electrocardiogram (EKG) in the immediate aftermath of the angiography. (2008) played relaxing music for older adults to improve sleeping. Seoul. psychiatric disease. unpublished Master’s thesis. confusion. Sleep-inducing music Music therapy is defined as ‘an established allied health profession using music and music activities to address 729 . religious music and client preferred music on sleep (Johnson 2003. the studies suffered from lack of randomisation of subjects. anxiety. surrounded by severe noises and impropriate lighting. Freedman et al. 1997. 1995. memory problems and decreased orientation or cognition (Granberg et al. lightness. sleeping disorders stimulate the sympathetic nerve system and promote the over-secretion of vasoconstrictors that increase cardiac loading. 1995. To improve sleeping in ICU patients. unpublished Master’s thesis). 2002). KK Park (Jeju National University. As well. and they are generally categorised as physical (illness. Among the interventions. 1992. Jeju National University. 2005). 1999). There has been no music intervention studies directed at patients with CVD in South Korea. unpublished Master’s thesis). However. Freedman et al. Jeong 2009. 1996). Keimyung University. In one study. 21. 1999). relaxation therapy. The use of ear plugs can improve both the quantity and quality of sleep (Haddock 1994. depression. humidity. Ziv et al. Jang & Choi 2008. but also decrease physical self-defence and sensitivity (Krachman et al. Kim et al. Peled et al. Generally. OK Park. Especially. 1997). over 50% of ICU patients suffered from serious sleeping disorders (Noh et al. Sleeping problems with ICU patients can include difficulty falling asleep. Kim 2001). 1999). Jeju. Sleeping is significantly related with cardiovascular conditions (Schafer et al. unpublished Master’s thesis). which reduces cardiac loading and increases cardiac life. discomfort and pain). 1994. The present study addressed this shortcoming. unpublished Master’s thesis) reported enhanced sleep using delta (d)-wave music compared with non-d-wave music. YJ Koo.Original article The effect of sleep-inducing music on sleep care (Novaes et al. To improve sleeping in ICU patients. Korea University. 1996. which should be addressed by controlling the sleep disorder (Schwab 1994. YJ Koo. smell and sound) factors (Kim & Suh 1992. unpublished Master’s thesis) can be helpful. 1997. Several studies have reported that the positive effects of classical music. Chan et al. Severe sleep disorders can negatively affect physiological parameters including protein synthesis. Pandi-Perumal et al. 1995). Schafer et al. sleep can suffer (Edell-Gustafsson et al. cell dissolution and immunity and can contribute to increased mortality (Krachman et al. Daegu. attention deficiency. stress and cognitive disorders) and environmental (temperature. persons who receive a percutaneous transluminal coronary angiography (PTCA) suffer from sleeping discomfort in the ICU because they are subject to intense observational scrutiny. systolic blood pressure decreases by 5–15% in humans. unpublished Master’s thesis). Daegu. There are many factors affecting sleep. noises. Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing. Lai & Good 2005. varied forms of nursing care have been tested (Haddock 1994. 1997. ICU patients report lower quantity and quality of sleeping than healthy persons (Kim & Suh 1992. Krachman et al. Sleep disorders in the ICU can cause anxiety. Fang & Liu 2006. emotional (anxiety. 1996). confusion. music intervention is costeffective because it is relatively easy to supply. 1998. Novaes et al. unsatisfactory sleep and decreased quality of sleep (Yinnon et al. and the subjects reported reduced anxiety and improved quality of sleep. Simpson et al. Jeju. Korea University. Park 2008. Park 2008. Seoul. 2010. This may interrupt normal sleep (Kim 2001). While sleeping. Keimyung University. Keimyung University. Lessened light intensity attained through diminished light (Fox 1999) or the use of eye bandages (YJ Koo. OK Park. Patients receiving a cardio-angiography in the cardiac care unit (CCU) typically require close observation for the first 24 hours with absolute bed rest (ABR). unpublished Master’s thesis. Daegu. diverse interventions such as aromatherapy. decreased duration of sleep. Most studies to date concerning the influence of music on sleep have involved persons with insomnia. despite a relatively short-term ICU stay compared to patients with other serious maladies (Kim 2001). OK Park. these steps did not completely alleviate the sources of sleep deprivation. Fang & Liu 2006. Schwab 1994. 1999). Sleep disorder in persons with CVD cause severe physical emotional changes including increased catecholamine secretion and unstable emotions. On the other hand. Freedman et al. Korea University.

are lessened when listening to sleep-inducing music compared to other types music or no music. unpublished Master’s thesis) played music for coronary angiography patients and reported improved sleep after listening to music. Jeju National University. admittance to CCU after PTCA and the occurrence of ABR immediately after angiocatheter removal in the CCU. with the aim of suggesting practical nursing interventions to improve sleep. and those with an odd number were assigned to the control group. consent was obtained from 60 of those attending who agreed to participate in this study. but 60 subjects enrolled after considering a 10% drop rate. (2008) offered relaxation music with muscle relaxation exercise to older adults with sleep disorders and compared the effect of music with relaxation exercise. Dijkstra et al. Participants The principal investigator gave a brief presentation to those scheduled for admittance to the CCU a coronary angiography. Music is also effective for ICU patients. Seoul. KK Park. use of sleep-inducing drugs or sedative medications. (2010) and Lai and Good (2005) also offered music to older adults. and sleep-inducing music (i. Sleep-inducing music is played at low volume to promote relaxation and lessen anxiety. One participant in the experimental group was excluded for having taken a sleepinducing drug taken. unpublished Master’s thesis) has been explored as a means of improving sleep in South Korean subjects experiencing sleeping problems. (2010) applied music to ventilator-assisted patients and reported a positive influence on pulse rate. Jeju National University. 2010). Exclusion criteria were use of ventilators. Finally. breathing rate and relaxation. Moradipanah et al. 29 subjects constituted the experimental group and 29 formed the control group. The inclusion criteria were ‡20 years of age. and sleep was improved in the music group compared to patients not receiving music. consent form and potential risks and benefits were reviewed and approved by the K University D Hospital Human Subjects Review committee. Jeju. depression and pain (Kim 2007. unpublished Master’s thesis). The effect of music on sleep has been studied in South Korea. 2010. two subjects dropped-out. unpublished Master’s thesis) reported that sleep-inducing music stimulates higher levels of d-wave brain pattern sleep compared to other types of music or no music at all. As PTCA is one of the most common processes administered to ICA patients with CVD. or sensory disorder. in particular those with CVD in the ICU. Huang et al. South Korean studies of the effect of sleep-inducing music have tended to be limited to persons with sleeping disorders. which stimulates sleep waves in the brain. One participant in the control group was transferred to another unit. diagnosis of coronary artery disease. Jeju. Park (2008) and OK Park (Korea University. it becomes of interest to determine the sleep-inducing effects of music to this patient population. Ziv et al. The 60 participants were randomly assigned to experimental group or control group using card number. Methods The research protocol. Anxiety was lower. 2009. Based on the calculation. and history of sleeping problem before admittance to CCU. d-wave music. neurologic disease. Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing. 728–735 730 . KK Park (Jeju National University. psychological. which are antagonistic to sleep. During the data collection. Alpha-waves. After the presentation. stress and sleep problems (KK Park. Chan et al. cognitive and social needs of individuals with disabilities’ (AMTA 1997). 21. Persons who listen to d-wave music report being relaxed by the music and that the music promoted a sound sleep.e. Nilsson (2009) offered music to coronary artery bypass graft patients and reported reduced oxytocin levels and increased relaxation. Music interventions have also been applied to control sleeping problems. Different types of music were offered to improve sleep. diagnosed of dementia. The sample was determined by power calculation based on Cohen’s (1988) effect size formulas using power 0Æ80 and effect size 0Æ70. and the quality of sleep was improved significantly in the music intervention group compared to the exercise group. Jeju. 52 subjects for two groups were needed.M-J Ryu et al. The experimental research design was driven by two hypotheses: (1) The quantity scores of sleeping in experimental group (sleep-inducing music) will be higher than in control group (ear plugs) and (2) The quality scores of sleeping in experimental group will be higher than in the control group. The present study investigated the effects of sleep-inducing music on sleep patterns in PTCA recipients in the ICU. Hong & Cho 2010. with far less information known of the influence of sleep-inducing music on patients. The documented positive effects of music on various health problems include anxiety. physical. Allred et al. stress. The participants having an even number were assigned to the experimental group.

If a subject fell asleep with the music still in progress.0 (IBM Corporation. 21. depth of sleep and self-evaluation of sleep. but ear plugs 370 Bilsom No. The research assistants were nurses having more than two years of experience in the CCU and who were blinded to which subject was assigned to the experimental group or the control group. Descriptive statistics were used to describe demographic and sleeping characteristics. so as not to disturb sleep. Eye bandage CS-204Ò (CS Berea Korea) was also applied to the participants at 10 PM and was removed at 5 AM the next morning. 988 (11 minutes one second) and Nature Sounds (two minutes 25 seconds). the first meeting was scheduled at the hospital to check demographic data and sleep characteristics. Kim & Kang 1994). the music was terminated and the earphones were removed. The same eye bandage used in the experimental group was also applied to the control participants. Mean age of the participants was 61Æ2 years. Quality of sleeping Quality of sleeping was measured using the modified Verran and Synder-Halpern (VSH) sleeping scale (Verran & SynderHalpern 1987. high school educated (41Æ4%). method and measurement. Goldberg Variations BWV.Original article The effect of sleep-inducing music on sleep Instruments Quantity of sleeping Quantity of sleeping questionnaire elicited information concerning the total number of sleeping hours. If a subject awoke for a short time during the night. The principle investigator played recorded sleep-inducing music at 10 PM .303Ò (Bacau-Dalloz Korea) were applied from at 10 PM –5 AM the next morning. The Cronbach’s alpha value of the modified VSH was 0Æ86 in Kim & Kang’s study. The participants in control group also answered the sleeping questionnaires at 7 AM . Experimental group Subjects who were assigned to the experimental group listened to sleep-inducing music in the CCU. Goldberg Variations BWV. The quantity of sleeping was counted as total number of minutes from the time of falling asleep to the time of awakening the next morning. The sleep-inducing music included Nature Sounds (two minutes and eight seconds). The sleep-inducing Data analysis Data analysis was conducted using SPSS program version 14. Independent t-test was used to test the two hypotheses. For example. with a total possible points ranging from 0–80. the earphone was not removed intentionally until 5 AM the next morning. The participants answered the questionnaires regarding the quantity and quality of sleeping at 7 AM on the same day. if a subject fell asleep at 11 PM and awoke at 4 AM . Buddhist (34Æ5%) and married (86Æ2%). unpublished Master’s thesis) and was entitled Korean’s brain: Thank you for doing such as great job-stable effect on sleeping: Delta wave Clinic Vol 1. The VSH includes eight questions regarding the frequencies of awakening while sleeping. The principle investigator trained the two research assistants regarding the general information of this study including purpose. Results Sample characteristics The findings of sample characteristics are presented in Table 1. Nature Sounds (four minutes 57 seconds). and the research assistants helped subjects to answer the questionnaires concerning the quantity and quality of sleep. the sleeping time was recorded as 240 minutes. Seoul. After consent to participate was obtained. The MP3 music was supplied through earphones to the participants from 10:00–10:53. 728–735 731 . If participants did not want to continue sleeping any time after 10 PM . 988 (27 minutes three seconds). Control group No music was offered to participants. but was awake for one hour during the night. The timing of the start of the music (10:00 PM ) and removal of the earphones (5 AM the next morning) coincided with the time of the last daily blood pressure check and the first blood pressure check of the day. Delta Wave Control Music (five minutes 21 seconds). respectively. music was developed by Park (2008) and OK Park (Korea University. Most participants were men (65Æ5%). There were 29 subjects in the experimental and control groups. The questions included the time falling asleep and the awakening time the next morning. Most participants were usually satisfied with their sleep before ICU Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing. Cronbach’s alpha value of the original VSH was 0Æ82 in Verran and Synder-Halpern’s study (1987). the time of wakefulness was subtracted from the sleeping minutes. Data collection Data collection was conducted at K University D hospital in D city from 3 September–4 October 2010. Cronbach’s alpha value of the modified VSH in this study was 0Æ83. USA). The VSH is a Likert scale that ranged from 0–10 for each question. Armonk. NY.

M-J Ryu et al. Hypotheses findings Two research hypotheses were tested in this study. Hypothesis 1: Independent t-test revealed that the quantity of sleeping in the experimental group was significantly higher than control group (t = 3Æ18. 728–735 . p < 0Æ001) (Table 3). 732 Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing. Table 1 Demographic characteristics (n = 58) Total f (%) Category Gender Male Female Age <50 51–60 61–70 71–80 Education Less than elementary Middle school High school More than college Religion None Christian Catholic Buddhist Marriage Married None Widowed or divorced Satisfaction on sleeping Generally satisfied Very satisfied Usual sleeping hours daily M ± SD Experimental group Control group (n = 29) (n = 29) f (%) M ± SD f (%) M ± SD v2 or t p 38 (65Æ5) 20 (34Æ5) 12 15 16 15 (20Æ7) (25Æ8) (27Æ6) (25Æ8) 19 (32Æ8) 10 (17Æ2) 8 5 7 9 (13Æ8) (8Æ6) (12Æ1) (15Æ5) 19 (32Æ8) 10 (17Æ2) 4 (6Æ9) 10 (17Æ2) 9 (15Æ5) 6 (10Æ3) 9 (15Æ5) 6 (10Æ3) 12 (20Æ7) 2 (3Æ4) 11 (19Æ0) 5 (8Æ6) 3 (5Æ2) 10 (17Æ2) 23 (39Æ7) 1 (1Æ7) 5 (8Æ6) 27 (46Æ6) 2 (3Æ4) 7Æ17 ± 0Æ75 0Æ00 1Æ000 3Æ85 0Æ278 15 (25Æ9) 15 (25Æ9) 24 (41Æ4) 4 (6Æ9) 20 (34Æ5) 15 (25Æ9) 3 (5Æ2) 20 (34Æ5) 50 (86Æ2) 2 (3Æ4) 6 (10Æ3) 6 (10Æ3) 9 (15Æ5) 12 (20Æ7) 2 (3Æ4) 9 (15Æ5) 10 (17Æ2) 0 (0Æ0) 10 (17Æ2) 27 (46Æ6) 1 (1Æ7) 1 (1Æ7) 1Æ20 0Æ753 4Æ86 0Æ182 2Æ98 0Æ225 51 (87Æ9) 24 (41Æ4) 7 (12Æ1) 5 (8Æ6) 7Æ12 ± 0Æ77 7Æ07 ± 0Æ79 1Æ46 0Æ65 0Æ227 0Æ615 Table 2 Difference in quantity of sleeping between groups (n = 58) Experimental group (n = 29) Category Quantity of sleeping (minutes) M ± SD 279Æ31 ± 43Æ99 Control group (n = 29) M ± SD 243Æ10 ± 42Æ68 t 3Æ18 p 0Æ002 Table 3 Difference in quality of sleeping between groups (n = 58) Experimental group (n = 29) Category Quality of sleeping (minutes) M ± SD 36Æ14 ± 5Æ68 Control group (n = 29) M ± SD 29Æ41 ± 3Æ85 t 5Æ26 p <0Æ001 admittance (87Æ9%). An alpha level of 0Æ05 was established for acceptance of the hypotheses. p < 0Æ05) (Table 2). There was no significant difference in demographic and sleeping characteristics between the experimental group and control group. and mean daily sleeping hours before hospital admittance was 7Æ12. hypothesis 2 was supported. Hypothesis 2: Independent t-test revealed that the quality of sleeping in the experimental group was significantly higher than control group (t = 5Æ26. hypothesis 1 was supported. Therefore. 21. Therefore.

however. there are many factors that can cause sleeping problems including severe noises. Lazic and Ogilvie (2007) tested the effect of music on sleep using polysomnographic and quantitative EKG analysis. Even though the positive effects of music on sleeping have been well established. and these medications are often addictive and cause undesirable effects. This study compared the effect of sleep-inducing music with earplugs on sleeping. JSP. but no effect of music on sleep was evident. Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing. This study tested the quality and quality of sleep only one time after removing angiocatheter. Even though diverse types of music can improved sleep. The current study tested both the qualitative and quantitative effects of music on sleep. 728–735 733 . The quantitative assessment involved subject responses concerning the number of hours slept. Earplugs can improve the quality of sleep by shutting out severe noises (YJ Koo. There is a need to investigate what kind of music is the best for Korean to sleep. The effect of music on sleep in these patients warrants study. unpublished Master’s thesis). unfamiliar medical tools and bright light. But. There is a need to compare the different types of music on sleep and investigate how the music affects sleep in a different way. Music may be an efficient alternative. nurses could apply earplugs to block noises. repetitive studies should be conducted to investigate the effect of sleepinducing music on sleep using different types of measurements and to compare the effect of sleep-inducing music with other types of music on sleeping in the CCU. testing at different points is needed. there is a lack of consistency concerning how music is offered to improve sleep in South Korea. Future studies should compare the sleepinducing music with other types of music such as relaxing music or patient-preferred music. Keimyung University. Music significantly increased the quantity and quality of sleep compared to the use of ear plugs. On the other hand. JSP. Relevance to clinical practice The clinical significance of this study is the acknowledgment for nurses that music is effective to improve ICU patient sleep problems. Future studies could be made more robust by including objective tools such as electroencephalography or brain wave testing. A systematic review or metaanalysis to determine what kind of method is the best to improve sleeping is required. 21. In future. but could also offer sleepinducing music. JSP. which reported improved sleep by classical. Contributions Limitations The current study only investigated ICU patients with PTCA. there are other types of CVD. HP and manuscript preparation: M-JR. To increase the validity and reliability of the Study design: M-JR. Conclusion The current study compared the effect of sleep-inducing music with noise-muffling earplugs on agitation in CCU patients who underwent PTCA. To improve sleep in the CCU. Jeju. Conflict of interest There is no conflict of interests. Many ICU patients are medicated to control sleeping problems. KK Park (Jeju National University. and the brain waves showed an improved quality of sleep. Presently. Nurses working in clinical areas might well consider offering earplugs and music to improve patient’s rest. so that the music could shut noises but also help patients relax and sleep. Many studies also reported the positive effects of music on sleeping and the music are diverse. unpublished Master’s thesis) and Levin (1998) tested the effect of music on sleep using brain wave monitoring. data collection and analysis: M-JR.Original article The effect of sleep-inducing music on sleep Discussion The current study compared the effect of earphone-delivered sleep-inducing music with the use of noise-muffling ear plugs on the quantity and quality of sleep in ICU patients who had received PTCA in the CCU. HP. In the CCU. The current finding of the positive effect of sleep-inducing music on sleeping echoes the findings of other studies. listening to sleep-inducing music using earphones or head phones make it possible to shut noises but also induce the relaxing d-waves. Most studies regarding the effect of music on sleep have been limited to the qualitative effect of music. whether there is one type of music that is superior in South Korea is unknown. religious and clientpreferred music. Daegu. Therefore. selecting appropriate instruments to measure sleep is required to increase the validity and reliability of the study findings. research finding. Patients who listened to sleep-inducing music showed significantly improved quantity and quality of sleep compared to those wearing earplugs.

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