Background Music Playback in the

Preoperative Setting: Does It Reduce the

Level of Preoperative Anxiety Among
Candidates for Elective Surgery?
Galina Kipnis, MA, OR, RN, Nili Tabak, MA, PhD, LLB, RN, Silvia Koton, PhD, MOccH, RN

Background: Contemporary medicine and nursing use music to stabilize

mood, relieve tension and anxiety, and achieve higher treatment effi-
ciency. Preoperative anxiety may be responsible for cognitive and behav-
ioral changes affecting treatment efficiency.
Purpose: To evaluate the effect of background music on preoperative anx-
iety in elective surgery patients and on noise levels in the surgery waiting
room.
Design: One hundred fifty-nine elective surgery patients were divided into
an intervention group (n 5 82) and a control group (n 5 77). Data were
collected and evaluated on the evening before surgery in the department,
on entering the waiting room, and 30 minutes later in the preoperative
setting. Data were gathered using the State-Trait Anxiety Inventory scale
and by measuring vital signs. Daily noise levels in the preoperative wait-
ing room were recorded as well.
Findings: Exposure to background music was associated with decreased
levels of state anxiety irrespective of age, sex, and previous exposure to sur-
gery or anesthesia (P , .001). Background music was also related to envi-
ronmental noise reduction in the surgery waiting room (P , .0001).
Conclusions: Background music can be useful as a means of decreasing
preoperative anxiety.
Keywords: state anxiety, vital signs, preoperative period, environmental
noise, background music.
Ó 2016 by American Society of PeriAnesthesia Nurses

HEALING SOUNDS HAVE BEEN CONSIDERED for the treatment of a variety of diseases and
an important component of treatment in medical health conditions. Anxiety before surgery can
practice for ages. Modern medicine and nursing change the way a person thinks, feels, and acts.
rely on the therapeutic effectiveness of music It may also influence the patients’ cognitive

Galina Kipnis, MA, OR, RN, Head Nurse, Pediatric Cardiac
Operating Room, Chaim Sheba Medical Center, Tel Hashomer,
Israel; Nili Tabak, MA, PhD, LLB, RN, Head of Tel Aviv Univer-
sity’s Steyer School of Health Professions, and is also head of
TAU’s Department of Nursing MA program; and Silvia Koton,
PhD, MOccH, RN, Associate Professor, Chair of the Department
of Nursing, Stanley Steyer School of Health Professions, Sack-
ler School of Medicine, Tel Aviv University; Adjunct Associate
Professor, Department of Epidemiology, Johns Hopkins
Bloomberg School of Public Health, Baltimore, MD; Consul-
tant Epidemiologist, Comprehensive Stroke Center Chaim
Sheba Medical Center, Tel Hashomer, Israel.
Conflict of interest: None to report.
Address correspondence to Nili Tabak, Department of
Nursing, Tel Aviv University, The Stanley Steyer School of
Health Professions, POB 39040, 6997801 Tel Aviv, Israel;
e-mail address: ntabak@post.tau.ac.il or tabak.nili@gmail.
com.
Ó 2016 by American Society of PeriAnesthesia Nurses
1089-9472/$36.00
http://dx.doi.org/10.1016/j.jopan.2014.05.015

Journal of PeriAnesthesia Nursing, Vol 31, No 3 (June), 2016: pp 209-216 209

210
status and behavior as well as affect their vital
signs.1 Studies have examined the effects of mu-
sic on patients using headphones2-5 or listening
to classical or New Age music in quieter
environments with no background noise.6 In
the present study, given the presence of disrup-
tive background noise, we aimed to evaluate the
effect of background music on the level of pa-
tients’ preoperative anxiety and on the level of
environmental noise in the preoperative waiting
room.
Literature Review
Irrespective of the disease, hospitalization and
especially forthcoming surgery induce anxiety in
patients. According to several surveys, a surgery
waiting room is a source of potential threat, upset-
ting the patients’ mental stability and causing anx-
iety.7-9 Grieve8 described the factors associated
with preoperative anxiety, noting that surgery
was linked to the possibility of pain, loss of inde-
pendence and control, changes in body image,
and unfavorable diagnosis. Other threats included
the uncertainty of recovery, concerns about family
members, and one’s job.1
Spielberger (referred to in Ref.10) defines anxiety
as an emotional state consisting of tension, fear,
nervousness, and concern, including a stress
reaction involving the autonomic nervous system.
Spielberger distinguishes between two compo-
nents of anxiety—state and trait anxiety. State
anxiety reflects temporary emotional responses
to perceptions of environmental stressors,
whereas trait anxiety reflects a constant tendency
toward the same responses to different
stressors.10 Differences in responses to stress
have been reported for men and women and are
associated with the patient’s personal history.
Women are exposed to more stressors and show
greater sensitivity to preoperative anxiety.9,11
Women also differ from men in the way they
experience stress and in the ways of coping
with it. Gender differences are also related to
biological differences and to women’s social role
in the family setting. In their study of 734
patients, Kindler et al12 found that young female
patients with lower formal education who had
never experienced anesthesia or who had some
negative experience with it showed higher preop-
erative anxiety levels.
KIPNIS, TABAK, AND KOTON
Different sounds affect patients in a variety of
ways. They may produce pleasure and calmness,
but may also have undesired negative effects.
Sound levels of 30 dB are defined as quiet, 60
to 80 dB is considered noisy, and levels of
more than 80 dB are detrimental. In hospitals,
it is recommended to maintain background noise
levels below 45 dB,13 but noise levels are usually
twice as high.14 According to Thorgaard et al,15
55% of patients report reduced environmental
noise in the presence of background music in
the surgery waiting room. In the waiting room
setting used for the present study, at any time
during the morning, as many as 16 patients
will be waiting for their surgery. Together with
the nurses, doctors, anesthetists, surgeons, and
stretcher bearers, they generate considerable
background noise.
Music has always been used to influence human
health. Archaeological evidence suggests that
our primitive ancestors used music to appease
the gods.16 In the 18th century, Florence Night-
ingale identified the beneficial effects of music
on wounded soldiers recovering in hospitals
during the Crimean War. Nightingale believed
that nurses should take control of the patients’
environment to contribute to a faster recovery
process, and this included the use of music as
a therapeutic means. The healing use of music
expanded in the early 20th century when music,
pain relief, and anesthesia were combined. In
1926, nurse Ilsen founded the National Asso-
ciation of Music in Hospitals in the United
States, which disseminated guidelines on the
therapeutic use of music. Nurse Ilsen identified
the significance of rhythm as a basic treatment
factor.16
Different theories and proposed mechanisms have
attempted to explain the effects of music on
health. In 1990, Dr Thaut17 suggested that music
affects human biology and behavior and that this
effect is generated by specific brain functions
related to memory, learning, and specific
emotional states. Auditory perception of music
takes place in the brain’s auditory center. Located
in the temporal lobe, the auditory center transmits
signals first to the thalamus and then to the
midbrain, pons, amygdale, medulla, and finally
the hypothalamus.17 Theory suggests that music
decreases the levels of stress, pain, and anxiety
MUSIC AND PREOPERATIVE ANXIETY
by diverting the patient’s attention from the
source of unpleasurable stimuli to something
pleasant and encouraging.16 A study by Burns
et al18 examined the effect of various kinds of mu-
sic on students under stress and concluded that
depending on personal choice, listening to clas-
sical or relaxing music decreases stress and anxi-
ety. Furthermore, the researchers found that
classical music, unlike rock, reduces physiological
arousal and lowers body temperature and heart
rate. Rhythm is an important factor as well. Slow
and soft music with a rhythm of 60 to 80 beats
per minute relaxes and relieves pain. Other
studies suggest that the therapeutic effect is
achieved by slow, soft, and low-pitched tunes
with a rhythm of 60 to 80 beats per minute and
not louder than 60 dB.
Theoretical Framework
The present study was based on the theory of psy-
chological stress and coping, known as the Trans-
actional Model,19 according to which music can
be used as a tool for emotional coping. The inter-
pretation of stress by Lazarus and Folkman19 is
based on the interaction between people and their
external environment and on their mutual influ-
ences. Stress is a result of an imbalance between
demands and resources. It occurs when stress
exceeds one’s perceived ability to cope. Stress
management has been developed based on the
idea that the stress response is mediated by one’s
resources and abilities to cope. Stress responses
are amenable to change, allowing stress to be
controllable. Music can be used as a means for
emotional coping. It may influence emotions lead-
ing to the evaluation of situations as less threat-
ening. Music may also reduce the staff’s noisy
behavior and decrease the level of environmental
noise.15
Purpose
The purpose of this study was to examine how
background music affects the level of state anxiety
and vital signs among patients scheduled for
elective surgeries, irrespective of age, gender,
complexity of surgery, or previous exposure to sur-
gery and anesthesia.
Five hypotheses were tested:
211
1. There will be an association between back-
ground music and changes in state anxiety
levels among patients waiting for surgery.
2. There will be an association between back-
ground music and changes in patients’ dia-
stolic blood pressure (DBP) and systolic
blood pressure (SBP), blood oxygen satura-
tion, and heart rate.
3. There will be gender-related differences
affecting changes in state anxiety.
4. There will be an association between the
evaluation of trait anxiety levels and changes
in state anxiety levels in patients waiting for
surgery.
5. There will be an association between back-
ground music and background noise levels
in the surgery waiting room.
Methods
A prospective interventional study using system-
atic probability sampling was used. Candidates
for different elective procedures were represented
in the study, the inclusion criteria being age 20 to
70, Hebrew speakers, and scheduled to undergo
elective surgeries under general anesthesia.
Patients with impaired hearing, documented
cognitive impairment, or a deficient level of con-
sciousness were excluded. Participants were hos-
pitalized on the evening before surgery and
consented to participate in this study.
In total, 159 patients, 55% of them women, took
part in the study. Eighty-two respondents were
exposed to background music: of these, 42 were
exposed to classical music and 40 to New Age
music. Seventy-seven participants were not
exposed to any music.
Data Collection
Data were collected using a structured question-
naire that included sociodemographic variables.
Two measurements of vital signs (SBP and DBP,
heart rate, and blood oxygen saturation, noninva-
sively measured) 30 minutes apart were recorded;
trait and state anxiety were measured using the
Spielberger’s scale.20 For a second assessment of
level of preoperative anxiety (30 minutes after
the first assessment before entering the surgery
waiting room), the Preoperative Anxiety
212
questionnaire12 was used. Patients gave their opin-
ions about music, preferred types of music, and
environmental noise.21 Environmental noise mea-
surements were recorded using an integrating
data logging sound device (level meter no: 2900).
This is a portable sound device with a dynamic
range of 140 dB designed to measure industrial
and environmental noises.
Research Process
The study was approved by the Hospital’s Helsinki
Committee for Clinical Trials on Humans and by
the University Ethics Committee. All participants
signed an informed consent form. Data on trait
anxiety and vital signs were first collected the eve-
ning before the scheduled surgery.
On first entering the preoperative waiting room,
patients filled out the state anxiety questionnaire
and underwent vital sign measurements. Thirty
minutes afterward, they completed the preopera-
tive anxiety questionnaire and underwent an
additional vital sign measurement. Then, they
were asked to fill out the patient opinions ques-
tionnaire. Environmental noise levels were re-
corded throughout the study period.
Statistical analysis was conducted using the SPSS-
PC (version 14; SPSS Inc., Chicago, IL) software.
Findings
The study sample comprised 159 respondents
whose average age was 51.5 years (standard
deviation 5 14.0). Most respondents were low-
middle-income working women, with 12 years of
formal education. Most of them were scheduled
for complex surgical procedures and had previous
experience with anesthesia, sedatives, and pre-
medication. No between-group differences were
found by type of surgery, previous experience
with surgery, or sedatives as preoperative
medication (Table 1). Furthermore, these
subgroups showed similar trait anxiety levels
(F (2; 156) 5 0.4; P , .67) and state anxiety
levels on arrival to the surgery waiting room
(F (2; 156) 5 0.2; P , .80). However, 30 minutes
later, changes in state anxiety were evident.
An analysis of variance (Scheffe’s method) was
used to measure the association between the
KIPNIS, TABAK, AND KOTON
respondents’ exposure to background music in
the surgery waiting room and corresponding
changes in state anxiety levels. There was a signif-
icant difference in state anxiety levels between the
study groups: compared with patients not
exposed to music (the control group), lower levels
of state anxiety were found both in those exposed
to New Age music (P , .005) and in patients
exposed to classical music (P , .01).
Associations between the patients’ exposure to
background music and subsequent changes in
vital signs were measured by analysis of vari-
ance (Scheffe’s method). The analysis indicated
a significant statistical difference in DBP and
SBP, blood oxygen saturation, and pulse among
all subgroups. The effect of classical and New
Age music on vital signs was approximately
the same.
An independent sample t test was applied to assess
gender-related differences in changes in state anx-
iety levels. This test did not indicate any significant
differences in preoperative anxiety levels between
men and women (Table 2).
A Pearson correlation test did not find any associ-
ation between participants’ levels of trait anxiety
and changes in state anxiety while waiting for
surgery (r 5 20.002; P , .98). Analysis of vari-
ance (Scheffe’s method) was used to measure
the association between background music and
background noise. Both types of music were
associated with a decreased level of background
noise (P , .0001). No significant difference
between New Age and classical music was
found in their effect on background noise levels
(P , .82).
Analysis of covariance was used to test for the
influence of age, gender, complexity of surgery,
and previous exposure to surgery or anesthesia
on the associations reported, but no evidence of
interactions was found.
In the intervention group, seventy-six (92.7%)
patients reported a beneficial effect of music.
Seventy-four (90.2%) patients were satisfied
with the type of music. Forty-three respondents
(53.1%) claimed that they would like to listen to
music via headphones during surgery, and 73
respondents (90.1%) expressed their wish to
wake up from anesthesia to music.
MUSIC AND PREOPERATIVE ANXIETY 213

Table 1. Demographic and Clinical Characteristics of Participants, by Study Group (n 5 159)

Control Group, New Age Music, Classical Music,
n (%) n 5 77 n 5 40 n 5 42 P
Gender
Female 90 (56.6) 41 (45.6) 19 (21.1) 30 (33.3) .55
Male 69 (43.4) 36 (52.2) 21 (30.4) 12 (17.4)
Marital status
Single 22 (13.8) 14 (63.6) 5 (22.7) 3 (13.6) .69
Married 105 (66.0) 50 (47.6) 25 (23.8) 30 (28.6)
Divorced 20 (12.6) 8 (40.0) 6 (30.0) 6 (30.0)
Widowed 12 (7.5) 5 (41.7) 4 (33.3) 3 (25.0)
Education
Primary 22 (13.8) 12 (54.5) 3 (13.6) 7 (31.8) .55
Secondary 74 (46.5) 32 (43.2) 22 (29.7) 20 (27.0)
College and higher 63 (39.6) 33 (52.4) 15 (23.8) 15 (23.8)
Employment status
Employed 93 (58.5) 38 (40.9) 28 (30.1) 27 (29.0) .07
Unemployed 66 (41.5) 39 (59.1) 12 (18.2) 15 (22.7)
Complexity of the current surgery*
Yes 96 (60.4) 48 (50.0) 17 (17.7) 31 (32.3) .01
No 63 (39.6) 29 (46.0) 23 (36.5) 11 (17.5)
Surgery experience
Yes 137 (86.2) 64 (46.7) 37 (27.0) 36 (26.3) .38
No 22 (13.8) 13 (59.1) 3 (13.6) 6 (27.3)
Premedication
Yes 126 (79.2) 60 (47.6) 34 (27.0) 32 (25.4) .57
No 33 (20.8) 17 (51.5) 6 (18.2) 10 (30.3)
*By definition of nursing administration Ministry of Health based on the ranking American Society of Anesthesiolo-
gists.33

In the control group, 25 (32.5%) patients reported Forty-two patients (54.5%) would have liked to
that background noise in the surgery waiting room listen to music during the surgery, and 54 patients
disturbed them. Sixty-two respondents (89.5%) (71.1%) would have enjoyed waking up to music in
were willing to listen to music while waiting. the recovery room.

Table 2. Anxiety, Vital Signs, and Background Noise, Means and Standard Deviations by Study
Group, N 5 159
P Value for
Comparison
Control Group, Any Music, New Age Classical Music, Among Groups,
Variables n 5 77 n 5 82 Music, n 5 40 n 5 42 df 5 157
Change in state anxiety 1.6 (11.9) 26.6 (14.7) 27.1 (16.4) 26.1 (13.1) , .0001
Change in SBP 6.3 (12.6) 28.7 (12.3) 211 (14.2) 26.4 (9.7) , .0001
Change in DBP 2.1 (8.6) 24.1 (7.2) 25.0 (8.1) 23.1 (6.3) , .0001
Change in heart rate 3 (6.8) 22.4 (6.3) 22.8 (6.1) 22.1 (6.6) , .0001
Change in arterial 20.6 (2.1) 0.6 (3.6) 0.1 (3.6) 1.1 (3.5) , .02
oxygen saturation
Change in background 76.1 (5.8) 70.64 (4.14) 70.3 (5.3) 71.0 (2.6) , .0001
noise
df, degrees of freedom; SBP, systolic blood pressure; DBP, diastolic blood pressure.
214
Discussion
This study examined the potential associations
between different kinds of background music
and changes in state anxiety levels and levels of
environmental noise in the surgery waiting room.
This study is the first to examine the direct effect
of classical or New Age background music on
patients waiting for any type of elective surgery.
Both classical and New Age background music
were associated with decreases in patients’ anxi-
ety levels. Music has been reported to signifi-
cantly decrease preoperative anxiety,2-4,6,22-24
probably through lowering the level of state
anxiety. One possible mechanism is that music
relaxes by affecting the autonomic nervous
system.25
Background music was associated with significant
changes in SBP and DBP, heart rate, and blood oxy-
gen saturation. Patients exposed to music showed a
decrease in heart rate and SBP and DBP along with
an increase in the blood oxygen saturation level.
Patients in the control group, by contrast, showed
increased heart rate and blood pressure and
decreased blood oxygen saturation levels. Previous
studies have reached similar conclusions regarding
SBP and DBP, as well as heart rate.4,24,26 It is
assumed that the improvement in vital signs as a
result of exposure to unobtrusive background
music is because of relaxation and the effect of
music on the autonomic nervous system, thus
allowing patients to cope more successfully with
environmental stressors.25,27 Music is also likely
to synchronize rhythms of breathing, heart
activity, blood circulation, and speech.28
In the present study, changes in levels of pre-
operative anxiety were not gender related. It has
been reported that women show an increase in
state anxiety levels in the preoperative waiting
room, as compared to men29-31 but other studies
have not found any significant gender difference
in preoperative state anxiety levels before
ambulatory surgeries.23,32,33
The findings of the present study do not point to
any association between the measurement of trait
anxiety and changes in state anxiety levels among
patients waiting for elective surgery. Recent
research on the association between trait and state
KIPNIS, TABAK, AND KOTON
anxiety before surgery offers no empirical evi-
dence of any association. Yet there is evidence
pointing to a decrease in state anxiety unrelated
to trait anxiety levels among patients exposed to
unobtrusive background music and scheduled for
diagnostic procedures such as colonoscopy or
esophagogastroduodenoscopy.18,34 It is not yet
clear if trait anxiety is associated with state
anxiety before medical procedures.
In this study, levels of background noise were
lower in the presence of background music.
Exploring mechanisms that might explain this
finding is beyond the scope of the present study.
However, it was noted that routine staff activities
were less noticeable when there was background
music, probably thanks to quieter behavior by
the multidisciplinary staff.
It is important to note that contrary to other
studies that have examined exposure to music
via headphones2-5 or exposure to music in a
quiet environment with no background noise,7
this study focused on the effects of unmediated
classical or New Age music in a setting beset by
disruptive background noise. Lee et al33 carried
out a comparative study on the effect of exposure
to music with or without headphones and
concluded that neither made any difference to
anxiety levels. Nevertheless, background music is
preferable and safer as it avoids the infections
transmittable by hospital headphones.
Research Limitations
The study was conducted in a single medical cen-
ter, but, being a major university medical center
that conducts a broad variety of surgical proce-
dures, findings are not limited to specific types
of surgery. It is important however to conduct
similar studies in more medical centers. Because
only patients aged 20 to 70 years were included,
the findings are not necessarily generalizable to
other age groups. Last, levels of trait anxiety
were assessed the evening before surgery. Earlier
evaluation of this type of anxiety could have been
more reliable.
Conclusions
Exposure to background music is associated with
decreased levels of state anxiety and the
MUSIC AND PREOPERATIVE ANXIETY
normalization of vital signs in patients scheduled
for elective surgery. Background music is also
associated with decreased background noise.
Playing background music in the surgery waiting
room is an inexpensive and accessible means for
creating a pleasant and quiet environment and for
References
1. Rosen S, Svensson M, Nilsson U. Calm or not calm: The
question of anxiety in the perianesthesia patient. J Perianesth
Nurs. 2008;23:237-246.
2. Yung PM, Chui-Kam S, French P, Chan TM. A controlled
trial of music and pre-operative anxiety in Chinese men under-
going transurethral resection of the prostate. J Adv Nurs. 2002;
39:352-359.
3. Wang SM, Kulkarni L, Dolev J, Kain ZN. Music and preop-
erative anxiety: A randomized, controlled study. Anesth Analg.
2002;94:1489-1494.
4. Ni CH, Tsai WH, Lee LM, Kao CC, Chen YC. Minimising
preoperative anxiety with music for day surgery patients—
a randomised clinical trial. J Clin Nurs. 2012;21:620-625.
5. Lee KC, Chao YH, Yiin JJ, Chiang PY, Chao YF. Effective-
ness of different music-playing devices for reducing preopera-
tive anxiety: A clinical control study. Int J Nurs Stud. 2011;48:
1180-1187.
6. Padmanabhan R, Hildreth AJ, Laws D. A prospective, rand-
omised, controlled study examining binaural beat audio and
pre-operative anxiety in patients undergoing general anaes-
thesia for day case surgery. Anaesthesia. 2005;60:874-877.
7. Gilmartin J, Wright K. Day surgery: Patients’ felt aban-
doned during preoperative wait. J Clin Nurs. 2008;17:
2418-2425.
8. Grieve R. Day surgery preoperative anxiety reduction and
coping strategies. Br J Nurs. 2002;11:670-678.
9. Haugen AS, Eide GE, Olsen MV, Haukeland B, Remme AR,
Wahl AK. Anxiety in the operating theatre: A study of frequency
and environmental impact in patients having local, plexus or
regional anesthesia. J Clin Nurs. 2009;18:2301-2310.
10. Buffum MD, Sasso C, Sands LP, Lanier E, Yellen M,
Hayes A. A music intervention to reduce anxiety before vascular
angiography procedures. J Vasc Nurs. 2006;24:68-73.
11. Walker JA. Emotional and psychological preoperative
preparation in adults. Br J Nurs. 2002;11:567-575.
12. Kindler CH, Harms C, Amsler F, Ihde-Scholl T,
Scheidegger D. The visual analog scale allows effective measure-
ment of preoperative anxiety and detection of patients’ anes-
thetic concerns. Anesth Analg. 2000;90:706-712.
13. Ministry of Environment. (1992). Abatement of nuisances
regulations (prevention of noise). Available at: http://www.sviva.
gov.il/Enviroment/Static/Binaries/law/raash03_1.pdf. Accessed
November 1, 2014.
14. Stanton C. Controlling noise in the OR. AORN Connec-
tions. 2009;7:10-11.
15. Thorgaard P, Ertmann E, Hansen V, Noerregaard A,
Hansen V, Spanggaard L. Designed sound and music environment
in postanaesthesia care units—A multicentre study of patients
and staff. Intensive Crit Care Nurs. 2005;21:220-225.
215
reducing preoperative anxiety among patients
waiting for elective surgery.
Acknowledgments
The authors thank patients and staff of the surgical departments
at Sheba Medical Center for their cooperation.
16. Nilsson U. The anxiety- and pain-reducing effects of
music interventions: A systematic review. AORN J. 2008;87:
780-807.
17. Newman A, Boyd C, Debbie M, Bonanno L. Implementa-
tion of music as an anesthetic adjunct during monitored anes-
thesia care. J Perianesth Nurs. 2010;25:387-391.
18. Burns JL, Labbe E, Arke B, et al. The effects of different
types of music on perceived and physiological measures of
stress. J Music Ther. 2002;39:101-116.
19. Lazarus RS, Folkman S. Stress, Appraisal and Coping.
New York, NY: Springer; 1984.
20. Spielberger C, Gorsuch R, Lushene P. State-Trait Anxiety
Inventory for Adults Instrument (Adult Form) and Scoring
Guide, Reproduction License. Published by Mind Garden, Inc.,
855 Oak Grove Avenue, Suite 215, Menlo Park, CA 94025,
USA. Available at: www.mindgarden.com. Received from Mind
Garden, Inc. Accessed November 1, 2014.
21. Cunningham MF, Monson B, Bookbinder M. Introducing
a music program in the perioperative area. AORN J. 1997;66:
674-682.
22. DeMarco J, Alexander JL, Nehrenz G, Gallagher L. The
benefit of music for the reduction of stress and anxiety in
patients undergoing elective cosmetic surgery. Music Med.
2012;4:44-48.
23. Cooke M, Chaboyer W, Schluter P, Hiratos M. The effect
of music on preoperative anxiety in day surgery. J Adv Nurs.
2005;52:47-55.
24. Lee D, Henderson A, Shum D. The effect of music on pre-
procedure anxiety in Hong Kong Chinese day patients. J Clin
Nurs. 2004;13:297-303.
25. Cooke M, Chaboyer W, Hiratos MA. Music and its effect
on anxiety in short waiting periods: A critical appraisal. J Clin
Nurs. 2005;14:145-155.
26. Pittman S, Kridli S. Music intervention and preoperative
anxiety: An integrative review. Int Nurs Rev. 2011;58:157-163.
27. Han L, Li J, Sit JWH, Chung L, Jiao ZY, Ma WG. Effects of
music intervention on physiological stress response and anxiety
level of mechanically ventilated patients in China: A randomized
controlled trial. J Clin Nurs. 2010;19:978-987.
28. Chlan L, Evans D, Greenleaf M, Walker J. Effects of a sin-
gle music therapy intervention on anxiety, discomfort, satisfac-
tion and compliance with screening guidelines in outpatients
undergoing flexible sigmoidoscopy. Gastroenterol Nurs.
2000;23:148-156.
29. Jafar MF, Khan FA. Frequency of preoperative anxiety in
Pakistani surgical patients. J Pak Med Assoc. 2009;59:359-363.
30. Caumo W, Schmidt AP, Schneider CN, et al. Risk factors
for preoperative anxiety in adults. Acta Anaesthesiol Scand.
2001;45:298-307.
216
31. Nishimori M, Moerman N, Fukuhara S, et al. Translation
and validation of the Amsterdam Preoperative Anxiety and
Information Scale (APAIS) for use in Japan. Qual Life Res.
2002;11:361-364.
32. Calvin RL, Lane PL. Perioperative uncertainty and state
anxiety of orthopaedic surgical patients. Orthop Nurs. 1999;
18:61-66.
KIPNIS, TABAK, AND KOTON
33. Lee KC, Chao YH, Yiin JJ, Hsieh HY, Dai WJ, Chao YF.
Evidence that music listening reduces preoperative patients’
anxiety. Biol Res Nurs. 2012;14:78-84.
34. Hayes A, Buffum M, Lanier E, Rodahl E, Sasso C.
A music intervention to reduce anxiety prior to gastroin-
testinal procedures. Gastroenterol Nurs. 2003;26:145-
149.