This is an excellent example of a student research utilization project.
(Note: All student example papers have been formatted for the WWW and are not in formal APA format )
Music Therapy as a Nursing Intervention to Reduce State Anxiety
Susan M. Cohen, B.S.N., Julie Gunter, A.D.N.,
Susan E. Hoffmann, B.S.N., and Shirley J. McDonald, B.S.N.
University of Kansas School of Nursing
December 2000
Music has been perceived as a healing tool since preliterate times. Florence Nightingale recognized the beneficial effects of certain types of music on the sick. In Notes on Nursing (1992, p. 33) she wrote, the effect of music upon the sick has been scarcely at all noticed. . .wind instruments, including the human voice, and stringed instruments have a beneficent effect. Music was used in the World War II era as an adjunct to the rehabilitation of veterans to promote morale and socialization. These notations establish music therapy as a healing intervention with an impressive legacy. Nightingale’s recognition laid the groundwork for the use of music in nursing.
The purpose of this paper is to identify state anxiety as a nursing problem and to decide whether music therapy is an appropriate nursing intervention for reduction of state anxiety. We intend to review the pertinent literature, determine the level of knowledge in the nursing community as to the research findings, and develop a plan to increase dissemination of findings about music therapy and state anxiety to the nursing community. We will use The Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler, et al., in press) to guide our inquiry.
Music has been described as, the science or art of ordering tones or sounds in succession, in combination and in temporal relationships to produce a composition having unity and continuity (Merriam-Webster, 1991, p. 718). Music therapy, as defined by Munro and Mount (as cited in Snyder & Chlan, 1999, p. 4) is the controlled use of music and its influence on the human being to aid in physiologic, psychologic, and emotional integration of the individual during treatment of an illness or disability. The therapeutic application of music has evolved over the last few decades and research investigations to determine the efficacy of music interventions have been conducted by nurses, music therapists, and other health care professionals.
Spielberger (as cited in White, 1992) described anxiety as an emotional state of tension, apprehension, nervousness and worry, with activation and arousal of the autonomic nervous system. He further identified two different components of anxiety. State anxiety is defined as a transitory emotional state in response to interpretation of a stressful situation. Trait anxiety is described as the more stable differences in anxiety proneness and the frequency with which one experiences elevations in state anxiety. State anxiety is most often cited as being amenable to music therapy (Snyder & Chlan, 1999).
As graduate students in nursing from a wide variety of clinical backgrounds, we chose this topic because anxiety is a nursing problem that transcends all practice settings. Hanser (as cited in Miluk-Kolasa, Matajek, & Stuphicki, 1996) estimates that up to 75% of all medical disorders are anxiety or stress related. Therefore, the efficacy of music therapy as a non-pharmacological intervention to reduce state anxiety must be considered and evaluated. Furthermore, music therapy is cost-effective and can be applied in almost any therapeutic setting. Despite our professional diversity, music therapy as an intervention to reduce state anxiety is a potentially valuable tool for each of us.
Research Utilization Model
The Iowa Model of Evidence-Based Practice to Promote Quality Care (see appendix) by Titler et al. (in press) is chosen to guide the utilization of our research findings. The model is a flow chart assisting and guiding nurses through the process of incorporating research into practice. This model identifies triggers that are stimuli for improving practice through research. They serve to assist nurses to pursue the science of nursing rather than simply relying on traditional methods to guide them in nursing care. Titler et al. (1994) propose the incorporation of research activities into job descriptions and clinical ladders, creating an atmosphere that supports and fosters research activity.
As described previously, the entry points for this flow chart are two types of triggers: problem focused and knowledge focused. After a trigger is identified, a team considers whether or not the topic is a priority for the organization to review. The team assembles, critiques and evaluates relevant and related research. If the topic is chosen as a priority, the team must then decide if a sufficient research base exists.
In some cases, research findings support current clinical practice and no changes are made (White, 1995). However, if the determination is made that a sufficient and adequate research base exists, arrangements are made to pilot the changes in practice (Titler et al., in press). If the research base is lacking, further research is conducted while experts are consulted and other principles are considered (White, 1995).
Several steps must occur in order for the test pilot to take place. The first step is outcome selection. Next, baseline data must be collected. Third, evidence-based practice guidelines have to be developed and implemented on test units. Next, the process and the outcomes must be evaluated. Finally, the guidelines are modified as needed.
The next step in the model is the decision to adopt the research into practice. If the intervention is not fully incorporated into clinical practice, research continues in new knowledge areas and quality of care continues to be evaluated. However, if the intervention is adopted, the change is made in all areas of clinical practice.
If the change is instituted, the next step calls for the intervention’s structure, process and outcomes to be monitored and analyzed. The intervention results may then be disseminated to the appropriate staff and units.
In order to examine the current research literature on music therapy and anxiety, we searched the Cumulative Index of Nursing and Allied Health and Medline databases. We limited our review to English language reports published between 1986 and 2000.
Numerous researchers have found music therapy to be an effective anxiolytic. Chlan (1998) found that listening to self-selected classical music was effective in reducing state anxiety in patients supported by mechanical ventilation as measured by the Spielberger State Anxiety Inventory (STAI). Two studies by White (1992, 1999) found significant lowering of scores on the STAI in acute myocardial infarction (MI) patients who were exposed to investigator selected classical music when compared with a control group who received uninterrupted rest. Similarly, Bolwerk (1990) reported a decrease in state anxiety scores after exposure to investigator selected classical music in Coronary Care Unit (CCU) patients with a diagnosis of MI. Guzzetta (1989) also studied this population and discovered that music following a guided relaxation exercise was more effective than the relaxation therapy alone in reducing apical pulse and raising peripheral body temperature (physiologic measures of anxiety level).
Studies by Barnason, Zimmerman, and Nieveen (1994) and by Zimmerman, Pierson, and Marker (1988) failed to find significant differences in state anxiety measures after music therapy intervention in a coronary care unit. The Barnason et al. (1994) study tested 96 post-coronary artery bypass graft patients, and documented a significant improvement in mood after the second of two music interventions.
Nurse researchers have also studied the effects of music therapy on patient anxiety in the perioperative setting. Augustin and Hains (1996) found that ambulatory surgery patients who had standard pre-operative teaching, then listened to self-selected music in the pre-operative holding area had lower heart rates and STAI scores (state anxiety portion) than patients who had only pre-operative teaching. Winter, Paskin, and Baker (1994) were able to demonstrate a lowering of state anxiety in patients who listened to self-selected music for before surgery. Steelman (1990) examined the effects of music on anxiety and blood pressure on patients undergoing hand surgery under local anesthesia. Findings were significant for reduction of blood pressure when compared with a control group who didn’t receive the music therapy intervention. In another study, Kaempf and Amodei (1989) found that listening to classical music decreased patient anxiety and respiratory rate in a preoperative holding area with subjects undergoing arthroscopic surgery. Heiser, Chiles, Fudge, and Gray (1997) were unable to demonstrate a significant decrease in anxiety (measured by visual analog scale) after application of music therapy in the operating room and in the Post Anesthesia Care Unit (PACU) for patients undergoing elective lumbar surgery when compared with a control group.
Iwanaga, Ikeda, and Iwaki (1996) and Miluk-Kolasa, Matejek, and Stuphicki (1996) conducted studies on the effects of music on physiological parameters associated with anxiety and reported significant reductions in blood pressure, heart rate and blood glucose after exposure to self-selected music in subjects when compared with controls.
The impact of music on anxiety associated with diagnostic procedures has also been explored. Palakanis, DeNobile, Sweeney, and Blankenship (1994) studied a sample of 50 adults undergoing sigmoidoscopy and found significant reductions in STAI scores, and heart rate for the subjects who listened to self-selected music during the procedure when compared with a control group who received standard procedural care. Adolescent females viewing music videos while undergoing colposcopy were found to be less anxious and require less physician reassurance than those not viewing the videos (Rickert, Kozlowski, Warren, Hendon, & Davis, 1994). Other studies (Colt, Powers, & Shanks, 1999; Dubois, Bartter, & Pratter, 1995) failed to demonstrate a significant effect in this arena. However, Dubois et al. (1995) did document improved levels of patient comfort and less cough in patients who listened to music during outpatient bronchoscopy as compared with a control group.
In one study, music therapy was investigated in the home setting. Anxiety and dyspnea were decreased in subjects with Chronic Obstructive Pulmonary Disease living at home after music intervention (McBride, Graydon, Sidani, & Hall, 1999).
Summary of Current Research Knowledge
Given the historical beliefs about the benefits of music, it was interesting to note the lack of published reports concerning the effects of music prior to 1980. On the whole, music therapy has been shown to be effective in reducing state anxiety in a variety of patient populations. Studies of Coronary Care Unit (CCU) patients, patients on mechanical ventilation, patients undergoing stressful diagnostic procedures, those in the perioperative area, and COPD patients at home have demonstrated music to be an effective anxiolytic.
However, as reflected in the literature review, the effectiveness of music therapy has not been consistently demonstrated. Studies in this review have been limited by small sample sizes, lack of power analysis, extensive use of self-report tools for measurement, and lack of consistency from study to study of the operational definition of music therapy. It is therefore difficult to make specific pronouncements about the type or amount of music therapy that is necessary to effect changes in state anxiety level. Nevertheless, it may be stated that there has been an association between music intervention and decreased state anxiety levels in multiple clinical trials.
Critique of Body of Research
The conceptual framework that guided the studies of music intervention and decreasing anxiety was based on research and theories regarding stress and coping, the relaxation response, and on physiological theory (White, 1999). Each of the theories offered knowledge of the effects of anxiety, and suggested problem focus to a nursing intervention to reduce state anxiety. The use of the Titler et al. (in press) research utilization model fit well within the combined conceptual framework.
The design used in the majority of studies was quantitative, based upon an independent multiple-sample and two-group pretest/posttest, as well as repeated measures experimental design to compare groups matched for gender and age. Random selection was used in assigning study participants recruited from a convenience sample. The pretest/posttest was the most useful design for this type of study. The test takes into consideration the level of anxiety prior to the initiation of the musical intervention. Most studies were conducted in hospital settings in the Midwest, with a majority of the studies being performed in the coronary and intensive care units, especially involving patients presenting with myocardial infarction. In order for these candidates to participate, they were required to have confirmed MI, and be in stable condition.
The method used to assess results of anxiety and musical intervention research in all cases was the Spielberger STAI. Participants completed the state portion first, followed by the trait portion. A ten-point Likert scale was used, and indicated significant decrease in the patient’s perceptions of tension. Autonomic nervous system indicators of heart rate and respiratory rate were used. Holter monitors were used to measure effects of music on EKG results and heart rate variability.
The analysis of data was performed with a variety of measures. Repeated measures of multivariate analysis of variance, (MANOVA) was often used. When significant group-by-item interaction effects were obtained, change scores were determined for dependent variables and one-way analysis of variances (ANOVAs) were performed on these change scores. To examine demographic data, descriptive statistics were used including 2X2 analysis of covariance to determine the difference between the experimental and the control groups’ baseline data. Paired T-test was used to check variation in heart rate and respiratory rate. Multiple analysis of covariance (MANCOVA) was performed to examine whether there was greater variability between the control and experimental groups as opposed to within the groups. All studies documented statistics both in the body of the literature and in the form of descriptive tables. The majority of studies supported the hypothesis that listening to music decreased STAI scores. The evidence also suggested that music intervention affected the autonomic nervous system by decreasing heart rate, respiratory rate, blood pressure, myocardial demand, and heart rate variability. Patients consistently reported that listening to music helped them relax and improved their emotional state even when physiological indicators were absent.
Current Use of Research Findings
A 300-bed teaching hospital for veterans located in the Midwest was chosen as a sample to examine the extent to which the research findings about the effects of music are in use in practice. A mixture of nursing staff, student nurses, and nursing instructors were interviewed regarding their knowledge and use of the research findings in their practice. Each person was asked what they knew about the use of music to promote reduction of anxiety from research findings, practice, and personal experience. All were asked if they used music as a planned anxiolytic intervention.
Three nurse managers in the psychiatric services were consulted. Two (D. V. and C. C., personal communication, October 17, 2000) indicated an awareness of the use of music as an anxiolytic agent, but stated that music was not used as a planned intervention in their area. The third nurse manager (P. T., personal communication, October 17, 2000) was more knowledgeable about specific research findings. She is in the process of developing a planned music intervention to reduce anxiety and agitation with Alzheimer’s patients. Her unit has an active music therapy program targeted to memory enhancement, socialization, and maintenance of physical activity. None of the three commented on their personal use of music to relieve anxiety.
The head nurse of the Intensive Care Unit (ICU) was interviewed. M. B. (personal communication, October, 11, 2000) indicated awareness of the use of music to reduce anxiety in ventilator dependent patients, but noted that music is not used as a planned intervention in the ICU. She personally uses music to relax and reduce anxiety.
An evening shift house supervisor was also consulted. M. H. (personal communication, October 11, 2000) had awareness of music used to help manage pain. She was not aware of music therapy as a planned intervention in the designated hospital. She has personally used music to reduce pain, but did not address anxiety reduction.
Two staff nurses offered their perspectives. T. B. & A. L. (personal communication, October 20, 2000) indicated some awareness of research findings regarding the anxiolytic effects of music and the use of music therapy with psychiatric patients. Both nurses work on a unit that has used planned music intervention to reduce depression and anxiety, to facilitate discussion of feelings, and to promote relaxation. According to T.B., patients on the unit who have been recipients of the music interventions report less anxiety, particularly when they listen to familiar music. He further noted that self-selection of the music appears to aid the relaxation effect. A.L. has used music as a planned intervention in a psycho-educational class on techniques of self-regulation. She finds that music used with imagery is a powerful anxiolytic as evidenced by patient self-report, observed breathing patterns, facial expression, and verbal interaction. Both personally use music for anxiety reduction and relaxation.
Three nursing instructors who supervise students at the hospital were interviewed. In addition to the questions asked of other informants, the nursing instructors were asked about what is taught in their nursing program about music as an anxiolytic agent. All three instructors (N. Kerr, M. McBride, & J. Melland, personal communication, October, 24, 2000) reported that music therapy is mentioned in lecture and that their respective textbooks had only a paragraph or two about the use of music therapy as an intervention. Upon review, one text (Wilson and Kneisl, 1996) included five short paragraphs on the use of music and music therapy as a nursing intervention to enhance relaxation. The second text (Townsend, 2000) presented even less information. The instructors said that students frequently chose to study music therapy for research projects. All attested to the personal use of music to reduce anxiety, and on reflection found it curious that they don’t promote the use of music as an anxiolytic, in light of research and personal experience.
Senior level nursing students were asked if the use of music as a planned intervention to reduce anxiety was taught in their nursing program. J. K., K. B., & G. S. (personal communication, October 26, 2000) responded that a brief mention was the norm. K.B. and G.S. were unaware of research relating to music as an anxiolytic. J. K. was involved in a research project regarding the use of music to reduce agitation in Alzheimer’s patients. All three personally use music to reduce anxiety and relax.
Evaluation of the data provided indicates that there is an awareness of research findings about music as an anxiolytic agent. The subjective evaluation of all the informants was that music is effective in reducing anxiety. However, music therapy appears to be underutilized as a planned nursing intervention.
Decision and Plan for Utilization of Research—Link to Iowa Utilization Model
Following the decision tree of the Iowa Model, we determined that a sufficient research base regarding music as an anxiolytic agent exists. We elected to design a test pilot project to be implemented in an outpatient surgical center. The following outline documents our suggested plan.
A committee from the outpatient surgical center will form to plan the implementation of the test pilot. The committee will include one physician and two nurses; one is the staff education coordinator. The nurses will be the primary educators and organizers for the project. The pilot program will have full support of the clinic directors and the nurse manager. The planning process will take approximately one month.
The implementation committee will conduct a four-hour meeting the first week to outline the process. Three subsequent meetings to discuss final implementation plans will occur weekly, in one-hour sessions. The committee will emphasize the need for extensive staff education and comprehensive communication to ensure the program has every opportunity for success. The staff educator will create a bulletin board in the staff lounge outlining the principles of music therapy to enhance staff knowledge.
Next, the entire medical staff will receive two one-hour presentations to provide information on music therapy. The first one-hour presentation will detail the research on music therapy as an anxiolytic. During the first presentation, the staff will receive a handout outlining the presentation, and copies of supporting research articles. The second presentation will consist of a demonstration of the proposed music therapy intervention.
The following week, the nurses from the implementation committee will present an hour-long brief to the staff. The information provided will also be posted in the staff lounge as a visual reminder. The day following the staff information session, the director will hold a meeting to discuss any issues or concerns. Also, an e-mail group will be created to promote discussion of the program. The e-mail group will be a prime source of communication of positives and concerns with the program during the test period. The staff will have one week to address their issues and concerns. Staff support would be ongoing in the form of weekly discussion meetings, group e-mail forum, direct availability of nurse implementers, and bulletin board updates. During weekly staff meetings, the test pilot program will be discussed. The nurse implementers will encourage the staff to meet with them if issues or concerns exist.
The test music therapy program will be conducted in the following manner. Each nurse will assess each patient’s level of anxiety during the preoperative counseling session. Music therapy will be offered to all patients. The patient will receive an educational brochure about music therapy. Participating patients will then select preferred music prior to surgery. On the day of surgery, the nurse assigned to the patient will assess the level of state anxiety preoperatively and post-operatively using the Speilberger State-Trait Anxiety Inventory. Prior to surgery, the patient will be given a headphone set to listen to the music 15 minutes preoperatively. At the end of each day, each patient’s anxiety assessment tool will be collected and analyzed. Daily data will be posted in the staff lounge for everyone to see. At the end of the one-month test period, all data will be tallied, analyzed and evaluated to determine the overall outcomes of the music therapy program.
Using the Iowa Model, an evaluation program will be implemented after the test period to analyze the outcomes of the music therapy program. The two clinical directors and the nurse manager will make the decision whether or not to institute a music therapy program in their clinical practice. If a change is appropriate for adoption into practice, office policies and practices will be rewritten to reflect the change in clinical practice. During the one-month test period, the program will be monitored closely. Changes to the program will be made accordingly.
Following the decision tree, if the group chooses not to incorporate the program into practice, the office will continue to seek clinical opportunities to benefit patients.
Recommendations and Conclusions
Research involving music and its application for relieving anxiety is extensive. We were delighted at the amount of material obtained through the literature review that confirmed the benefits of music interventions. Though there were non-supportive studies, the majority of investigations indicated that music has an effect on decreasing state anxiety levels. Most of the studies, however, were limited by subjective interpretation of patient satisfaction obtained by rated scales, and not biophysical measures.
In conclusion, the amount of research performed thus far in the areas exploring the effect of music on anxiety is plentiful, but not complete. Areas of interest for future study should include the effect of music intervention on human physiology, comparative effects of a variety of types of music and intensity of music, duration of music therapy effects, and investigation into which types of situations benefit most from musical intervention.
References
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Dr. Phoebe Williams has our permission to post our research utilization paper on the internet as an example for future classes.