The Effect of Complementary Music

Therapy on the Patient's Postoperative

State Anxiety, Pain Control, and
Environmental Noise Satisfaction
Tressa Comeaux
Susan Steele-Moses
nrelieved postoperative pain
remains a common problem
despite advances in pain
management. Lack of sleep, often
caused by environmental noise in
hospitals, can contribute to irritability, anxiety, and increased pain.
While analgesia is capable of modifying many of the pathophysiological
responses to pain (Layzell, 2008),
pain in the postoperative patient is
often unrelieved. Complementary
music therapy can create a distraction ftom pain, anxiety, worry, and
sadness, thereby increasing patient
satisfaction with the postoperative
experience (Koelsch, 2009).

Background
Our Lady of the Lake Regional
Medical Center (OLOLRMC) is a
Magnet-designated, DAISY Hospital Partner with surgical volume of
11,270 cases annually. Postoperatively, patients are admitted primarily to the inpatient surgical unit
(SURG). SURG is a 27-bed inpatient
unit with two wings (A hall=ll beds;
B hall=16 beds). Its staff manages
care of patients after planned surgical procedures, predominately abdominal, vascular, and oncology
diagnoses. In fiscal year 2010, 2,191
patients were discharged ftom SURG
with an average length of stay of
3.57 days.

(RBC) delivery model supported the

study. Three crucial relafionships in
RBC include care of self, care of colleagues, and care of patients and families. Nurses convey caring and compassion through touch, kindness, clinical interventions, active listening,
and understanding of the pafient's
experience (Koloroutis, 2009). The
purpose of this study was to determine if the use of music therapy was
an effective adjunct to decrease state
anxiety while increasing pain management and environmental noise
satisfaction in the postoperative
pafient.

Literature Review
The review of literature was conducted ufilizing the following databases: Cumulafive Index to Nursing and
Allied Health Literature (CINAHL)

Plus, The Cochrane Library, LexisNexis Academic, PubMed, Medline,

and the Joanna Briggs Institute.
Literature reviewed was limited to
the period ftom 2007-2012. Search
terms included complementary music
therapy, postoperative pain, postoperative anxiety, relationship-based care,
state-trait anxiety, and environmental
noise. The review of literature provided evidence that complementary
music therapy is eftective in reducing postoperative anxiety while
increasing pain control satisfaction.
According to the Joanna Briggs
Institute (2009), music therapy as a
non-pharmacological adjuvant to
opioid analgesia is best practice in
the management of pain and anxiety. Unrelieved postoperative pain
can lead to complications, such as
ineftective breathing patterns and
delayed ambulation, resulting in

Tressa Comeaux, APRN, FNP-C, CEN, is CICU Staff Nurse, Our Lady of the Lake Regional
Medical Center, Patient Care Services, Baton Rouge, LA.
Susan Steele-Moses, DNS, APRN-CNS, AOCN, is Research Director, Our Lady of the Lake
Regional Medical Center, Academic Affairs, Baton Rouge, LA.

Theoretical Model
As part of the professional model
of care at OLOLRMC, principles
inherent to Relationship-Based Care

MEDSURG

Postoperative pain is difficult to manage with analgesia alone.

Complementary interventions such as music therapy provide a level of
distraction, thus promoting comfort. In this study decreased pain and
environmental noise were demonstrated, without diminishing state
anxiety, in a group of postoperative patients.

Acknowledgments: This study was funded by a non-restricted grant from the DAISY Foundation:
JPB-021-A. The authors wish to thank Angela Dykes, BSN, RN; Sandra Wade, MN, APRN-CNS;
and Yvette Robson, RN-BC, who conducted the ongoing study on the SURG unit at Our Lady of
the Lake Regional Medical Center, Baton Rouge, LA.

September-October 2013 Vol. 22/No. 5

313

Research for Practice

Introduction
Unrelieved postoperative pain remains a common problem despite advances in
pain management. Complementary music has been suggested as an adjuvant to
the standard of care treatment for postoperative pain.
Purpose
The purpose of this study was to determine if music therapy was an effective
adjunct to decrease state anxiety, and increase pain management and environmental noise satisfaction in the postoperative patient.

Method
A quasi-experimental non-equivalent control group design was used in this study
with participants assigned based on room assignment rather than randomly. The
control group, which consisted of participants admitted to the A hallway, received
the standard of care. The intervention group, which consisted of participants
admitted to the B hallway, received complementary music therapy in the form of
pre-programmed MP3 players, in addition to the standard of care. Based on the
premise of a non-equivalent control design, neither analgesia type nor route was
controlled. Each participant was enrolled for a total of 3 days or until discharge,
whichever came first. Outcome measures were collected upon enrollment (Time
One) and for the next 2 consecutive days (Time Two and Time Three). Participants
in the intervention group were encouraged to listen to a selection of non-lyrical
low decibel (less than 60 db) pre-programmed music, for at least 30 minutes via
a MP3 player after their prescribed analgesia was administered. Non-lyrical low
decibel music was chosen for this study because previous research supported its
effectiveness. State trait anxiety as well as pain and environmental noise satisfaction were assessed using the State-Trait Anxiety Inventory and two standardized
questions from the Press Ganey survey.
Findings
Before the intervention was implemented, both groups were the same related to
their average level of state and trait anxiety, pain, and noise perception. The
patient's state anxiety, pain perception, and noise perception were measured 1
day after the intervention was in place. A significant difference was found from
Time One to Time Two in pain management (t=3.938, p<0.001 ) and environmental noise satisfaction (t=3.457, p=0.001), while there was no change in state anxiety (t=0.373, p=0.7n). The intervention group experienced improved pain management (t=7.385, p<0.011) and environmental noise satisfaction over time
(t=4.371; p<0.001); however, there was no improvement in state anxiety (t=1.47;
p=0.159). The findings suggest music therapy decreases pain and environmental
noise perception, although there was no effect on state anxiety.
Conclusions
Use of music therapy improves patients' postoperative experience by increasing
their pain management and white noise satisfaction. Because the intervention was
tested on a busy post-surgical unit with a short inpatient stay (mean=3.57), the
effect of music therapy over more than 2 days could not be measured. This intervention was inexpensive and easy to implement in the clinical setting, and therefore recommended to improve postoperative outcomes in other facilities. It is recommended the study be replicated with a larger sample size and different patient
populations to validate these findings.

314

increased postoperative morbidity,

delayed recovery and return to normal daily living, and reduced patient
satisfaction (Macintyre, Schug, Scort,
Visser, & Walker, 2010).
Effect of Music Therapy
Research indicates music therapy
provides distraction, promotes relaxation, and decreases anxiety (Engwall
& Duppils, 2009). Music therapy has
a beneficial effect on a patient's perceived pain, relaxation, respiratory
rate, self-reported anxiety level, and
the amount of analgesia required for
eftective pain management (American Music Therapy Association,
2010). When used in conjunction
with pharmacologie pain management strategies, music therapy promotes a sense of well-being and an
overall positive patient experience
(Walworth, Rumana, Nguyen, &
Jarred, 2008). While music therapy
has the propensity to promote distraction and relaxation, limited
research has focused on the effectiveness of music therapy for pain management in postoperative patients
outside a controlled environment
Goanna Briggs Institute, 2009).
Relationship hetween Pain
and Anxiety
Postoperative pain, while an expected consequence of a surgical
procedure, is infiuenced by psychological factors, such as fear and anxiety (Engwall & Duppils, 2009). Because trait anxiety inherently is individualized and aftects the ability to
address a perceived threat, persons
with heightened anxiety may experience more postoperative pain than
those who are less prone to anxiety
(Lin, Lin, Huang, Hsu, & Lin, 2011).
Conversely, patients with low trait
anxiety may be more pain tolerant
than those with high trait anxiety.
Researchers recommend interventions should be stratified based on
the participant's trait anxiety score
(Binns-Turner, 2008; Nilsson, 2008).
Contrary to trait anxiety, state anxiety refers to feeling nervous or anxious when faced vnth an immediate
danger or stressful situation. It is
transient, fiuctuates over time, and
varies in intensity (Lin et al., 2011).

3SrX7Xl
September-October 2013 Vol. 22/No. S M E D S U
RG s

IISTG.

The Effect of Complementary Music Therapy on the Patient's Postoperative State Anxiety, Pain Control, and Environmental Noise Satisfaction

TABLE 1.
Demographic Data by Croup

Environmental Noise
Reduction
Environmental noise is a significant barrier to sleep for hospitalized
patients; research supports sleep as
therapeutic to overall health, wound
healing, and recovery (Gardner,
Collins, Osborne, Henderson, &
Eastwood, 2009). Noise in and
around the nurses' station can be
especially problematic (Haupt, 2012).
Music therapy functions as a distracter ftom hospital noise, thereby
reducing emotional anxiety and
pain (Gardner et al., 2009). To promote relaxation, music should: (a) be
non-lyrical, (ti) have predominantly
low tones, (c) have minimal brass
and percussion, and (d) have a maximum decibel volume of 60 db
(Nilsson, 2008).

Purpose and Hypothesis

The purpose of this study was to
determine the eftect of music therapy on state anxiety, postoperative
pain, and environmental noise perception. The hypothesis for this
study was as follows: Music therapy
will decrease state anxiety, increase
pain management eftectiveness, and
increase environmental noise satisfaction in postoperative patients.

Method
The first 41 data sets collected to
test the efficacy and feasibility of the
study methods are reported here.
The larger study, which is still ongoing, consists of three groups: (a) control, (b) music therapy, and (c) white
noise therapy. The pilot study and
the larger study were provided
exempt status by both the Nursing
Research Council and Clinical Research Steering Committee of OLOLRMC. An implied consent process
was used because a wriften consent
would have tied the participant to
the study, thereby precluding
exempt criteria definition. Providing
complementary music therapy via
pre-programmed MP3 players was
an inexpensive intervention that
was implemented easily to enhance
the patient's postoperative experience.

MEDSURG

Variable
Gender (A/=41)

Standard of Care

Intervention

Male (n=27)

14 (34.2%)

13 (31.7%)

8 (19.5%)

6 (14.6%)

13 (31.7%)

12 (29.3%)

African American (n=15)

8 (19.5%)

7 (17.1%)

Not disclosed (n=1 )

1 (2.4%)

Female (n=14)
Race (/V=41)
Caucasian (n=25)

Sample and Setting

All patients admitted to the surgical unit who met the following
inclusion criteria were asked to participate in the study: anticipated 3day hospital length of stay, alert and
oriented, age 18 or older, able to read
and write English, and hematologyoncology diagnosis. Participants
were not assigned randomly to the
intervention but rather placed into
groups based on the hallway assignment. Participants admifted to the A
hallway received the standard of care
(control group), while participants
admifted to the B hallway received
complementary music therapy (intervention group) (see Table 1). Both
groups received the provider-ordered
analgesia. Participants in the intervention group were encouraged to
listen to a selection of non-lyrical
pre-programmed music via MP3
players for 30 minutes following the
administration of prescribed analgesia. Each participant was enrolled in
the study for 3 consecutive days
(Time One, Time Two, Time Three)
or until discharge, whichever came
first.

Measures
The State-Trait Anxiety Inventory
(STAI) was used to evaluate anxiety.
The STAI is divided into the two subscales: STAI Form Y-1 and STAI Form
Y-2. The 20-item STAI Form Y-1
(Chronbach's alpha = 0.62) was used
to measure state anxiety (Spielberger,
Gorsuch, & Luschene, 1970). The
STAI Form Y-1 (range score 20-80)
measures the participant's current
emotional feeling, such as calm or

September-October 2013 Vol. 22/No. S

nervous. Participants rated the degree to which the item represented

how they currently felt using a 4point Likert scale ranging ftom not at
all to very much so, with the higher
score indicating greater state anxiety
(Spielberger et al., 1970).
The 20-item STAI Form Y-2
(Chronbach's alpha = 0.86) was used
to measure trait anxiety. The STAI
Form Y-2 (range score of 20-80) measures participants' usual emotional
feelings, such as feelings of inadequacy or happiness (Spielberger et al.,
1970). Parcipants rated the degree
to which the item represented how
they generally felt using a 4-point
Likert scale with responses ranging
ftom almost never to almost always;
the higher score indicated higher
trait anxiety (Spielberger et al., 1970).
Two standardized items concerning patient satisfaction, which were
developed and used extensively by a
national vendor, measured the participant's satisfaction with pain management and environmental noise.
Participants were asked to rate each
item: (a) "During the previous 24
hours, I am satisfied with my pain
control," (r2 = 0.72) (Press Ganey,
2010) and (b) "During the previous
24 hours, I am satisfied with the
noise level in and around my room"
(r^ = 0.74) (Press Ganey, 2010), on a
4-point Likert scale ranging ftom 1
(not at all) to 4 {very much so), with a
higher score indicating greater satisfaction.

Data Collection Procedures

A member of the clinical support
team, which consisted of a clinical
nurse specialist, clinical educator.
315

Research for Practice

program direetor for nursing researeh, and direet-eare nurse, approaehed eaeh patient on the first
postoperative day, explained the
purpose of the study, obtained verbal
eonsent, and provided data eolleetion paekets. Patients loeated on the
B hallway also reeeived the musie
intervention. The data eoUeefion
paeket eonsisted of a manila envelope eontaining the initial survey
(Time One), two follow-up surveys
(Time Two and Time Three), and
three white envelopes. To proteef
patient anonj^nity and assure aeeurate data analysis, surveys were
eoded based on the hallway assignment, partieipant number, and day
of completion (e.g.: A-100-Time 1, A100-Time 2, A-100-Time 3). The parfieipant's state anxiety, trait anxiety,
and pain management and environmental noise satisfaetion over the
previous 24-hour period were measured on enrollment (Time One).
State anxiety, the patient's pain
seore, and noise satisfaetion were
measured at Time Two and Time
Three or until diseharge, whiehever
eame first. The patient was instrueted to plaee eaeh eompleted questionnaire in a white envelope, seal if, and
plaee fhe sealed envelope in the
manila envelope to maintain eonfidentiality. Daily, the clinieal support
staft rounded, enrolled new patients,
distributed paekets, reminded patients to eomplete the questionnaire,
and eoUeeted eompleted paekets. In
the event the patient was diseharged
between rounding periods, a survey
eolleetion box was plaeed at the
nurses' station for the patient to
deposit the MP3 players and eompleted data eolleefion paekets. MP3
players were wiped with a germieidal disinfeetant between patients;
however, the ear buds were not
reused.
Data Analysis Procedures
Deseriptive statisties were used to
summarize the sample dmographie
eharaeteristies. A eomparative analysis of the mean difterenees within
groups was eompleted using a paired
t test. Analysis between groups was
eompleted using an independent t
test.

316

TABLE 2.
Difference between Groups per Study Variable, Time One (N=4^)
Variable

M'

State Anxiety
Music

19

9.63

Control

22

36.05

Trait Anxiety
Music

19

37.42

Control

22

32.81

Pain Management Satisfaction

Music

19

2.42

Control

22

2.73

Music

19

2.74

Control

22

3.14

Environmental Noise Satisfaction

t
1.112

P
0.273

1.448

0.156

1.694

0.098

1.864

0.070

TABLE 3.
Difference between Croups per Study Variable, Time Two (/y/=41)

State Anxiety

0.373

Music

19

37.11

Control

22

35.68

Pain Management Satisfaction

3.938 <0.001

Music

19

3.47

Control

22

2.77

Environmental Noise Satisfaction

3.457

Music

19

3.53

Control

22

3.05

Findings
At Time One, no significant differenee existed in state anxiety, trait
anxiety, or pain management or
environmental noise satisfaetion
between groups (see Table 2). The
partieipant's state anxiety, pain management satisfaetion, and noise satisfaetion were measured again 1 day
after the intervenfion was in plaee
(Time Two). At Time Two, a signifieant inerease was found in pain
management (t=3.938; p<0.001) and
environmental noise satisfaetion
(t=3.457; p=0.001), while no ehange
was found in state anxiety (t=0.373;
p=0.711)(seeTable3).
The efteetiveness of the intervenfion was analyzed over time. For the

0.711

0.001

eontrol group, no difterenee existed

in state anxiety (t=0.149; p=0.883),
pain management (t=0.237;p=0.815),
or environmental noise (t=0.568;
p=0.576) satisfaetion ftom Time One
to Time Two (see Table 4). The intervention group experieneed a signifieant improvement in pain management (t=7.385;p<0.001) and satisfaetion with environmental noise
(t=4.371; p<O,OOiy, however, no
ehange was found in the partieipant's
state anxiety (f=1.47; /7=0.159) ftom
Time One to Time Two (see Table 5).

Discussion
Both groups expressed average
levels of general anxiety (trait) and
situational anxiety (state) at the

September-October 2013 Vol, 22/No, S M E D S U R G

The Effect of Complementary Music Therapy on the Patient's Postoperative State Anxiety, Pain Control, and Environmental Noise Satisfaction

TABLE 4.
Difference within Group from Time One to Time Two, Controi (N=22)

State Anxiety
Time One

0.149

0.883

0.237

0.815

0.568

0.576

36.05

Time Two

35.68

Pain Management Satisfaction

Time One

2.73

Time Two

2.77

Environmental Noise Satisfaction

Time One

3.14

Time Two

3.05

TABLE 5.
Difference within Group from Time One to Time Two, Music (N=19)

State Anxiety
Music

39.63

1.47

Control

37.11

Pain Management Satisfaction

7.385 <0.001

Music

2.42

Control

3.47

Environmental Noise Satisfaction

4.371

Music

2.74

Control

3.53

completion of the Time One measure. The Time One measurement of

pain and environmental noise satisfaction indicated participants generally were not satisfied with pain.
management or with noise levels in
and around their rooms. During the
Time One measurement, all participants reported being only somewhat
satisfied with pain management over
the previous 24 hours (music group
li=2.42; control group ]i=2.74), suggesting participants were not satisfied with the standard of care alone.
At Time One, environmental noise
satisfaction was slightly higher in
the control group (p=3.14) than with
the music group (p=2.74). The difference in noise perception can be
attributed to renovations on the A
hallway, placing the bed behind a
double wall, further away from the
doorway, along with the installation
of acoustic tiles in each room.

MEDSURG

0.159

<0.001

The difference between groups at

Time Two revealed no significant
change in state anxiety (t=0.373,
p=0.711), suggesting music therapy
did not decrease situational anxiety
levels as previously predicted. Because the majority of the patients on
this unit had surgical oncology diagnoses, the lack of relationship between music and state anxiety may
be understandable. Results of this
study partially supported the hypothesis that music therapy is effecfive
as a non-pharmacological adjunct to
analgesia in increasing pain management and environmental noise satisfaction; however, state anxiety remained unchanged.

Nursing Implications
In this study, use of music therapy
improved pain management and
environmental noise satisfaction

September-October 2013 Vol. 22/No. 5

when used as a complementary therapy. Therefore, distraction from negative experiences through use of
music therapy can increase satisfaction in patients recovering from surgery. This intervention was inexpensive and easy to implement in the
clinical setting, and therefore recommended for use to improve postoperative outcomes. MP3 player technology decreased in cost, providing a
viable option for hospitals. The players can be cleaned easily, patients
can be given their own ear buds to
keep, and music discs are a one-time
purchase. Nurse leaders may consider purchasing MP3 players inscribed
with their hospital logo for the
patients to keep, thus promoting the
intervention after discharge.
Findings ftom this study can be
incorporated easily into the nurse's
practice. The medical-surgical nurse
could encourage family members to
bring the patient's favorite music
ftom home to augment analgesia.
Portable CD players, MP3 players,
and cell phones are all viable portable options to provide music.
Family members also should be
reminded to bring earphones or ear
buds to prevent disrupting other
patients. The nurse can encourage
the patient to listen to the music
immediately after analgesia administration for a period of at least 30
minutes. Not only will the patient's
favorite music decrease anxiety, but
it also masks routine hospital noise
that patients often find annojng.

Limitations and
Recommendations for
Future Research
Preliminary analysis identified
some limitations in the study. First,
patients were not assigned randomly to the intervention; although
room assignments were non-predictive, they were not random. In addition, use of personal distraction may
have confounded the findings of
this study. Patients in the control
group also reported listening to
music. Patients may have brought
their own music with them or listened to music provided on the television network. Because no manipulation occurred to change usual
317

Research for Practice

care, some unanticipated crossover
eftect may have occurred. While the
sample size is small, the significant
difference observed may have
occurred by chance; however, findings ftom the larger study support
the findings reported here. The
study should be replicated with a
larger sample size and with difterent
patient populations to validate these
findings. Data collected at Time
Three were limited due to the unit's
average length of stay or participants' failure to complete the questionnaire on the day of discharge.
The STAI Questionnaire was tedious,
somewhat repetitive, and upsetting
for some, especially those with new
cancer diagnoses. Beginning the
intervention earlier in the preoperative period also may be helpful so
the patient could benefit ftom the
intervention through the surgical
experience and hospitalization.

Conclusion
Findings of this study suggest
music therapy improves the postoperative experience through enhanced pain management and environmental noise satisfaction. The
intervention was inexpensive and
easy to implement in the clinical set-

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September-October 2013 Vol. 22/No. S M E D S U R G

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