Aims. The aim of this study was to investigate if relaxing music is an effective method of reducing the physiological signs of
anxiety in patients receiving mechanical ventilatory support.
Background. Few studies have focused on the effect of music on physiological signs of anxiety in patients receiving mechanical
ventilatory support.
Design. A studycasecontrol, experimental repeated measures design was used.
Method. Sixty patients aged 1870 years, receiving mechanical ventilatory support and hospitalised in the intensive care unit,
were taken as a convenience sample. Participants were randomised to a control group or intervention group, who received
60 minutes of music therapy. Classical music was played to patients using media player (MP3) and headphones. Subjects had
physiological signs taken immediately before the intervention and at the 30th, 60th and 90th minutes of the intervention.
Physiological signs of anxiety assessed in this study were mean systolic and diastolic blood pressure, pulse rate, respiratory rate
and oxygen saturation in blood measured by pulse oxymetry. Data were collected over eight months in 20062007.
Results. The music group had significantly lower respiratory rates, and systolic and diastolic blood pressure, than the control
group. This decrease improved progressively in the 30th, 60th and 90th minutes of the intervention, indicating a cumulative
dose effect.
Conclusion. Music can provide an effective method of reducing potentially harmful physiological responses arising from
anxiety.
Relevance to clinical practice. As indicated by the results of this study, music therapy can be supplied to allay anxiety in patients
receiving mechanical ventilation. Nurses may include music therapy in the routine care of patients receiving mechanical
ventilation.
Key words: anxiety, blood pressure, mechanical ventilatory support, music therapy, pulse rate, respiratory rate
Accepted for publication: 3 July 2010
Introduction
Intensive care treatment is a highly technological branch of
medicine. Even in what may appear to be hopeless cases, lives
can be saved through the application of this modern
technology (Aldridge et al. 1990). Intensive care units are
Authors: Esra Akin Korhan, MSc, RN, Research Assistant,
Department of Fundamentals of Nursing, School of Nursing, Ege
University; Leyla Khorshid, PhD, RN, Professor, Department of
Fundamentals of Nursing, School of Nursing, Ege University;
Mehmet Uyar, MD, Professor, Department of Anesthesia and
_
Reanimation, Ege University Medical Faculty, Izmir,
Turkey
1026
Original article
Background
Music therapy is a branch of health care dedicated to the use
of music for emotional, physical, functional and educational
improvement in a broad range of settings and conditions
(Esch et al. 2004). Paterson and Zderad described the arts
(e.g. music, painting) as an important part of the nursing
discipline. In previous studies, music has been shown to have
positive physiological and psychological effects on patients
(McCaffrey & Good 2000). Relaxing music has been shown
to influence a persons emotional feelings and physiological
responses. Calm and soothing music is found to be the most
appropriate in reducing anxiety (Wong et al. 2001).
Researchers have examined the effectiveness of music in
pain and stress management in women during labour and
birth (Komurcu 1999, Browning 2000) and caesarean delivery (Chang & Chen 2005), in patients undergoing bronchoscopy (Smolen et al. 2002), in patients undergoing medical/
dental treatment (Paul & Ramsey 2000), in patients undergoing hysterosalpingography (Agwu & Okoye 2006), in
patients experiencing an acute myocardial infarction (Elliott
1994, Byers & Smyth 1997, Barclay & Vega 2005), in
patients experiencing surgical anxiety (Murphy 1999, Brunges & Avigne 2003, Ikonomidou et al. 2004) and in patients
undergoing colonoscopy (Smolen et al. 2002, Ovayolu et al.
2006). In another study, it was found that when controlling
for ambient operation room noise, intraoperative music
decreased propofol requirements of both Lebanese and
American patients undergoing urological surgery under
spinal anaesthesia (Ayoub et al. 2005).
Minimal music therapy research has been conducted in
patients on mechanical ventilation. In a literature review, it
was reported that music therapy had been shown to reduce
anxiety and pain levels, heart and respiratory rates and blood
pressure in critical care and perioperative populations (Lindgren & Ames 2005). Music therapy has been found useful in
intensive care settings because of its anxiolytic effects in
reducing anxiety, heart rate, mean blood pressure and
respiratory rate (Chlan 1998, Wong et al. 2001, Angela
et al. 2005, Arnon et al. 2006). Almerud and Peterson (2003)
implemented a study with the aim of ascertaining whether
music therapy had a measurable relaxing effect on patients
(n:20) who were temporarily on a respirator in an intensive
care unit. The results showed a significant fall in systolic and
diastolic blood pressure during the music therapy and a
corresponding rise after cessation of treatment (Almerud &
1027
EA Korhan et al.
Aim
This study was implemented to evaluate the effect of music
therapy on a group of Turkish patients and the value of
including music therapy in nursing care in this country. The
aim of the study was to examine the effects of classical music
on physiological signs of anxiety (systolic blood pressure,
diastolic blood pressure, heart rate, respiratory rate and
oxygen saturation) in Turkish patients receiving mechanical
ventilatory support and to investigate the effects of sociodemographical characteristics on the variation in physiological signs of anxiety occurring as a result of music therapy in
the experimental group.
Methods
Design
Studycasecontrol design was used in this research. The
intensive care unit of a university hospital in Izmir was used
as the setting for the study. The research hypotheses for the
study were as follows:
1028
1 There are significant differences between a music intervention group and a control group in terms of the mean
systolic blood pressure, diastolic blood pressure, heart rate,
respiratory rate and oxygen saturation of patients receiving
mechanical ventilatory support.
2 There are significant differences between 0 and the 30th
minute, 0 and the 60th minute, 0 and the 90th minute, the
30th and 60th minutes and the 30th and 90th minutes in
the music intervention group in terms of mean systolic
blood pressure, diastolic blood pressure, heart rate, respiratory rate and oxygen saturation of patients receiving
mechanical ventilatory support.
3 There was an interaction between sociodemographical
variables and differences in physiological signs of anxiety
in the music intervention group of the patients receiving
mechanical ventilatory support.
Participants
Sample size was determined based on Repeated Measures
ANOVA Power Analysis to achieve a power of 081 and the
sample size was 60. The population for the research was
formed from patients who were hospitalised in the intensive
care unit of the hospital. A convenience sample was taken of
patients (n:60) who were hospitalised in the intensive care unit
between 1 July 20061 March 2007, who met the study
criteria and who were receiving mechanical ventilatory support. Subjects were of Turkish nationality, were aged 18
70 years (range 1870, mean 4531 SD 1473, 32 male), had
no psychiatric or neurological illnesses, were not receiving
inotropic support, had not taken any neuromuscular blocker
and antihypertensive drug, had haemodynamic stability, were
on pressure support ventilation mode, were able to hear and
had Glasgow Coma Scale Point 9 or above. Demographical
data were collected from the patients medical records on age,
sex, ethnicity, ventilator settings, current medications, medical
diagnosis and number of days receiving ventilatory support.
Intervention
Patients were randomised to a control group or an intervention group, who received 60 minutes of music therapy.
Sedation by intravenous propofol infusion at a dose of
13 mg/kg/h was stopped daily 30 minutes before the start of
the experiment in both groups. Propofol is the sedative of
choice in intensive care units because it has a relatively short
half-life when compared with other sedatives traditionally
used in critical care. Propofols short half-life and quick onset
of action allow the rapid awakening preferred for neurological examinations (Ho & Ng 2008). Stopping propofol
Original article
Data collection
The research nurse stayed with the patients during the whole
intervention period to collect physiological data. Subjects in
the two groups had physiological signs taken immediately
before the intervention, at 30 -minute intervals throughout
the intervention and 30 minutes after the intervention
finished. Pressure support ventilation is the most popular
made of ventilatory support in intensive care units internationally (Ala & Esteban 2000). In this mode, each breath is
triggered by an inspiratory effort on the part of the patient. In
pressure support ventilation, the patient determines the
frequency and cycle length, while the degree of pressure
support is preset (Pierce et al. 1993). In our study, all patients
were on pressure support mode with the inspiratory pressure
adjusted to provide a tidal volume of 68 ml/kg, with
FiO2 04 and PEEP 6 cmH2O. Data were collected over
eight months in 20062007.
Physiological measures
The physiological signs of anxiety assessed in this study were
systolic and diastolic blood pressure, pulse rate, respiratory
rate and oxygen saturation. Systolic and diastolic blood
pressure, pulse rate and respiratory rate values were obtained
by means of indwelling arterial lines, and oxygen saturation
in the blood was measured by pulse oxymetry.
Demographical descriptive data and clinical characteristics of
subjects
Data were collected from subjects relatives and from their
medical records to assess comparability between the experimental and control groups with respect to age, sex, educational level, marital status, primary medical diagnosis,
ventilator settings, number of days receiving mechanical
ventilation and Glasgow Coma Scale Point.
Ethical considerations
The Ethic Committees of the School of Nursing and of the
Hospital approved the research. Patients relatives were
informed and their consent was taken verbally and in writing
after the first meeting with the researchers.
Data analysis
The data were analysed using SPSS version 13.0. Descriptive
analyses were used to summarise the data. Chi-Square tests
were used to detect any significant differences in the baseline
data of each intervention (age, sex, marital status, educational level, number of ventilator-dependent days) and
MannWhitney U-test was used for detect any significant
differences in the baseline data of the Glasgow Coma Scale.
Independent Sample t-tests were used to detect any significant differences in the baseline data of each intervention
(mean systolic blood pressure value, mean diastolic blood
pressure value, respiratory rate and pulse rate and oxygen
saturation).
The KolmogorovSmirnov test was used for accordance of
dependent variables and to provide their normal distribution
(p > 005). Then, because there were no variables which
deviated from normal distribution, five different repeated
measures analyses of variance (R_ANOVA ) were used for every
variable. Repeated measures analysis of variance (R_ANOVA )
was also used to examine mean systolic and diastolic blood
pressure, respiratory rate, pulse rate and oxygen saturation
across the intervention period, measured at 30-minute
intervals within groups and between groups. Therefore, the
Bonferroni test was used to examine the difference between
the intervals within each group and to examine the interaction between group and interval. The Bonferroni test was
carried out in the periods between 0 and the 30th, 0 and the
60th, 0 and the 90th, the 30th and 60th and the 30th and
90th minutes. Repeated measures analysis of variance
(R_ANOVA ) was used to examine the effects of sociodemographical characteristics on the difference in physiological signs of anxiety occurring during the music therapy in the
experimental group.
Results
Demographical characteristics
The study participants ranged in age from 1870 years (mean
4531 SD 1473). The sample consisted of 60 Turkish subjects
32 men and 28 women. Most of them were educated to
primary school level (n = 33), 16 to secondary school level
1029
EA Korhan et al.
Experimental group
Control group
7500
7000
6500
6000
5500
0
30
60
90
Time (min)
Experimental group
2300
Experimenal group
Control group
Control group
14000
Respiratory rate
2200
13000
12000
2100
2000
1900
1800
11000
1700
30
60
Time (min)
1030
90
30
60
90
Time (min)
Original article
Experimental group
10500
Control group
Discussion
Heart rate
10250
10000
9750
9500
9250
0
30
60
Time (min)
90
Experimental group
Control group
Oxygen saturation
9700
9680
9660
9640
0
30
60
Time (min)
90
1031
EA Korhan et al.
Conclusion
Respiratory rate and systolic and diastolic blood pressure
were reduced significantly after completion of music therapy.
Findings support the benefits of music therapy for ventilatordependent patients. Music has the ability to be used as a
therapeutic tool for lowering respiratory rate and systolic and
diastolic blood pressure in mechanically ventilated patients.
Music is a safe intervention that is not detrimental to
patients. Music therapy can be applied with advantage for
managing anxiety in ventilator-dependent patients without
risking unwanted side effects. Nurses can implement music
intervention using music with a tempo of 6080 beats per
minute to induce relaxation for short-term benefit.
Music therapy is a non-invasive, inexpensive and non-timeconsuming nursing intervention. It is recommended that
studies be conducted to explore the optimal time, duration,
or number of music sessions to be used when implementing
music therapy. Intensive care nurses can apply music therapy
as a non-pharmacological intervention to decrease signs of
anxiety in critically ill patients receiving mechanical ventilatory support.
Original article
Study limitations
Each subject undertook the music session at different times
during the day. Anxiety might be affected by the time of
the day at which the data were collected. The choice of
musical selection might present another limitation. Music
that is relaxing for one person might not be relaxing for
another. The efficiency of music to act as an anxietyreducing agent is dependent on the type of music used, the
preferences of the patient and the patients interest in
music. This could be a threat to the external validity of the
study, thereby affecting the generalisability of the findings
to other settings or samples. In this study, the preferences
of the patient were not considered, because some of the
patients were conscious, but others were unconscious or
semi-conscious. This is the first study implemented in
patients at mixed conscious levels. However, this may have
had an effect on the results. Because of cultural diversity
among the patients, their choices might differ. To provide
standards in the research, the choice of music was not left
to patients and classical music, which is known to have a
therapeutic effect (Almerud & Peterson 2003), was used in
the study.
The research nurse was not blinded as to the allocation of
each group. This is a limitation of the study. Because heart
rate, respiratory rate, systolic blood pressure, diastolic blood
pressure, oxygen saturation of patients were recorded from a
monitoring device which recorded all the results, no kind of
Acknowledgement
We thank all the people who so willingly participated in this
study.
Contributions
Study design: EK, LK, MU; data collection and analysis: EK
and manuscript preparation: EK, LK, MU.
Conflict of interest
This research was funded by Ege University Research
Foundation.
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