Orthopedic Outpatients' Perception of Perioperative Music Listening as Therapy
Lukas, Linda K., Journal of Theory Construction and Testing
Abstract: Anxiety and pain are natural responses for patients who must undergo surgery. Recent studies have shown that music therapy can be a low cost, effective adjunct to traditional pain and anxiety management. In the present study, 31 surgical patients selected music from a set of compact disc (CD) recordings and listened to the music preoperatively, intraoperatively, and postoperatively. A 10-item survey was administered to participants approximately 24 hours following their dismissal from the surgery center. Study results indicate that participants overwhelmingly felt that music listening was a positive addition to traditional pain and anxiety management.
Key Words: Anxiety, Music therapy, Orthopedics, Surgical pain
The Agency for Health Care Policy and Research (1992) reported that over half of the 23 million Americans who undergo surgery each year do not get adequate pain relief from most traditional methods. As we move forward through the first decade of the twenty-first century, more and more patients are having surgery performed on an outpatient basis. Patients are usually sent home one to two hours following surgery with a family member or friend to act as caregiver.
BACKGROUND AND SIGNIFICANCE
One of the greatest fears patients and their caregivers have is the potential for postoperative pain and their inability to manage that pain. A relatively large number of patients are afraid of addiction with the use of narcotics (Francke, Garssen, Abu-Saad, & Grypdonck, 1996), yet they do not want to experience the sensation of pain. Some patients experience more postoperative pain following hospital discharge than previously thought (McDonald, 1999). Uncontrolled pain can result in fears and anxiety associated with the pain, mobility problems, and sleep disruption. Pain is a multifaceted process made up of physiologic, psychosocial, and cultural parts. Creativity in relief of postoperative pain must be explored and utilized by healthcare workers for more positive patient outcomes. Today, some researchers are reporting that better acute pain management may be achieved for the patient through a combination of such traditional pain management techniques as opioids and such nontraditional techniques as music, relaxation, massage, or guided imagery (Van Kooten, 1999).
Music listening as therapy in the perioperative phase can bean effective adjuvant to analgesics for postoperative pain (Good, Stanton-Hicks, Grass, Anderson, Choi, Schoolmeesters, & Salman, 1999). Unfortunately most nurses, physicians, and other healthcare workers do not use music therapy as often as possible to decrease postoperative pain because they may be unaware of the effectiveness of this nonpharmacologic technique. Potentially, if healthcare workers used music therapy consistently as an adjunct to decrease postoperative pain and anxiety levels in surgical patients, a positive physiological and psychological effect might be achieved. It is also important, however, to consider if patients perceive music as helpful in controlling their pain and anxiety. This study investigated using survey methods to determine how participants perceived music listening when used perioperatively as an adjunct therapy to control postoperative pain and anxiety.
Will orthopedic outpatients perceive music listening therapy as a positive addition to traditional pain management when used perioperatively to control postoperative pain and anxiety?
Orthopedic outpatients will have a positive perception of music listening therapy when it is used perioperatively as an adjuvant to traditional pain management.
Rationale for Hypothesis
McDonald (1999) reported that orthopedic surgery might present more challenges for pain management than other surgeries. In a study done with 10,008 ambulatory patients in the post anesthesia care unit (PACU), orthopedic patients had the highest incident of pain (Chung, Ritchie, & Su, 1997). In the past, it has been reported that further studies need to be done regarding pain prevention treatments for this special group of surgical patients (McDonald, 1999). From a patients' perspective, using music in the surgical setting yielded positive results (Stevens, 1990). There are many methods for relieving postoperative pain, most of which include pharmacologic agents such as opioids. Because all patients respond differently to pain, it is important that nurses have the ability and knowledge to offer other options as an adjuvant to narcotics. Research demonstrates that alternative methods for pain relief, such as relaxation techniques and music therapy, can decrease pain by interrupting the postoperative cycle of pain, muscle tension and sympathetic activity (Good, 1996).
Historical literature about sounds used for medicinal purposes dates to three thousand years before Christ's birth. Pythagoras, the Greek philosopher and mathematician, was the intellectual and spiritual godfather of sound medicine and was the first to use music for spiritual and emotional healing (Gaynor, 1999). In biblical times, David used music as a healing art when he played the harp to ease King Saul's suffering (The New International Version Study Bible, 1985). During the Middle Ages and renaissance, the French used music to restore and maintain harmony of the body and soul (Olsen, 1998). In the 19th century, Florence Nightingale (1992) hypothesized that certain types of music, especially wind instruments, stringed instruments, and the human voice, could have a positive effect on healing the hospitalized patient.
Although many nonpharmacologic pain management techniques have been used in recent years, their use has been somewhat limited due to a lack of knowledge on the caregivers' part. Alternative therapies are seldom included as part of a perioperative protocol (Good, 1996). This study will explore by survey methods if using music listening as an alternative pain management technique alone or in combination with traditional pain medications can evoke a positive response from orthopedic outpatients.
The usefulness of alternative therapies to reduce pain in the postoperative period has been reported many times in the literature (Kaempf & Amodei, 1989, AHCPR, 1992, Good, 1996, Kuperberg & Grubbs, 1997, Garbee & Beare, 2001). Nurse theorist, Jean Watson observes that modern medicine has focused increasingly on technological cures for disease with medications and surgery. Nonetheless, she reports that new paradigms are emerging in health care that focus on a caring approach using compassionate skills to help patients reach a healthy state of mind, body, and spirit (Watson, 1999). Watson states that auditory modalities must be systematically viewed as caring arts. The conscious use of auditory modalities is basic to health, healing, and self-care (Watson, 1999). Music listening as therapy is one of the caring-healing therapies that is safe, inexpensive, and effective; it has great potential to decrease stress, anxiety, and pain for the surgical patient.
Watson's philosophy and her middle-range theory of human caring focus on human-to-human caring processes and caring transactions (Patton, Barnhart, Bennett, Porter, & Sloan, 1998). Middle-range theories are narrow in locus and consist of relational concepts that can be used to convey, illustrate, or predict phenomenon; they are suitable for studies concerning direct patient care (Howk, Brophy, Carey, Noll, Rassmussen, et al., 1998). Watson's (1985) framework often carative factors supports a focus on alternative therapies for pain management. In the present study, patients were surveyed to determine their perceptions of music listening as therapy in the orthopedic outpatient setting.
DEFINITIONS OF STUDY VARIABLES
Postoperative pain is an unpleasant sensory and emotional experience caused by surgical tissue damage (Merskey & Bogduk, 1994). Postoperative pain was operationally defined as the patient's self report of pain using the Wong-Baker FACES Pain Rating Scale (Wong, Hackenberry-Eaton, Wilson, Winkelstein, & Swartz, 2001). The Wong-Baker FACES Pain Rating Scale uses six different facial expressions combined with a numerical rating scale (0-10) to help the patient describe the intensity of pain to the caregiver.
Music Listening as Therapy
Music listening as theraphy is listening to selected music using headphones for the purpose of healing (Buckwalter, Hartsock, & Gaffney, 1985). Music listening as theraphy was operationally defined as listening to compact discs of musical selections classified as relaxing - having a regular sustained melodic quality through headphones - preoperatively in the holding area, intraoperatively in the surgical suite, and postoperatively in the post-anesthesia care unit (PACU).
Positive perception is showing affirmation by becoming aware through one of the senses (Webster, 1998). Positive perception was operationally defined as having four or more "yes" answers on the post-surgical music therapy survey (see Table 1) given to the participant twenty-four to forty-eight hours following dismissal from the surgery center.
REVIEW OF LITERATURE
Pain management research done with orthopedic patients using preoperative and postoperative pain assessment charts and questionnaires reveals numerous factors that contribute to pain perception, such as gender, culture, environment, and past medical history (Walker, 1998). Clinical practice guidelines on acute pain management include cognitive-behavioral interventions such as relaxation, distraction, and imagery, used in conjunction with pharmacologic interventions for the treatment of postoperative pain (AHCPR, 1992). The guidelines state that patient-preferred and "easy listening" music can be effective in reducing mild to moderate pain. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) cites music therapy as one of the alternative or complementary interventions that may be used individually or in combination with medications as a pain management technique (JCAHO, 2002).
Arguments for Nonpharmacologic Therapies
Kuperberg and Grubbs (1997) studied coronary artery bypass patients' perceptions of acute postoperative pain, utilizing a 10-point numerical rating scale and descriptive questions to assess expectations, beliefs, and perceptions about the experience of postoperative pain. Patients reported objectionable side effects to pain medication, fears of addiction, and thoughts that pain should be present for healing. Because of these beliefs, pain medication was used much less frequently and in smaller amounts than what was actually ordered. The researchers concluded that giving more pain medication is not necessarily the correct approach for postoperative patients.
Van Kooten (1999) conducted a study to test the effects of nonpharmacologic pain management strategies. Twenty postoperative coronary artery bypass patients were asked to complete the Short-Form McGill Pain Questionnaire which included 15 verbal descriptors to describe pain. Patients were asked about their use of nonpharmacologic interventions for pain relief. Seventy-eight percent (78%) of the patients studied reported that use of alternative methods made a difference in helping to decrease their perception and sensation of pain over medication given alone. Wilkinson (1996) reported that non-pharmacological pain management could be as effective as pharmacological management, particularly when two or more therapies are used in combination. A cumulative effect can be produced by combined therapies, yielding a very powerful weapon in the reduction of pain.
Support for Music Listening as Therapy
Researchers in several health care settings have documented that music listening reduces anxiety and pain. Sedative music has proved effective in decreasing sympathetic nervous system activity and reducing situational or state anxiety associated with surgery (Moss, 1988). Benefits of music listening have been observed among patients undergoing arthroscopic procedures, hysterectomies, and day surgeries.
Ninety-seven individuals, divided into two groups, undergoing same day surgery at a large Veterans Administration hospital in the Midwest were included in a quasi-experimental pain study (Shertzer & Keck, 2001). Pain was measured in the PACU using an 11-point Numerical Rating Scale (NRS). The experimental group listened to music in the PACU on a day when the staff kept extraneous noise to a minimum. The control group experienced the PACU on a typical day without music intervention. Results of the NRS showed the experimental group had a significant reduction in pain from PACU admission to discharge. The study findings support the use of music played in the PACU, which can reduce pain levels and improve satisfaction of those undergoing day surgery.
Mullooly, Levin and Feldman (1988) examined the role of music in reducing postoperative pain and anxiety on twenty-eight women scheduled for elective abdominal hysterectomies. The experimental group received a tape recorder, headphones, and a ten-minute tape of "easy listening" music. After using the tape, the women rated their pain level using a visual analogue scale on the first and second postoperative day. On day one, anxiety was reduced in the group receiving the music therapy. On day two, both pain and anxiety were reduced when music therapy was used.
One study reported that when soothing music was used in the preoperative holding area, anxiety was reduced in 33 patients poised to have arthroscopic surgery (Kaempf, 1989). 1 he patients' respiratory rates along with systolic blood pressure readings and anxiety test scores were significantly lower in the experimental group as compared to the control group.
Other Orthopedic procedures
In Eisenman and Cohen's study (1995) of 30 orthopedic surgical patients, music had a positive effect on the surgical experience by converting potentially traumatic and stressful experiences to more pleasant ones. Anxiety and fear were reduced. The patient's blood pressure and pulse were more stable, and less anesthesia was needed. Winter, Paskin and Baker (1994) found that by providing music to patients in the surgical holding area, anxiety and stress were significantly reduced. Every participant recommended that music be available for all future patients.
Music Combined with Other Therapies
Heiser, Chiles, Fudge and Gray (1997) evaluated the effects of music used in combination with a pharmacologie agent (IV morphine sulfate) on postoperative surgical pain and anxiety levels, physiologic parameters, and satisfaction, using a repeated measures experimental design. The treatment group listened to music through headphones the last 30 minutes of their surgery and for the next hour in the post-anesthesia care unit (PACU). The control group was given the same preoperative medications, managed with the same anesthesia protocol but did not listen to music in the operating room or PACU. Although no statistical difference was found between the two groups, the patients in the treatment group reported that the music helped them to relax, lowered their anxiety levels, and served as an escape tool.
Good and associates (2001) observed the effects of relaxation, music, and a combination of the two on postoperative pain. Experimental interventions were taught preoperatively to patients in five midwestern hospitals using audiotapes and earphones. Testing of 468 patients at ambulation and rest on day one and day two revealed that relaxation and music, or a combination of the two, reduced postoperative pain during ambulation. This research was important because it showed that use of relaxation and music may make ambulation more appealing, thus decreasing risk for postoperative complications resulting from bed rest.
The Cleveland Clinic Foundation studied music and guided imagery using a prospective randomized trial involving 130 patients (Tusek, Church, & Fazio, 1997). The control group received routine perioperative care, while the experimental group received routine care and listened to guided imagery and music cassette tapes twice each day for three days before their surgical procedures. During surgical induction, and intraoperative and postoperative periods in the PACU, the experimental group listened to tapes with music alone. The experimental group had significantly lower total analgesic requirements than the control group and had considerably less pain and anxiety on all postoperative days.
Additional Benefits of Music Listening
A research project conducted on 60 patients in a PACU concluded that listening to music using headphones had no effect on pain level, requirement for narcotics, hemodynamics, respiration, or length of stay in the PACU (Heitz, Symreng, & Scamman, 1992). Yet, when these patients were compared to other groups that had headphones but no music and with groups having no headphones or music, the group that listened to the music waited longer before calling for pain medication. Additionally, the group having headphones with music also evaluated the stay in the PACU to be more pleasant than the patients with no music.
Bonebakker, et al (1996) and Munte, et al (1999) conducted studies regarding memory and anesthesia, which concluded that anesthetized patients could process information that is presented intraoperatively. A double-blind randomized clinical investigation that showed when day surgery patients were exposed to music in combination with therapeutic suggestions, they required less rescue analgesic compared with the controls. The patients also experienced more effective analgesia the first day after surgery and could be mobilized earlier after surgery (Nilsson, Rawal, Unestahl, Zetterberg, Unosson, 2001).
Orthopedic patients experience high levels of pain that challenge traditional pain management techniques. Traditional pain modalities such as opioids can effectively reduce postoperative pain, but often with untoward side effects. Although the literature reveals that music therapy can have a positive effect on postoperative pain, very little research has been done using music listening as a pain management technique with orthopedic outpatients. This study may make a contribution to the literature because it addresses orthopedic outpatients' perception of music listening as therapy when combined with traditional pain modalities during the perioperative period.
PURPOSE OF THE PROJECT
Patients who undergo orthopedic surgery can experience significant levels of postoperative pain and anxiety. The purpose of this project was to determine by survey method if using music listening as therapy in conjunction with traditional pain modalities during the perioperative period would be perceived as positive by orthopedic outpatients to help reduce their postoperative pain and anxiety.
The setting for this study was an outpatient surgical center located in the southwestern U.S. This center serves approximately 1500 orthopedic patients annually.
Baseline pain assessment
This facility's pain assessment and management begins with a pie-anesthetic patient history obtained by a registered nurse in the physicians office several days prior to the surgical procedure. A numerical rating scale (NRS) is used to rate the patients pain level at the time of the visit. On the day of surgery, the patient is asked to arrive one hour prior to their scheduled surgical procedure. Pain assessment is repeated using the Wong-Raker FACES Pain Rating Scale, and results are recorded on the pre-anesthetic history form by the registered nurse in the perioperativc holding area. During the interview, the patient is asked if there is any pain at the proposed operative site. If the answer is yes, the patient is asked to state the specific location of the pain, the onset, frequency of pain, quality of pain, and if sensation is normal or decreased. Severity is assessed using a Wong-Raker KACRS Pain Rating Scale.
The patient is escorted to the preoperative holding area and prepared for surgery. Preemptive analgesia is begun with oral administration of rofecoxib (Vioxx) 50mg, a COX-2 inhibitor, given for its anti-inflammatory and analgesic effects, metoclopramide (Reglan) 10 mg to stimulate motility of the upper gastrointestinal tract thus accelerating intestinal transit and gastric emptying, and ranitidine (Zantac) 150 mg to inhibit gastric acid secretion. The patient waits approximately 30 minutes in this area before being transported to the surgical suite. Patients having Anterior Cruciate Ligament (ACL) reconstruction also receive a femoral block administered by the anesthesiologist in the holding area for control of postoperative pain. Effects of the block last for approximately 24 hours. Prior to administration of the femoral block midazolam (i.e., Versed) 2 to 5 mg is given IV for sedation. A general anesthetic is administered for the surgical procedure with anesthesia protocol used by each anesthesiologist being generally the same with slight differences based on patient need. Anesthesia rime varies depending on the procedure from 30 minutes to 2 hours.
In the post-anesthesia care unit (PACU), pain is assessed using the numerical rating scale (NRS) and recorded on the PACU record every 10 to 15 minutes until the patient is discharged. Pain is managed in the PACU using IV morphine sulfate 8 to 12 mg every five minutes as needed. Patients arc generally in the PACU from one to two hours. The patient is sent home with a prescription of thirty tablets of hydrocodonc 7.5 mg for oral administration every four to six hours as needed for pain. The patient is in the facility approximately 3 to 4 hours from time of admission to discharge.
Facility nurses that participated in the study were given a 30-minute orientation of the study description. The role of nurses in the study was clearly outlined. All questions regarding study methods were addressed prior to commencing the study. The patient population for this study consisted of men and women between the ages of 20 and 70 years undergoing arthroscopic surgery of the knee done by one surgeon practicing in the facility. Thirty-one patients were solicited for participation in the study. The study was conducted during May and June 2003.
Patients excluded from the study were people unable to understand or speak English and those with a) a self-reported hearing impairment, b) a known substance abuse history, c) psychological disorders, or d) a self-reported history of chronic pain. Payor mix included both private insurance and workers compensation. Demographic data collected during the prcopcrative visit in the physicians office included age, gender, ethnicity, education, yearly income, self-reported health status, and relaxing music preference.
Human Subject Protections
Approval for the study was obtained from the Internal Review Board of the facility where the surgeries were performed. All applicable human subjects protections were provided. Willing participants were given a full explanation of the study one to two weeks prior to surgery. Sufficient time was also given for the patients to ask questions. Written informed consents were obtained from all willing participants during the preoperative visit, two to three days prior to surgery.
Music Listening Intervention
A variety of music from four different categories was offered from country, easy listening, instrumental, and classical categories. The music was deemed relaxing and had a regular rhythm. The participants were allowed to choose from the selections available. Each participant was given a compact disc player to use while in the facility, headphones with new foam earpieces, and a CD of their music selection when they were admitted to the preoperative holding area. The compact disc players used in the study were inspected by the biomedical department of the facility and approved for patient use. Participants placed the headphones on themselves and were asked to set the volume control on the compact disc player to a level that was comfortable. The volume control was taped in place to avoid accidental change while participants were under general anesthesia. After surgical preparation in the holding area, the participant was given approximately 20 minutes of uninterrupted music listening time prior to entering the surgical suite. When transported to the surgical suite, participants continued listening to music intraoperatively. Postoperatively, participants listened to music throughout their stay in the PACU.
Within twenty-four to forty-eight hours following surgery, the nurse researcher contacted and interviewed all participants, recording their answers on the survey sheet. The survey was composed often questions in a multiple choice and short answer format (see Table 1). The survey instrument was determined to have content validity based on the review of literature, which revealed benefits resulting from the use of music listening as therapy such as decreased anxiety and decreased pain. Furthermore, experts knowledgeable in survey techniques reviewed the post-surgical music therapy survey. The survey took approximately two to three minutes to complete. Participants were given time to ask questions following the postoperative survey. A "positive" experience with music listening therapy was four or more "yes" answers recorded on the survey for questions 3 through 9. After all surveys were completed the survey answers were scored.
Thirty-one patients were interviewed regarding participation in the music listening as therapy study. Every patient interviewed regarding participation in the music study volunteered to participate. Demographic data collected revealed the willing participants to be between 20 and 70 years of age with a mean age of 48 years.
An overwhelmingly positive response was obtained from the participants with 97% reporting a positive experience (i.e., four or more "yes" answers to the survey questions 3 through 9). Over half of the participants (57%) remembered their stay in the recovery room, but only 40% were aware of other sounds around them while listening to the music with headphones. Comments by participants confirmed that music listening as therapy, used during their stay in the outpatient surgical facility, helped to decrease anxiety and control pain: "The music helped me get my mind on something else; the music allowed me to forget about what was happening around me; because I could not hear the sounds around me I was less afraid; reminded me of the music my mother sang to me as a child; all I remember is the music playing when I woke up; it made me feel so peaceful; the music helped me take my mind off of my pain."
All participants indicated that, if given the opportunity, they would choose to listen to music again during a stay in the surgery center. Five participants stated they would have preferred to bring their own music because their favorite music was not available. One participant volunteered that when he arrived home and begin experiencing pain, he listened to a soothing music CD in his home and was able to delay taking his pain medication.
Although the majority of the responses were positive, one patient asked that the headphones be removed after listening to the music for only a brief period of time in the preoperative area. When questioned she stated, "the music made her feel nervous." Another patient was very combative in the PACU and removed the headphones, throwing them on the floor. When asked during the survey regarding their perioperative experience, neither patient could remember the incidents described.
The purpose of this study was to determine if orthopedic outpatients would find music listening therapy a positive addition to traditional pain medication for the relief of pain and anxiety. The results of this study suggest that music listening as therapy within the confines of an outpatient surgical facility can be viewed as a positive addition to traditional methods to control anxiety and postoperative pain. Cost of the study was under $100 including purchase four compact disc players, extra headphones, and some compact discs to add to the principal investigator's already comprehensive library.
The results of the study can be compared to Stevens' 1990 study where findings were consistent with easing surgical pain, acting to divert patients' attention away from their pain, and increasing pain threshold. More surgery is done today on an outpatient basis, which means that patients arrive at the surgery center with no sedation. Surgical patients are usually very anxious and stressed. Many times they have pain associated with their disease process. Patients also feel a loss of autonomy when they are asked to remove their clothing, makeup, and jewelry. Allowing patients to choose their music selections can restore some autonomy. Because music preference varies greatly between individuals, it is important to offer enough diversity in the music library. The majority of participants in this study were very pleased with the music selections available from the four categories.
In today's fast-paced surgical environment, perioperative nurses face many challenges to meet the needs of outpatients in helping to alleviate their pain and anxiety. Although most nurses have not been taught non-pharmacologic methods for control of pain and anxiety, they must recognise music as a successful tool in pain and anxiety management. Music listening as therapy is a cost effective, noninvasive, simple method to use as an adjunct to traditional pain management; it offers a more holistic approach to nursing care.
The results obtained from the music study survey were very positive; even so, the study did have some limitations. The sample size of thirty participants was small and restricted to patients having outpatient knee surgery. If the sample size had been larger, the study conducted over a longer period of time, and other types of surgical patients had been included, a more conclusive directive with regards to music therapy in the surgical arena may have been possible. Survey questions only allowed for a choice from predetermined answers rather than freely formulated answers. Had the survey allowed for more open-ended answers, the information obtained might have been more useful.
Offering music listening as therapy to patients can be a low cost, effective tool used as an adjunct to traditional methods to control pain and anxiety in the outpatient setting. This study provided a means to evaluate orthopedic patients' perception of music listening as therapy used in the perioperative outpatient setting. Music listening was perceived as a positive addition to traditional pain management. As a result of this study, every patient at the facility, where this study was done, is now offered the option of listening to music via headphones during their perioperative stay.
More research is necessary to evaluate music therapy and other nontraditional methods of pain and anxiety relief. As patient advocates, nurses must promote the use of these proven methods in the perioperative environment for a more holistic approach to patient care.
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Linda K. Lukas, RN, MSN, CNS, CRNFA
Linda K Lukas, RN, MSN, CNS, CRNFA is a perioperative clinical nurse specialist with The Texas Arthfoscopic Surgery-Clinic, Fort Worth, Texas. Mrs. Lukas can be reached at her office at (817) 336-5633 or by fax (817) 870-1703. Her e-mail address is email@example.com
Acknowledgement: The author wishes to acknowledge Dr. Jo Nell Wells, Texas Christian University, for her review of this manuscript and significant contribution to the development of the survey used in this study.…
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Publication information: Article title: Orthopedic Outpatients' Perception of Perioperative Music Listening as Therapy. Contributors: Lukas, Linda K. - Author. Journal title: Journal of Theory Construction and Testing. Volume: 8. Issue: 1 Publication date: Spring 2004. Page number: 7+. © Not available. Provided by ProQuest LLC. All Rights Reserved.