Part II: Mind–Body–Spirit Therapies
Chapter 7: Music Intervention
15. Revise intervention plan and goal(s) as needed
Initiating music intervention without first assessing a person’s likes and dislikes may produce deleterious effects. Because of music’s effect on the limbic system, it can bring about intense emotional responses.
Use of portable players with headphones may be inappropriate or pro-hibited for patients in psychiatric settings, who may use the equipment cords for self-harm.
Likewise, using music for diversion in patients with tenuous or unstable cardiovascular status should be done with extreme caution. Patients should be closely monitored for any untoward cardiovascular responses.
Age-Related Implications or Adjustments Needed for Optimal Implementation
Older adults may require additional precautions prior to using music for therapeutic listening purposes. For instance, volume and bass may need to be adjusted to match hearing acuity. Headphones are ideal
for masking background noise that can interfere with hearing acu-ity. Careful selection of equipment for music-listening interventions requires special attention to dexterity and/or vision impairments.
Diminishing dexterity or vision may impact the frequency or use of individual music listening.
USES
Music has been tested as a therapeutic intervention with many different patient populations; a majority of the nursing literature focuses on indi-vidualized music listening. Exhibit 7.2 shows those patient populations and the numerous therapeutic purposes that music has served. Two fre-quent uses are highlighted here.
Exhibit 7.2. Uses of Music Intervention
orientation/Minimizing Disruptive Behaviors
Older adults (Cooke, Moyle, Shum, Harrison, & Murfield, 2010; Hicks-Moore, 2005; Thomas & Smith, 2009)
Decreasing Anxiety
Pediatrics (Barrera et al., 2002; Kemper et al., 2008)
Surgical patients (Johnson, Raymond, & Goss, 2012; Kain, Sevarino, Alexander, Pincus, & Mayes, 2000; Lee, Henderson, & Shum, 2004; Yung et al., 2002)
Cancer patients (Clark et al., 2006; Ferrer, 2007) Cardiac patients (Hamel, 2001)
Flexible sigmoidoscopy (Chlan, Evans, Greenleaf, & Walker, 2000; Lee et al., 2002)
Ventilator-dependent intensive care unit (ICU) patients (Almerud &
Peterson, 2003; Chlan, 1998; Davis & Jones, 2012; Heiderscheit, Chlan, &
Donely, 2011; Wong et al., 2001) Pain Management
Acute pain (Dunn, 2004; Good et al., 2001; Huang, Good, & Zauszniewski, 2010; Koelsch et al., 2011; Laurion & Fetzer, 2003; Shertzer & Keck, 2001) Chronic pain management (Guetin et al., 2012)
Nursing care procedures/pediatrics (Whitehead-Pleaux, Zebrowski, Baryza, & Sheridan, 2007)
(continued)
7. MusIc InterVentIon 107
Interventional radiological procedures—decrease in pain and sedation (Kulkarni, Johnson, Kettles, & Kasthuri, 2012)
Stress Reduction and Relaxation
Neonatal intensive care (NICU) patients (Kemper et al., 2004); Nursing students (Bittman et al., 2004)
Mechanically ventilated ICU patients (Conrad et al., 2007) Hospitalized psychiatric patients (Yang et al., 2012)
Stimulation
Cognitive recovery and mood poststroke (Sarkamo et al., 2008) Sleep disturbances in college students (Harmat, Takacs, & Bodizs, 2008) Head injury (Formisano et al., 2001)
Distraction
Adjunct to spinal or general anesthesia (Lepage, Drolet, Girard, Grenier, & DeGagne, 2001; Nilsson, Rawal, Unesthahl, Zetterberg, &
Unosson, 2001)
Bone marrow biopsy and aspiration (Shabanloie, Golchin, Esfani, Dolatkhah, & Rasoulian 2010)
Burn care (Fratianne et al., 2001; Prensner et al., 2001)
Groin hemostasis with C-clamp application after percutaneous coro-nary intervention (Chan et al., 2006)
Hemodialysis-associated pain and anxiety (Lin et al., 2012; Pothoulaki et al., 2008)
Cardiac laboratory environmental enhancement (Thorgaard, Henriksen, Pedersbaek, & Thomsen, 2003)
Radiation therapy (Clark et al., 2006)
Decreasing Anxiety and Stress
One of the strongest effects of music is anxiety reduction (Pelletier, 2004).
Music can enhance the immediate environment, provide a diversion, and lessen the impact of potentially disturbing sounds for pediatric patients (Barrera, Rykov, & Doyle, 2002), and for patients experiencing a variety of surgical procedures (Ebneshahidi & Mohseni, 2008; Nilsson,
Exhibit 7.2. Uses of Music Intervention (continued)
2009). The effect of music intervention on the stress response has been documented in cardiac surgery patients (Yung, Chui-Kam, French, &
Chan, 2002), in coronary care unit patients (Hamel, 2001), and in ven-tilator-dependent ICU patients (Chlan, 1998; Almerud & Peterson, 2003; Conrad et al., 2007; Heiderscheit, Chlan, & Donely, 2011; Wong, Lopez-Nahas, & Molassiotis, 2001). Specially designed music can be effective in enhancing relaxation in an outpatient oncology setting for children (Kemper, Hamilton, McClean, & Lovato, 2008). Music can be an efficient intervention for enriching the NICU environment and reducing stress (Kemper, Martin, Block, Shoaf, & Woods, 2004) with such improvements as enhanced oxygenation during suction-ing (Chou, Wang, Chen, & Pay, 2003) and increased feedsuction-ing rates (Standley, 2003).
Distraction
Music is an effective adjunctive intervention for creating distraction, par-ticularly for procedures that induce untoward symptoms and distress, such as pain and anxiety with hemodialysis (Lin, Lu, Chen, & Chang, 2012; Pothoulaki et al., 2008). It has been found to be an adept diversional adjunct in the care of individuals with burns (Formisano et al., 2001;
Prensner, Yowler, Smith, Steele, & Fratianne, 2001), in the management of nausea and pain intensity after bone marrow transplantation (Sahler, Hunter, & Liesveld, 2003), in people undergoing regular hemodialy-sis (Pothoulaki et al., 2008), and for reduction in the amount of sedation required for adults during colonoscopy (Lee et al., 2002; Smolen, Topp, &
Singer, 2002).
How to Locate a Music Therapist for Consult or Collaboration
Given the importance of music preference assessment and knowledge of the physiological and psychological influences of music on the individual listener, it may be appropriate for a nurse to consult or collaborate with a professional music therapist prior to instituting music-listening interven-tions. One source that nurses can access to locate a music therapist in the United States is:
American Music Therapy Association 8455 Colesville Road, Suite 1000 Silver Spring, MD 20910
www.musictherapy.org (301) 589-3300
To locate a music therapist internationally, the World Federation of Music Therapy can be accessed at (www.musictherapyworld.net).
7. MusIc InterVentIon 109 CULTURAL ASPECTS
Although music may indeed be considered a universal phenomenon, there is no universal language to music. Various cultures structure music dif-ferently from what is usual to the average Western listener. For example, music from Eastern cultures contains very different tone structures and timbre, which can be foreign to the Western listener. Likewise, individu-als from a non-Western culture may find the classical music of Mozart or Beethoven as foreign sounding and irritating to the listener. These struc-tural differences in what various cultures consider music are crucial to consider when implementing music-listening interventions.
Across five pain intervention studies, Caucasians preferred orchestral music, African Americans favored jazz, and Taiwanese enjoyed harp music (Good et al., 2000). However, other investigators have found that minority older adults tend to prefer music that is familiar to their own cultural back-ground rather than Western music (Lai, 2004). These disparate findings high-light the need for careful music preference assessment prior to intervention.
It is imperative to keep in mind that music intervention should never be used in place of pharmacological therapy for the management of acute pain. Music can, however, serve as an adjunctive intervention for pain management.
There is interest in music for clinical applications around the world, and researchers in the context of their clinical settings are exploring the benefits of music to address patient conditions that they encounter.
Sidebar 7.1 provides an example of a program of clinical investigation to determine how music can benefit patients in emergency care.
Sidebar 7.1. Making a Difference in Emergency Care: Australian Music-Listening Applications
Alison Short, Sydney, Australia
People search for emergency care when they are sick, in pain, in shock, and distressed. Typically, they find this in a hospital emergency depart-ment (ED). Both their health problems and the ED environdepart-ment may contribute to their experience of stress and anxiety. High noise lev-els in the ED promote stress, aggravation, and sleep loss, with poten-tial effects on communication and behavior (Ortiga et al., 2013; Short, Ahern, Holdgate, Morris, & Sidhu, 2010; Short, Short, Holdgate, Ahern, &
Morris, 2011). Several Australian studies have used music-listening interventions in the ED to reduce anxiety and stress and promote calm (Daly et al., 2012/2013; Short et al., 2010; Weiland et al., 2011). Findings
(continued)
Sidebar 7.1. Making a Difference in Emergency Care: Australian Music-Listening Applications (continued)
suggest that music can reduce anxiety and negative affect for moder-ately anxious patients in triage categories 2 and 3 (Australasian College for Emergency Medicine, 2000), assisting them in feeling better during their stay in the ED (Short et al., 2010; Weiland et al., 2011). For exam-ple, patients commented: “Thought it was absolutely fabulous, blocked out conversations”; “Very good idea for passing the time, relaxes you”;
“Gives you more time out of here, more peaceful.” Combined with other modalities, music may also assist with reducing stress and anxiety levels in emergency nurses (Davis, Cooke, Holzhauser, Jones, & Finucane, 2005).
Planning a music-listening intervention in the ED needs careful con-sideration regarding the mode of delivery, the type of music to be used, patient choice, and volume levels. It may be difficult or inappropriate to use live music in many ED settings. Open-air broadcast of music may raise noise levels and be unsuitable, given the diverse sociocul-tural factors of the crowded multiaged and multiculsociocul-tural ED context.
Nevertheless, the use of music in the waiting room area is currently being trialed in a major Sydney hospital (Daly et al., 2012/2013). The use of headphones and music-listening equipment require careful consider-ation of operconsider-ational and infection- control issues (Short & Ahern, 2009).
In addition, decisions about what music to use are complex and need to consider many aspects of patient demographics, including language and ethnicity (Short & Ahern, 2009). Patient choice is generally understood to contribute to improved stress management (Chlan & Heiderscheit, 2014; Short et al., 2010). In using headphones, volume levels need to be tracked to avoid hearing damage; severe distraction by high noise lev-els may also potentially contribute to falls. As with other innovations, implementation of a music-listening intervention in the ED environment must first begin with a thorough consideration of the local context and its specific needs related to patients, staff, and the organization—as is consistent with the approach at our institution in Sydney, Australia.
References
Australasian College for Emergency Medicine [West Melbourne, Australia].
(2000). Guidelines on the implementation of the Australasian triage scale in emer-gency departments. Retrieved December 14, 2012, from: http://www.acem .org.au/media/ policies_and_guidelines/G24_Implementation_ATS.pdf Chlan, L., & Heiderscheit, A. (2014). Music intervention. In R. Lindquist,
M. Snyder, & M. F. Tracy, (Eds.), Complementary & alternative therapies in nurs-ing (7th ed., pp. 99–116). New York, NY: Sprnurs-inger Publishnurs-ing Company.
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7. MusIc InterVentIon 111
FUTURE RESEARCH
Although the evidence base is increasing, the following are areas in which research is needed to further build the science of music intervention:
■ Recent meta-analyses have been published on the consistent effects of music intervention on preoperative anxiety (Dileo, Bradt, & Murphy, 2008) and anxiety reduction in critically ill patients receiving mechani-cal ventilatory support (Bradt, Dileo, & Grocke, 2010). Whereas music consistently induces favorable outcomes, pooled effect sizes can be small. Common limitations are the inconsistent use of instruments to measure phenomena, such as anxiety, and lack of multisite clinical tri-als. Additional investigation is needed that builds on the findings of these meta-analyses through the consistent use of instruments and the conduct of multisite clinical trials.
■ Additional exploration into the management of symptom clusters would enhance the scientific base of music intervention. For example,
Sidebar 7.1. Making a Difference in Emergency Care: Australian Music-Listening Applications (continued)
Daly, B., Hilbers, J., Varndell, W., Chalkey, D., Cudmore, B., & Short, A.
(2012/2013). Auditory environments in healthcare: Reducing chaos and enhancing calm within the emergency department using music and recorded messages (Study in progress). Sydney, Australia: Australian Institute of Health Innovation, University of New South Wales.
Davis, C., Cooke, M., Holzhauser, K., Jones, M, & Finucane, J. (2005). The effect of aromatherapy massage with music on the stress and anxiety levels of emer-gency nurses. Australasian Emeremer-gency Nursing Journal, 8, 43–50.
Ortiga, J., Kanapathipillai, S., Daly, B., Hilbers, J., Varndell, W., & Short, A. (2013).
The sound of urgency: Understanding noise in the emergency department.
Music and Medicine, 5(1), 44–51.
Short, A., & Ahern, N. (2009). Theory into practice: A systematic decision-mak-ing process addressdecision-mak-ing patient needs for relaxdecision-mak-ing music in the emergency department context. Australian Journal of Music Therapy, 20, 3–28.
Short, A., Ahern, N., Holdgate, A., Morris, J., & Sidhu, B. (2010). Using music to reduce noise stress for patients in the emergency department: A pilot study.
Music & Medicine, 2 (4), 201–207.
Short, A., Short, K., Holdgate, A., Ahern, N., & Morris, J. (2011). Noise levels in an Australian emergency department. Australasian Emergency Nursing Journal, 14 (1), 26–31.
Weiland, T., Jelinek, G., Macarow, K., Samartzis, P., Brown, D., Grierson, E., &
Winter, C. (2011). Original sounds compositions reduce anxiety in emer-gency department patients: A randomised controlled trial. Medical Journal of Australia, 195 (11/12), 694–698.
persons with cancer typically experience nausea, vomiting, distress, and fatigue with treatments. Can the implementation of carefully selected music and its delivery improve a constellation of symptoms?
Can cancer patients be taught symptom management through the self-initiation of tailored or preferred music?
■ Cost and cost savings are significant issues in health care today. Little is known about the potential cost savings that could be realized with music intervention. Study is needed to determine whether music is a cost-effective or cost-neutral intervention and, if cost-effective, in which patient-care or symptom-management settings this is so.
■ Much of the nursing review focuses on immediate or short-term effects of music intervention. It is not known whether music can be effective for managing symptoms and distress in those with chronic conditions, or improve their quality of life. Appropriate longitudinal research designs are needed to answer these questions.
■ There is a paucity of explorations as to the appropriate or optimal tim-ing for delivery of music intervention to enhance effectiveness—and for which specific patient populations or symptoms.
■ There is limited research on the impact of music intervention on patient satisfaction or on the patient’s overall experience. Client satisfaction with music intervention is an important outcome and quality indi-cator in a variety of health care settings. Appropriate measures and instruments are needed to capture quality data, which requires further research to develop.
Although intervention study itself is labor intensive, there is a need for additional investigation on music intervention. The knowledge base about music intervention for promotion of patient/client health and well-being can be expanded through high-quality research and by dissemina-tion of those findings in a timely manner. To further build a strong body of knowledge surrounding the implementation and outcomes of music intervention, the authors of this chapter recommend an interdisciplinary approach, including nurses and music therapists conducting collabora-tive research. From quality evidence, music-intervention implementation guidelines can then be integrated into patient care.
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