A Survey of Surgeon, Nurse, Patient, and Family Perceptions of Music and Music Therapy in Surgical Contexts

A Survey of Surgeon, Nurse, Patient, and Family Perceptions of Music and Music Therapy in... Abstract While recent research suggests that music therapy interventions impact pre-surgical anxiety (Palmer, Lane, Mayo, Schluchter, & Leeming, 2015), staff and patron perceptions of the modality are not well established. A total of 629 surgical patients, surgeons, nurses, and family members were surveyed to identify factors that might affect willingness to participate and to educate practitioners on preferred methods of facilitation. The majority of participants (93%) believed music to be beneficial during the surgical experience. Subjects were welcoming of live preoperative music listening (74%), recorded preoperative music listening (84%), and intraoperative music listening (77%). Eighty-eight percent of patients reported that they would be willing to accept music if it was offered to them as part of surgical care. Fifty percent of patients relayed that they would rather listen to live or recorded music than any other preoperative activity. Music may be a welcome addition to the surgical arena, with all affected parties largely in support of music practices. Employment of a music therapist in the surgical arena may provide optimum benefits, as practitioners can tailor interventions to meet the ever-changing needs of patients. This study further reinforces the importance of educating staff and patients about music therapy and raising awareness about the differential benefits music therapy may offer. Music therapy, surgical procedures, operative Patient anxiety is a significant concern in the surgical arena (Clarke et al., 2013), and patients often feel abandoned as they wait for surgery (Gilmartin & Wright, 2008). While anxiety and comfort may be addressed through drug intervention, preoperative sedatives may delay recovery and increase the potential for adverse reactions (Giacalone, 1992). Therefore, non-pharmacologic techniques continue to be investigated (Au et al., 2015; Cheseaux, de Saint Lager, & Walder, 2014; DeMarco, Alexander, Nehrenz, & Gallagher, 2012; Wu, Liang, Zhu, Liu, & Miao, 2011). Music therapy, the clinical and individualized use of music to address specific goals assessed and facilitated by a trained professional (AMTA, 2016), has increasingly become a more common adjunct in the medical setting. A much less common use of music therapy is that which is practiced in a surgical context. Music therapy in surgical contexts is the evidence-based use of music interventions, facilitated by music therapists, to reduce anxiety, manage pain, reduce anesthesia requirements, and mask adverse sound stimuli during a surgery experience (Palmer et al., 2015). Music therapy in the surgical arena has been found to decrease patient anxiety (Bradt, Dileo, & Shim, 2013) and provide emotional support (Cowen, 1991), both of which may help combat feelings of anxiety and abandonment that are so prevalent in preoperative care. While time for complimentary modalities may be limited before surgery, Palmer, Lane, Mayo, Schluchter, and Leeming (2015) found that a brief, five-minute music therapy intervention, consisting of one therapist-facilitated preferred song (live or recorded), significantly reduced anxiety in women preparing for breast cancer surgery. Music therapy may also have a positive effect on a patient’s family members, improving satisfaction (Gooding, Yinger, & Iocono, 2015) as well as mood and verbalizations during this stressful time (Gallagher, Lagman, Walsh, Davis, & LeGrand, 2006). While music therapy in surgical contexts is rare, general perioperative music listening, without the presence of a board-certified music therapist, is practiced and studied more frequently. Anxiolytic uses of the phonograph during surgery were documented as early as 1914 (Moris & Linos, 2012). Continuing through the present day, surgical arenas have offered music-listening opportunities to patients (Cunningham, Monson, & Bookbinder, 1997; Trängeberg & Stomberg, 2013). Such practices, however, are mostly considered “music medicine” and not music therapy because they are usually facilitated by non-music therapy staff (Palmer, Lane, & Mayo, 2015), and surgical music programs tend to be general and not designed to meet the specific and changing needs of the individual patient and situation. The benefits of music medicine in surgery, however, are well documented. General music listening may reduce patient pain (Özer, Karaman Özlü, Arslan, & Günes, 2013), mask unpleasant sounds (Sener, Koylu, Ustun, Kocamanoglu, & Ozkan, 2010), improve satisfaction (Ilkkaya et al., 2014) and decrease anesthesia requirements (Bringman, Giesecke, Thörne, & Bringman, 2009). An early survey found that music listening was the most preferred pre-surgical waiting activity (Hyde, Bryden, & Asbury, 1998). Surgical staff may also be affected by music in surgical units. Sixty-three percent of surgeons claim to listen to music routinely in the operating room (Ullmann, Fodor, Schwarzberg, Carmi, Ullmann, & Ramon, 2008), and preferred music listening has been shown to improve surgery speed and quality (Lies & Zhang, 2015). Perioperative staff may enjoy hearing music in their work environment (Thorgaard, Ertmann, Hansen, Noerregaard, Hansen, & Spanggaard, 2005), yet they may also find music distracting and impeding to proper communication (Moris & Linos, 2013). Though evidence exists as to the benefits of music listening, there is limited research on how music in a surgical context is perceived by all affected parties. Implementation strategies for music therapy in surgery specifically, as well as differentiation from music medicine in surgery, are not well established. Understanding the perceived impact on patrons and staff will help investigators understand the next steps music therapists could take in this context, especially by learning where there are gaps that may not be filled by music listening alone. By discovering their unique merit in this area of practice, music therapists may learn how to appropriately present, create, integrate, and promote interventions that best serve all parties. To do so, we began by asking what the perceptions, preferences, and concerns of incorporating music in surgical contexts are to patients, families, surgeons, and perioperative nurses. By doing so, we investigated which factors might affect a patient’s willingness to participate in a music experience during their surgical experience, so that music therapy may integrate more often and successfully in the surgical realm. In conducting this survey, our secondary goals were to provide information that may assist clinicians in learning how to approach patients, families, and staff, and to educate music therapy practitioners about concerns that could be addressed in order to ensure patient, family, and staff buy-in. Methods Participants and Setting From December 15, 2015, to March 15, 2016, 629 subjects (249 surgical patients, 248 family members, 93 surgeons, and 39 perioperative nurses) were surveyed at Mather Surgery Center at University Hospitals Cleveland Medical Center. This study was approved by the University Hospitals Case Medical Center institutional review board, which also gave feedback and approved the questionnaires and study design prior to research commencement. Tools An experimenter-designed questionnaire was used to survey participants. It was tested for clarity and brevity (3–5 min) with board-certified music therapists and patients, who gave feedback prior to implementation. Most questions asked for one response, while some allowed for multiple answers. See Appendix A for survey questions. Procedure Upon arrival for surgery, the medical receptionist distributed paper surveys to all patients and one accompanying family member on one specific day each week for 14 successive weeks. All patient and family surveys were completed in the waiting room. The patients did not receive a music intervention but were surveyed on their perceptions of the possibility of music as an addition to their treatment. Surgeons and nurses were sent electronic surveys via email four times, one being the initial request with three subsequent reminders during the three-month period. Emails included a link to an online questionnaire and details about the study. Online surveys were presented through REDCap, a secure web application used for building, collecting, and managing survey data. Paper surveys were also made available at one nurse meeting on January 20, 2016, and were distributed in the surgeon lounge on February 12, 2016. Analysis In our original survey, we included questions about music use and whether music therapy might be a welcome addition to the surgical arena. In reviewing the responses, we discovered that the term “music therapy” may have been misunderstood by respondents and confused with their experience with general music listening, not music therapy, as questions were intended. Participants may not have understood what music therapy was when answering the survey, leading them to depend on their own understanding of music therapy when answering questions. We therefore approached survey findings with caution, being mindful that participants may not have understood the differences between a music medicine (e.g., nurse-facilitated music listening with headphones) and music therapy intervention (e.g., music therapist–facilitated live preferred song singing). Electronic surveys were analyzed through the survey platform, RedCap, while paper surveys were analyzed using SAS 9.4 and R3.2.2 statistical software. Once results were gathered, percentages were calculated. After finding suggested correlations from survey percentages, data regarding age, gender, or musicality and acceptance of music therapy, chi squared, and/or Fischer exact tests were calculated to identify associations between the groups. A Fischer exact test is a statistical test used for a contingency table (2x2 table) to test if two specific population distributions are associated or not. This exact test is usually used for small sample size, especially when the number of any of the cells is below 5. Chi-squared tests were run first, and in instances where one cell was less than 5 counts, a Fischer exact test was performed to determine significance. Results Summary of Participant Responses Of the 919 surgeons, perioperative nurses, patients, and family members invited to take the survey, 629 completed questionnaires were submitted, giving the study a 68% response rate. A summary of the baseline characteristics for all participants can be found in Table 1. Table 1 Background Characteristics of Participants Family Patient Surgeon Nurse All participants Age 18–24 3(1.2%) 10(4.1%) 0(0%) 4(10.3%) 17(2.6%) 25–34 19(7.7%) 23(9.3%) 5(5.3%) 10(25.6%) 57(8.7%) 35–44 43(17.3%) 26(10.5%) 30(31.9%) 4(10.3%) 103(15.7%) 45–54 70(28.2%) 44(17.8%) 28(29.8%) 7(18%) 149(22.7%) 55–64 58(23.4%) 54(21.9%) 14(14.9%) 13(33.3%) 139(21.2%) 65–74 44(17.7%) 62(25.1%) 17(18.1%) 1(2.6%) 124(18.9%) 75+ 11(4.4%) 28(11.3%) 0(0%) 0(0%) 39(5.9%) Gender Male 67(27.1%) 119(48.4%) 63(67%) 6(15.4%) 255(40.7%) Female 180(72.9%) 127(51.6%) 31(33%) 33(84.6%) 371(59.3%) Race Asian 3(1.2%) 2(0.8%) 12(12.8%) 0(0%) 17(2.7%) Black or African American 49(20.2%) 51(20.9%) 1(1.1%) 3(7.9%) 104(16.8%) White 184(75.7%) 184(75.4%) 76(80.9%) 34(89.5%) 478(77.2%) Other 7(2.9%) 7(2.9%) 5(5.3%) 1(2.6%) 20(3.2%) Family Patient Surgeon Nurse All participants Age 18–24 3(1.2%) 10(4.1%) 0(0%) 4(10.3%) 17(2.6%) 25–34 19(7.7%) 23(9.3%) 5(5.3%) 10(25.6%) 57(8.7%) 35–44 43(17.3%) 26(10.5%) 30(31.9%) 4(10.3%) 103(15.7%) 45–54 70(28.2%) 44(17.8%) 28(29.8%) 7(18%) 149(22.7%) 55–64 58(23.4%) 54(21.9%) 14(14.9%) 13(33.3%) 139(21.2%) 65–74 44(17.7%) 62(25.1%) 17(18.1%) 1(2.6%) 124(18.9%) 75+ 11(4.4%) 28(11.3%) 0(0%) 0(0%) 39(5.9%) Gender Male 67(27.1%) 119(48.4%) 63(67%) 6(15.4%) 255(40.7%) Female 180(72.9%) 127(51.6%) 31(33%) 33(84.6%) 371(59.3%) Race Asian 3(1.2%) 2(0.8%) 12(12.8%) 0(0%) 17(2.7%) Black or African American 49(20.2%) 51(20.9%) 1(1.1%) 3(7.9%) 104(16.8%) White 184(75.7%) 184(75.4%) 76(80.9%) 34(89.5%) 478(77.2%) Other 7(2.9%) 7(2.9%) 5(5.3%) 1(2.6%) 20(3.2%) View Large Table 1 Background Characteristics of Participants Family Patient Surgeon Nurse All participants Age 18–24 3(1.2%) 10(4.1%) 0(0%) 4(10.3%) 17(2.6%) 25–34 19(7.7%) 23(9.3%) 5(5.3%) 10(25.6%) 57(8.7%) 35–44 43(17.3%) 26(10.5%) 30(31.9%) 4(10.3%) 103(15.7%) 45–54 70(28.2%) 44(17.8%) 28(29.8%) 7(18%) 149(22.7%) 55–64 58(23.4%) 54(21.9%) 14(14.9%) 13(33.3%) 139(21.2%) 65–74 44(17.7%) 62(25.1%) 17(18.1%) 1(2.6%) 124(18.9%) 75+ 11(4.4%) 28(11.3%) 0(0%) 0(0%) 39(5.9%) Gender Male 67(27.1%) 119(48.4%) 63(67%) 6(15.4%) 255(40.7%) Female 180(72.9%) 127(51.6%) 31(33%) 33(84.6%) 371(59.3%) Race Asian 3(1.2%) 2(0.8%) 12(12.8%) 0(0%) 17(2.7%) Black or African American 49(20.2%) 51(20.9%) 1(1.1%) 3(7.9%) 104(16.8%) White 184(75.7%) 184(75.4%) 76(80.9%) 34(89.5%) 478(77.2%) Other 7(2.9%) 7(2.9%) 5(5.3%) 1(2.6%) 20(3.2%) Family Patient Surgeon Nurse All participants Age 18–24 3(1.2%) 10(4.1%) 0(0%) 4(10.3%) 17(2.6%) 25–34 19(7.7%) 23(9.3%) 5(5.3%) 10(25.6%) 57(8.7%) 35–44 43(17.3%) 26(10.5%) 30(31.9%) 4(10.3%) 103(15.7%) 45–54 70(28.2%) 44(17.8%) 28(29.8%) 7(18%) 149(22.7%) 55–64 58(23.4%) 54(21.9%) 14(14.9%) 13(33.3%) 139(21.2%) 65–74 44(17.7%) 62(25.1%) 17(18.1%) 1(2.6%) 124(18.9%) 75+ 11(4.4%) 28(11.3%) 0(0%) 0(0%) 39(5.9%) Gender Male 67(27.1%) 119(48.4%) 63(67%) 6(15.4%) 255(40.7%) Female 180(72.9%) 127(51.6%) 31(33%) 33(84.6%) 371(59.3%) Race Asian 3(1.2%) 2(0.8%) 12(12.8%) 0(0%) 17(2.7%) Black or African American 49(20.2%) 51(20.9%) 1(1.1%) 3(7.9%) 104(16.8%) White 184(75.7%) 184(75.4%) 76(80.9%) 34(89.5%) 478(77.2%) Other 7(2.9%) 7(2.9%) 5(5.3%) 1(2.6%) 20(3.2%) View Large The majority of participants (93%) believed listening to music would be a beneficial practice during the surgical experience. Overall, subjects were welcoming of live preoperative music listening (74%), recorded preoperative music listening (84%), and intraoperative music listening (77%). All four groups felt that anxiety reduction would be the greatest benefit of surgical music (76%), while top concerns with surgical music varied between groups. A summary of each participant group follows. Patients Of the 295 patients invited to participate, 251 (85%) accepted the survey and 249 (99%) of the distributed surveys were returned. Median age range was 55 to 64 years. A similar percentage of females (52%) and males (48%) took the survey. Most participants were of Caucasian (75%) or Black/African American (21%) race (see Table 1). Patients were facing many types of surgical procedures, the most common being orthopedic (35%), neurological (16%), and thoracic (10%) surgeries. Ninety-nine percent of patients claimed to enjoy music, and half of surveyed patients (50%) expressed that they would benefit from listening to music more than any other preoperative waiting activity. Specifically, 43% of patients believed that they could most benefit from recorded music listening while only 7% claimed live music listening would be most valuable. Other preferences included watching television (11%), listening to relaxation recordings (9%), talking (8%), sitting in silence (6%), reading (6%), and a combination of the listed activities (9%). Most patients reported feeling anxious (71%) and believed that hearing music might reduce their current anxiety level (86%). In considering music listening before, during, and after surgery, patients felt that it would be most beneficial in the period just before surgery (48%), followed by the period just after surgery (24%) and during surgery (15%). In the preoperative stage, the majority of patients expressed that they would enjoy listening to preferred recorded music through headphones (76%) and/or quiet live music listening (71%). Sixty-four percent of patients believed they would enjoy preferred music listening via headphones during surgery (see Figure 1). Figure 1. View largeDownload slide Overall, participants were mostly welcoming of intraoperative music listening (77%), recorded preoperative music listening (84%), and quiet, live preoperative music listening (74%). Figure 1. View largeDownload slide Overall, participants were mostly welcoming of intraoperative music listening (77%), recorded preoperative music listening (84%), and quiet, live preoperative music listening (74%). Patients believed the greatest benefits of music listening (see Figure 2) would be: “being less anxious” (73%), “refocusing my mind on something positive” (55%), and “occupying my time as I wait for surgery” (39%). Figure 2. View largeDownload slide Participants from all four groups agreed that reducing patient anxiety would be the greatest benefit of music listening in a surgical context. Figure 2. View largeDownload slide Participants from all four groups agreed that reducing patient anxiety would be the greatest benefit of music listening in a surgical context. Patient’s chief concerns for music listening were (see Figure 3): “headphone discomfort” (35%), “audio equipment getting in the way” (31%), and “not being able to hear staff” (29%), although the most popular answer was “no concerns” (36%). Figure 3. View largeDownload slide Greatest concerns about music listening during the surgical experience varied between groups. Patients mostly expressed no concern (36%), family was concerned that patients would not hear the staff (32%), and surgeons (44%) and nurses (55%) were mainly concerned that music would disturb other patients. Figure 3. View largeDownload slide Greatest concerns about music listening during the surgical experience varied between groups. Patients mostly expressed no concern (36%), family was concerned that patients would not hear the staff (32%), and surgeons (44%) and nurses (55%) were mainly concerned that music would disturb other patients. Forty-one percent of patients revealed that they sang or played a musical instrument themselves, 91% of surveyed patients felt they could benefit from music listening (see Figure 4), and 88% reported that they would be willing to participate in music listening if it was offered to them as part of surgical care. Figure 4. View largeDownload slide Overall, the majority of participants (93% total) believed music listening to be a beneficial practice. Figure 4. View largeDownload slide Overall, the majority of participants (93% total) believed music listening to be a beneficial practice. Singing or playing a musical instrument was positively correlated to acceptance of music in surgery (P = .01). Using an exact test, an association was found between patient age range and willingness to participate in surgical music (P = .04). Although acceptance of music during the surgical experience was high across all ages, in this study, those aged 45–54 were found to be more willing to participate, while those aged 35–44 and 75+ were less likely to accept music during the surgical experience. Family Members A total of 293 accompanying family members were offered a questionnaire and 251 family members (86%), accepted it, with 248 (99%) returning it after completion. Median age range of family members was 45–54, and more females (73%) than males (27%) volunteered to take the survey. Most participants were Caucasian 76% or Black/African American (20%) (see Table 1). Family members described themselves mostly as spouses (43%), adult children (20%), parents (12%), partners (9%), or siblings (8%). A majority of participants felt anxious as their loved one prepared for surgery (64%) and felt that hearing live music might reduce their own anxiety level (75%). Ninety-nine percent of family members admitted to enjoying music. Most questioned family members reacted favorable to the possibility of the following music-in-surgery experiences being offered to their relative: recorded music listening via headphones before surgery (89%), quiet, live music listening before surgery (82%), and preferred recorded music listening via headphones during surgery (87%) (see Figure 1). When asked how witnessing live music being played for their loved one might affect them personally, over half of surveyed family members (55%) responded, “It would relax me,” while 41% stated, “It would take my mind off things” and 41% responded with “it would offer a comforting presence.” The majority of family members (61%) felt that music listening could be most beneficial for their loved one in the period just before surgery. Family members believed that the greatest benefits to music listening during the surgical experience would be (see Figure 2): “decreased patient anxiety” (76%), “refocusing the patient’s mind on something positive” (66%), and “occupying the patient’s time as he/she waits for surgery” (37%). Biggest concerns were: “patient not hearing staff” (32%), “audio equipment getting in the way” (24%), “preoperative music disturbing other patients (22%), and “headphone discomfort” (22%). A substantial group of family members (28%) voiced that they had “no concerns” (see Figure 3). When asked what they would think about a facility that offered music listening to their loved one, family members revealed that it would make them view the institution as: one that “offers unique services” (69%), “cares about patients” (67%), and/or “a top facility” (35%). A majority of family members admitted that they would be happy to have their family member experience music (93%), believed the patient could benefit from music listening (94%) (see Figure 4), and agreed that they would be more likely to recommend a surgery center that offered music services (76%). Surgeons A total of 288 surgeons were sent an electronic questionnaire, and 93 (32%) took the survey. Using an exact test and chi-squared test when applicable, we found that our surgeon sample was representative of the population in terms of gender (P = .8), but not age (P = .02). The majority of surgeons completed the survey online (n = 71, 76%), while the remainder (n = 22, 24%) completed a paper questionnaire. Median age range was 55–64. More men than women took the survey (67% vs. 33%), and participant race was largely Caucasian (81%) and Asian (13%) (see Table 1). Surveyed surgeons specialized in a wide array of surgeries, the most common being orthopedic (23%), obstetrics (15%), and otolaryngology (9%). Almost all surgeons (98%) reported enjoying music listening, with 35% singing or playing a musical instrument themselves. Most surgeons (84%) revealed that they listened to music while performing surgery “always” (36%), “often” (27%), or “sometimes” (21%). Ninety-eight percent of questioned surgeons believed their patients could benefit from music listening (see Figure 4), with the three greatest reasons being (see Figure 2) “decreased patient anxiety” (87%), “raised patient satisfaction” (46%), and “refocusing the patient’s mind to a positive stimulus (40%).” They believe music listening could be most beneficial preoperatively (77%). Surgeons were receptive of music practices, stating that they would specifically welcome preoperative recorded music listening via headphones (87%), preoperative live music listening (68%), and/or intraoperative music listening via headphones (73%) (see Figure 1). Biggest concerns with perioperative music were “preoperative music disturbing other patients” (44%), “patient not hearing staff” (37%), and “music listening delaying surgery schedule” (29%) (see Figure 3). When asked if they would be willing to collaborate in making music listening a usual part of surgical care, 76% of surgeons answered affirmatively. Surgeon age (P = .90) and gender (P = .22) were not associated with willingness to collaborate, as was evaluated through exact and chi-squared tests, respectively. Nurses Thirty-nine of the 43 nurses invited to take the survey completed it (91%). Twenty-one surveys (53%) were taken electronically, while 18 nurses (47%) filled out paper documents. Median age range was 55–64. More woman than men completed the survey (85% vs. 15%). Nurse participant race was mostly relayed as Caucasian (90%) and Black (8%) (see Table 1). One hundred percent of surveyed nurses enjoy music, and 80% would like to hear it in their work environment. Forty percent of nurses sing or play a musical instrument. Ninety-seven percent feel their patients could benefit from music listening (see Figure 4) and that it could have the greatest benefit in PACU (53%), then preoperative care (40%). The majority of surveyed perianesthesia nursing staff would welcome recorded preoperative music listening via headphones (87%), quiet live music listening in preop (56%), and intraoperative recorded music listening via headphones (95%) (see Figure 1). There was no interaction between nurses’ age and acceptance of live music (P = .3). Greatest perceived benefits of music listening by perioperative nursing staff were “decreased patient anxiety” (68%), “refocusing the patient’s mind on a positive stimulus” (47%), and “raised patient satisfaction” (42%) (see Figure 2). Biggest concerns were “preoperative music disturbing other patients” (55%), “ward becoming overcrowded” (42%), and “patient not hearing staff” (40%) (see Figure 3). Seventy-four percent of questioned perioperative nurses would be willing to collaborate in creating a surgical music program. Using exact tests, it was found that neither age (P = .38) nor gender (P = .10) was associated with perioperative nursing staff’s willingness to collaborate in making music practices a usual part of surgical care. Genre Preferences Participants were questioned about their preferred music genres, both generally and in a surgical context. Generally, patients claimed to prefer popular (21%), country (17%), and rock (15%) music genres. Surgeons mostly enjoyed popular (35%), rock (32%), and classical (9%) genres (see Figure 5). Nurses showed preference for country (26%), popular (23%), and rock (23%) music. Other genres written in by participants as favorites were: alternative, bluegrass, folk, hiphop, musicals, Motown, and oldies. Figure 5. View largeDownload slide What is your most preferred style of music to listen to? Figure 5. View largeDownload slide What is your most preferred style of music to listen to? Intraoperatively, patients expressed a preference for popular (14%), classical (12%), or gospel (11%) music, yet most claimed it wouldn’t matter because they’d be asleep (32%). Surveyed surgeons mostly prefer listening to rock (39%), popular (36%), and classical (14%) genres while preforming surgery. Nurses expressed a preference for classical (48%), popular (19%), or country (13%) music (see Figure 6) in their work environment. Other genres mentioned by participants as most preferred during surgery were: Celtic, Christian, folk, and oldies. Figure 6. View largeDownload slide What would be your most preferred style of music to be played during surgery? Figure 6. View largeDownload slide What would be your most preferred style of music to be played during surgery? Discussion To the best of the investigators’ knowledge, this is the first study to examine and compare preferences, perceptions, and concerns regarding music and music therapy in surgical contexts by the four populations affected by its practice. We found that the vast majority of surveyed surgeons, nurses, patients, and family members were supportive of music in the perioperative arena and regarded music listening in surgery as a beneficial practice, supporting both live and recorded perioperative music engagement. Music listening appears to be a welcome addition for practitioners and patrons alike. Eighty-four percent of surgeons choose to listen to music in the operating room, and 50% of patients similarly found merit in listening to music much more than any other pre-surgical activity. These findings support earlier studies, which suggest that both surgeons and patients have a preference for music listening during the surgical experience (Hyde, Bryden, & Asbury, 1998; Ullmann et al., 2008). The popularity and affinity for music listening across the spectrum may relate to the desired and varied effects it may promote (Bosanquet, Glasbey, & Chavez, 2014). For patients, preferred music listening may not only lessen anxiety, but also introduce comfort, normalization, and familiarity during a time of uncertainty (Thorgaard, Ertmann, Hansen, Noerregaard, & Spanggaard, 2005). In this study, researchers found that the desire to include music in surgery may be significantly heightened if the patient has some musical skill, training, or ability. This aligns with related research suggesting that those with musical experience are more likely to be impacted by music (Pelletier, 2004). Additionally, patient age significantly affects one’s willingness to participate (P = .04), with middle-aged patients, aged 45–54, most accepting of music in surgical contexts. Importantly, over half of surveyed family members believed that witnessing live music with their loved one during the surgery process would help relax them personally. This reflects the findings of past research, which found music therapy to improve family satisfaction (Gooding, Yinger, & Iocono, 2015), mood, and communication (Gallagher, Lagman, Walsh, Davis, & LeGrand, 2006). Having a less anxious visitor may allow guests to be more manageable for staff and calmer for the patients who need their support. Because patient and family satisfaction ratings can be components of the progressively important focus of quality care (Hartog & Jensen, 2013), offering an enjoyable, beneficial, and welcome complementary medicine modality such as music therapy may help surgery units prioritize satisfaction and, thus, improve quality care. Surgeons, on the other hand, may choose music listening for themselves to promote motivation, alertness, and focus in addition to offering a joint music listening experience to fortify team spirit and create camaraderie among staff (Özalp, 2016). While nurses were also generally supportive of recorded perioperative music listening, only 56% of surveyed nurses welcomed quiet live music listening for patients preoperatively and, unlike the other populations, largely believed music to be most beneficial after surgery. This contrast may be due to the implication that live preoperative music listening would impact a perioperative nurse’s standard routine and environment (Palmer, Lane, & Mayo, 2016) more than the other groups questioned. Genre Preferences When asked about favorite music genres, patients, surgeons, and nurses differed in music preferences, both generally and perioperatively, overall expressing a wide range of partialities. While popular music was the most preferred music genre by patients, both in and out of surgical contexts, participants also favorited country and rock music in general, while conversely expressing a preference for classical and gospel music intraoperatively. During a randomized trial, mechanically ventilated patients also selected a wide range of music preferences when choosing self-directed music (Heiderscheit, Breckenridge, Chlan, & Savik, 2014), thus corroborating our findings that patients have distinct and differing preferences when empowered to select their own music for listening during a stressful medical circumstance. Recommendations for Music Therapists While this study reinforced the lack of clarity surrounding music listening interventions and music therapy, it also provided information that music therapists may find helpful in their practice, particularly those concerned with approaching, assuring, and working with patients and staff in the surgical arena. In approaching potential clients, music therapists may wish to begin by explaining exactly what music therapy is, followed by its differential benefits. Next, music therapists can inquire if the patient has ever sung or played an instrument, since there is a greater chance of buy-in for those who are musical themselves. For those who are not musical, therapists can reassure patients that experience isn’t necessary. Music therapists may also wish to address possible concerns by reassuring the patient that participation will not have negative consequences such as being bothersome to others or impeding the patient’s ability to hear surgeon or nurse instruction. By approaching patients in this fashion, patients may better understand the nature of participating in a session. Music therapists may be referred to pediatric surgical patients as well as those adult patients living with dementia, developmental disability, psychological diagnosis, or pain. In this survey, patients believed anxiety reduction might be the greatest benefit of music therapy. Because surgery and anesthesia may be anxiety provoking (Clarke et al., 2013, Mavridou, Dimitriou, Manataki, Arnaoutoglou, & Papadopoulos, 2013), music therapists can offer an intervention to any patient expressing fear before surgery. This can be accessed via a visual analog scale (patients draw a vertical line over a horizontal line to rate severity of anxiety), Likert scale (patient self-rating of 1–10), face representation scales (patient self-rating of distress via face drawing associations), or simply by observing patient behavior and vital signs (e.g., shaking, crying, hypomania, high heart rate, or high blood pressure). Music therapy may also help those who are generally dissatisfied with services. Dissatisfaction may arise from long wait times, and music therapists may be able to help patients manage stressful surgery delays in a way that is supportive of their overall emotional state. Nurses and physicians can refer patients to music therapy services on surgery day or in advance, if possible. Music therapists may also assess patients waiting in the preoperative stage to ascertain who is appropriate for music therapy intervention. This study also found that patients were accepting of music, both live and recorded, in all stages of surgery. The scope of practice for music therapists in the surgical arena includes using both modes of live and recorded music listening to reduce anxiety, allow verbal expression, manage pain, and provide support to patients and their families. As suggested by patients in this survey, music therapists can likely be most beneficial prior to surgery, by providing preferred live music to patients, as an intervention of just one preferred song was found to reduce preoperative anxiety by 42% (Palmer, Lane, Mayo, Schluchter, & Leeming, 2015). Yet, for those patients preferring audio recordings, music therapists may still help patients by assisting them in organizing personalized playlists, choosing appropriate genres, processing any potential emotions that may arise from the music listening, and offering a comforting presence to manage their feelings before, during, and after surgery. Music therapists may also positively alter a patient’s sound environment intraoperatively when his or her preferences differ from that being played by staff in the operating room, especially during monitored anesthesia care (where patients often remain awake). With such a wide range of preferred genres, the employment of a music therapist may help make the surgery experience more pleasant, helping patients navigate toward the most appropriate aural experience for the situation. For those patients not wanting to make music decisions, music therapists may offer headphones and MP3 players programmed with music and genres specifically chosen by the therapist for surgery. Therapist-selected music can also be therapeutic (Pelletier, 2004), chosen with regard to evidence-based parameters such as steady tempos and consistent dynamics (Gooding, Swezey, & Zwischenberger, 2012). The addition of music therapist–guided recorded music listening may also benefit a patient intraoperatively and during postoperative recovery. The benefit of a board-certified music therapist is his/her ability to discern and choose from a variety of interventions that create an experience unique to each client and his/her situation. The aforementioned points are possible needs that music therapists are trained to handle and that music listening alone does not encompass. Music medicine interventions, typically facilitated by nurses, often consists of only the addition of audio equipment with surgery, and not interaction with a music therapist who can adapt, tailor, discuss, and process music interventions based on the varied needs of the patient. While music listening without the presence of a music therapist may also prove beneficial, music therapy, which always involves a relationship between a trained music therapist and patient, allows for interventions to meet the ever-changing needs of a patient and the surgery environment. While only 7% of patients admitted that live music listening would be most beneficial to them before surgery (over television, reading, talking, silence, or recorded music), 88% of patients reported that they would indeed accept music during the surgical experience and 71% would welcome live music listening specifically if it were offered to them preoperatively. Though mostly accepted, the lack of priority associated with live music in this survey may be due to the fact that survey respondents may associate live music listening with past experiences such as choir concerts, rock shows, marching bands, and other performance-based music-making, and not the therapeutic potential contained with a live music therapy experience. Without prior involvement with music therapy, survey participants may not be able to distinguish it from other kinds of live music they may have encountered. Appropriate education and experience with music therapy may increase acceptance of live music practices in surgery. While participants embraced music and the term “music therapy” during this study, they may not have understood exactly what music therapy is when completing the survey. Because of this, one of the key outcomes researchers found in this study was the need for advocacy. Since many may not understand or differentiate music therapy apart from music listening, surgical patients and their families would benefit from learning about music therapy prior to their operations. Letters or phone calls to patients prior to surgery could help introduce music therapy services. In a recent study conducted by Palmer, Lane, Mayo, Schluchter, & Leeming (2015), music therapists called patients to offer and explain music therapy a few days prior to surgery. With proper education and personalization, 94% of patients accepted the addition of music therapy to their surgery experience. When music therapists are not able to call patients prior to surgery, flyers may be handed out to patients during their pre-surgery doctor’s appointment or additional verbiage may be included during the patient-scheduling phone call to help educate patients about music therapy services. All survey groups indicated support for the concept of music listening during the surgery experience; however, each group identified specific concerns with perioperative music. While “no concern” was the most frequent answer given from patients in regard to surgical music, the three items most worrisome to this group all concerned audio equipment. The greatest concern voiced by both surgeons and family groups was the possibility of muting staff instruction. Additionally, nurses largely feared that music may disturb neighboring surgical patients while also expressing concerns about patient headphone discomfort. Music therapy may solve these chief concerns, since board-certified music therapists are trained to consider all aspects of a changing medical setting in order to discern and adapt interventions to the individual and environment. Live preoperative music therapy, for example, avoids the possibility of headphone discomfort or audio equipment obstruction, and also allows for intelligent volume management that ensures that patients can hear staff instruction and are respectful of neighboring patrons, ultimately addressing all major concerns voiced by the four parties. A music therapist can also work to provide emotional support and anxiety reduction to patients while simultaneously supporting family members in a manner that is mindful to staff and neighboring patients. To capture medical staff’s attention, music therapists can hold in-services, attend staff meetings, create demonstration projects, and invite nurses and doctors to shadow them on rounds to clarify the role music therapy is taking (and could take) in the surgical arena. In-services for medical staff can include videos, testimonials, examples, and information about how a music therapist can support patients, nurses, and physicians without complicating their unit procedures. Because nurses showed the greatest concern with music in the preoperative setting, music therapists should especially work with nurse allies to determine how the two professions can be utilized without infringing upon standard medical practices and protocols. Limitations This study has several limitations. While the overall response rate was sufficient, the moderate response rate from surgeons may lend itself to non-response bias and threaten the validity of the findings with this particular group in comparison to the others surveyed. Additionally, since patients did not receive a music intervention, questions related only to the possibility of music listening, which may have affected the responses. Finally, many of the survey items were answered within the context of the term “music therapy,” but there was no way to discern if participants had any understanding of music therapy when answering the questions. Future research, especially across institutions and regions, including larger surgeon response rates, and clearer articulation of music therapy interventions, is needed to clarify these study findings. Conclusion Patients, their family members, surgeons, and perianesthesia nurses are largely supportive of the presence of music during the surgical experience and cognizant of the potential benefits. Those with music ability and experience may be especially receptive. Both live and recorded music listening practices are welcome and viewed as beneficial by all surveyed surgical populations. While apprehension exists in regard to music listening in and around surgery, employment of a music therapist may provide optimum benefit while solving the chief concerns of these study participants. Funding This work was supported by the Kulas Foundation, grant award J0251. Deforia Lane is Associate Director of Seidman Cancer Center and Director of Art and Music Therapy at University Hospitals in Cleveland, Ohio. Jaclyn Bradley Palmer holds a master’s degree in music therapy from Colorado State University and specializes in developing and researching music therapy in surgical contexts. Yanwen Chen is a biostatistician with the Case Comprehensive Cancer Center. Acknowledgments We are extremely grateful to the following contributors: Marsha Vaughn, Diane Mayo, MSN, CRNA, Celeste Brewer-Edwards, George Stamatis, Maryjo Rutkowski, Brooke Beringuel, BSN, RN, Stephan Zyzanski, PhD, Lindsey Rians, Laurie Canala, and Libby Gill, MT-BC. References American Music Therapy Association (AMTA) . 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Injury , 39 ( 5 ), 592 – 597 . doi: 10.1016/j.injury.2006.06.021 Google Scholar CrossRef Search ADS PubMed Wu , S. , Liang , J. , Zhu , X. , Liu , X. , & Miao , D . ( 2011 ). Comparing the treatment effectiveness of body acupuncture and auricular acupuncture in preoperative anxiety treatment . Journal of Research in Medical Sciences , 16 ( 1 ), 39 – 42 . Google Scholar PubMed © American Music Therapy Association 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Music Therapy Perspectives Oxford University Press

A Survey of Surgeon, Nurse, Patient, and Family Perceptions of Music and Music Therapy in Surgical Contexts

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© American Music Therapy Association 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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Abstract

Abstract While recent research suggests that music therapy interventions impact pre-surgical anxiety (Palmer, Lane, Mayo, Schluchter, & Leeming, 2015), staff and patron perceptions of the modality are not well established. A total of 629 surgical patients, surgeons, nurses, and family members were surveyed to identify factors that might affect willingness to participate and to educate practitioners on preferred methods of facilitation. The majority of participants (93%) believed music to be beneficial during the surgical experience. Subjects were welcoming of live preoperative music listening (74%), recorded preoperative music listening (84%), and intraoperative music listening (77%). Eighty-eight percent of patients reported that they would be willing to accept music if it was offered to them as part of surgical care. Fifty percent of patients relayed that they would rather listen to live or recorded music than any other preoperative activity. Music may be a welcome addition to the surgical arena, with all affected parties largely in support of music practices. Employment of a music therapist in the surgical arena may provide optimum benefits, as practitioners can tailor interventions to meet the ever-changing needs of patients. This study further reinforces the importance of educating staff and patients about music therapy and raising awareness about the differential benefits music therapy may offer. Music therapy, surgical procedures, operative Patient anxiety is a significant concern in the surgical arena (Clarke et al., 2013), and patients often feel abandoned as they wait for surgery (Gilmartin & Wright, 2008). While anxiety and comfort may be addressed through drug intervention, preoperative sedatives may delay recovery and increase the potential for adverse reactions (Giacalone, 1992). Therefore, non-pharmacologic techniques continue to be investigated (Au et al., 2015; Cheseaux, de Saint Lager, & Walder, 2014; DeMarco, Alexander, Nehrenz, & Gallagher, 2012; Wu, Liang, Zhu, Liu, & Miao, 2011). Music therapy, the clinical and individualized use of music to address specific goals assessed and facilitated by a trained professional (AMTA, 2016), has increasingly become a more common adjunct in the medical setting. A much less common use of music therapy is that which is practiced in a surgical context. Music therapy in surgical contexts is the evidence-based use of music interventions, facilitated by music therapists, to reduce anxiety, manage pain, reduce anesthesia requirements, and mask adverse sound stimuli during a surgery experience (Palmer et al., 2015). Music therapy in the surgical arena has been found to decrease patient anxiety (Bradt, Dileo, & Shim, 2013) and provide emotional support (Cowen, 1991), both of which may help combat feelings of anxiety and abandonment that are so prevalent in preoperative care. While time for complimentary modalities may be limited before surgery, Palmer, Lane, Mayo, Schluchter, and Leeming (2015) found that a brief, five-minute music therapy intervention, consisting of one therapist-facilitated preferred song (live or recorded), significantly reduced anxiety in women preparing for breast cancer surgery. Music therapy may also have a positive effect on a patient’s family members, improving satisfaction (Gooding, Yinger, & Iocono, 2015) as well as mood and verbalizations during this stressful time (Gallagher, Lagman, Walsh, Davis, & LeGrand, 2006). While music therapy in surgical contexts is rare, general perioperative music listening, without the presence of a board-certified music therapist, is practiced and studied more frequently. Anxiolytic uses of the phonograph during surgery were documented as early as 1914 (Moris & Linos, 2012). Continuing through the present day, surgical arenas have offered music-listening opportunities to patients (Cunningham, Monson, & Bookbinder, 1997; Trängeberg & Stomberg, 2013). Such practices, however, are mostly considered “music medicine” and not music therapy because they are usually facilitated by non-music therapy staff (Palmer, Lane, & Mayo, 2015), and surgical music programs tend to be general and not designed to meet the specific and changing needs of the individual patient and situation. The benefits of music medicine in surgery, however, are well documented. General music listening may reduce patient pain (Özer, Karaman Özlü, Arslan, & Günes, 2013), mask unpleasant sounds (Sener, Koylu, Ustun, Kocamanoglu, & Ozkan, 2010), improve satisfaction (Ilkkaya et al., 2014) and decrease anesthesia requirements (Bringman, Giesecke, Thörne, & Bringman, 2009). An early survey found that music listening was the most preferred pre-surgical waiting activity (Hyde, Bryden, & Asbury, 1998). Surgical staff may also be affected by music in surgical units. Sixty-three percent of surgeons claim to listen to music routinely in the operating room (Ullmann, Fodor, Schwarzberg, Carmi, Ullmann, & Ramon, 2008), and preferred music listening has been shown to improve surgery speed and quality (Lies & Zhang, 2015). Perioperative staff may enjoy hearing music in their work environment (Thorgaard, Ertmann, Hansen, Noerregaard, Hansen, & Spanggaard, 2005), yet they may also find music distracting and impeding to proper communication (Moris & Linos, 2013). Though evidence exists as to the benefits of music listening, there is limited research on how music in a surgical context is perceived by all affected parties. Implementation strategies for music therapy in surgery specifically, as well as differentiation from music medicine in surgery, are not well established. Understanding the perceived impact on patrons and staff will help investigators understand the next steps music therapists could take in this context, especially by learning where there are gaps that may not be filled by music listening alone. By discovering their unique merit in this area of practice, music therapists may learn how to appropriately present, create, integrate, and promote interventions that best serve all parties. To do so, we began by asking what the perceptions, preferences, and concerns of incorporating music in surgical contexts are to patients, families, surgeons, and perioperative nurses. By doing so, we investigated which factors might affect a patient’s willingness to participate in a music experience during their surgical experience, so that music therapy may integrate more often and successfully in the surgical realm. In conducting this survey, our secondary goals were to provide information that may assist clinicians in learning how to approach patients, families, and staff, and to educate music therapy practitioners about concerns that could be addressed in order to ensure patient, family, and staff buy-in. Methods Participants and Setting From December 15, 2015, to March 15, 2016, 629 subjects (249 surgical patients, 248 family members, 93 surgeons, and 39 perioperative nurses) were surveyed at Mather Surgery Center at University Hospitals Cleveland Medical Center. This study was approved by the University Hospitals Case Medical Center institutional review board, which also gave feedback and approved the questionnaires and study design prior to research commencement. Tools An experimenter-designed questionnaire was used to survey participants. It was tested for clarity and brevity (3–5 min) with board-certified music therapists and patients, who gave feedback prior to implementation. Most questions asked for one response, while some allowed for multiple answers. See Appendix A for survey questions. Procedure Upon arrival for surgery, the medical receptionist distributed paper surveys to all patients and one accompanying family member on one specific day each week for 14 successive weeks. All patient and family surveys were completed in the waiting room. The patients did not receive a music intervention but were surveyed on their perceptions of the possibility of music as an addition to their treatment. Surgeons and nurses were sent electronic surveys via email four times, one being the initial request with three subsequent reminders during the three-month period. Emails included a link to an online questionnaire and details about the study. Online surveys were presented through REDCap, a secure web application used for building, collecting, and managing survey data. Paper surveys were also made available at one nurse meeting on January 20, 2016, and were distributed in the surgeon lounge on February 12, 2016. Analysis In our original survey, we included questions about music use and whether music therapy might be a welcome addition to the surgical arena. In reviewing the responses, we discovered that the term “music therapy” may have been misunderstood by respondents and confused with their experience with general music listening, not music therapy, as questions were intended. Participants may not have understood what music therapy was when answering the survey, leading them to depend on their own understanding of music therapy when answering questions. We therefore approached survey findings with caution, being mindful that participants may not have understood the differences between a music medicine (e.g., nurse-facilitated music listening with headphones) and music therapy intervention (e.g., music therapist–facilitated live preferred song singing). Electronic surveys were analyzed through the survey platform, RedCap, while paper surveys were analyzed using SAS 9.4 and R3.2.2 statistical software. Once results were gathered, percentages were calculated. After finding suggested correlations from survey percentages, data regarding age, gender, or musicality and acceptance of music therapy, chi squared, and/or Fischer exact tests were calculated to identify associations between the groups. A Fischer exact test is a statistical test used for a contingency table (2x2 table) to test if two specific population distributions are associated or not. This exact test is usually used for small sample size, especially when the number of any of the cells is below 5. Chi-squared tests were run first, and in instances where one cell was less than 5 counts, a Fischer exact test was performed to determine significance. Results Summary of Participant Responses Of the 919 surgeons, perioperative nurses, patients, and family members invited to take the survey, 629 completed questionnaires were submitted, giving the study a 68% response rate. A summary of the baseline characteristics for all participants can be found in Table 1. Table 1 Background Characteristics of Participants Family Patient Surgeon Nurse All participants Age 18–24 3(1.2%) 10(4.1%) 0(0%) 4(10.3%) 17(2.6%) 25–34 19(7.7%) 23(9.3%) 5(5.3%) 10(25.6%) 57(8.7%) 35–44 43(17.3%) 26(10.5%) 30(31.9%) 4(10.3%) 103(15.7%) 45–54 70(28.2%) 44(17.8%) 28(29.8%) 7(18%) 149(22.7%) 55–64 58(23.4%) 54(21.9%) 14(14.9%) 13(33.3%) 139(21.2%) 65–74 44(17.7%) 62(25.1%) 17(18.1%) 1(2.6%) 124(18.9%) 75+ 11(4.4%) 28(11.3%) 0(0%) 0(0%) 39(5.9%) Gender Male 67(27.1%) 119(48.4%) 63(67%) 6(15.4%) 255(40.7%) Female 180(72.9%) 127(51.6%) 31(33%) 33(84.6%) 371(59.3%) Race Asian 3(1.2%) 2(0.8%) 12(12.8%) 0(0%) 17(2.7%) Black or African American 49(20.2%) 51(20.9%) 1(1.1%) 3(7.9%) 104(16.8%) White 184(75.7%) 184(75.4%) 76(80.9%) 34(89.5%) 478(77.2%) Other 7(2.9%) 7(2.9%) 5(5.3%) 1(2.6%) 20(3.2%) Family Patient Surgeon Nurse All participants Age 18–24 3(1.2%) 10(4.1%) 0(0%) 4(10.3%) 17(2.6%) 25–34 19(7.7%) 23(9.3%) 5(5.3%) 10(25.6%) 57(8.7%) 35–44 43(17.3%) 26(10.5%) 30(31.9%) 4(10.3%) 103(15.7%) 45–54 70(28.2%) 44(17.8%) 28(29.8%) 7(18%) 149(22.7%) 55–64 58(23.4%) 54(21.9%) 14(14.9%) 13(33.3%) 139(21.2%) 65–74 44(17.7%) 62(25.1%) 17(18.1%) 1(2.6%) 124(18.9%) 75+ 11(4.4%) 28(11.3%) 0(0%) 0(0%) 39(5.9%) Gender Male 67(27.1%) 119(48.4%) 63(67%) 6(15.4%) 255(40.7%) Female 180(72.9%) 127(51.6%) 31(33%) 33(84.6%) 371(59.3%) Race Asian 3(1.2%) 2(0.8%) 12(12.8%) 0(0%) 17(2.7%) Black or African American 49(20.2%) 51(20.9%) 1(1.1%) 3(7.9%) 104(16.8%) White 184(75.7%) 184(75.4%) 76(80.9%) 34(89.5%) 478(77.2%) Other 7(2.9%) 7(2.9%) 5(5.3%) 1(2.6%) 20(3.2%) View Large Table 1 Background Characteristics of Participants Family Patient Surgeon Nurse All participants Age 18–24 3(1.2%) 10(4.1%) 0(0%) 4(10.3%) 17(2.6%) 25–34 19(7.7%) 23(9.3%) 5(5.3%) 10(25.6%) 57(8.7%) 35–44 43(17.3%) 26(10.5%) 30(31.9%) 4(10.3%) 103(15.7%) 45–54 70(28.2%) 44(17.8%) 28(29.8%) 7(18%) 149(22.7%) 55–64 58(23.4%) 54(21.9%) 14(14.9%) 13(33.3%) 139(21.2%) 65–74 44(17.7%) 62(25.1%) 17(18.1%) 1(2.6%) 124(18.9%) 75+ 11(4.4%) 28(11.3%) 0(0%) 0(0%) 39(5.9%) Gender Male 67(27.1%) 119(48.4%) 63(67%) 6(15.4%) 255(40.7%) Female 180(72.9%) 127(51.6%) 31(33%) 33(84.6%) 371(59.3%) Race Asian 3(1.2%) 2(0.8%) 12(12.8%) 0(0%) 17(2.7%) Black or African American 49(20.2%) 51(20.9%) 1(1.1%) 3(7.9%) 104(16.8%) White 184(75.7%) 184(75.4%) 76(80.9%) 34(89.5%) 478(77.2%) Other 7(2.9%) 7(2.9%) 5(5.3%) 1(2.6%) 20(3.2%) Family Patient Surgeon Nurse All participants Age 18–24 3(1.2%) 10(4.1%) 0(0%) 4(10.3%) 17(2.6%) 25–34 19(7.7%) 23(9.3%) 5(5.3%) 10(25.6%) 57(8.7%) 35–44 43(17.3%) 26(10.5%) 30(31.9%) 4(10.3%) 103(15.7%) 45–54 70(28.2%) 44(17.8%) 28(29.8%) 7(18%) 149(22.7%) 55–64 58(23.4%) 54(21.9%) 14(14.9%) 13(33.3%) 139(21.2%) 65–74 44(17.7%) 62(25.1%) 17(18.1%) 1(2.6%) 124(18.9%) 75+ 11(4.4%) 28(11.3%) 0(0%) 0(0%) 39(5.9%) Gender Male 67(27.1%) 119(48.4%) 63(67%) 6(15.4%) 255(40.7%) Female 180(72.9%) 127(51.6%) 31(33%) 33(84.6%) 371(59.3%) Race Asian 3(1.2%) 2(0.8%) 12(12.8%) 0(0%) 17(2.7%) Black or African American 49(20.2%) 51(20.9%) 1(1.1%) 3(7.9%) 104(16.8%) White 184(75.7%) 184(75.4%) 76(80.9%) 34(89.5%) 478(77.2%) Other 7(2.9%) 7(2.9%) 5(5.3%) 1(2.6%) 20(3.2%) View Large The majority of participants (93%) believed listening to music would be a beneficial practice during the surgical experience. Overall, subjects were welcoming of live preoperative music listening (74%), recorded preoperative music listening (84%), and intraoperative music listening (77%). All four groups felt that anxiety reduction would be the greatest benefit of surgical music (76%), while top concerns with surgical music varied between groups. A summary of each participant group follows. Patients Of the 295 patients invited to participate, 251 (85%) accepted the survey and 249 (99%) of the distributed surveys were returned. Median age range was 55 to 64 years. A similar percentage of females (52%) and males (48%) took the survey. Most participants were of Caucasian (75%) or Black/African American (21%) race (see Table 1). Patients were facing many types of surgical procedures, the most common being orthopedic (35%), neurological (16%), and thoracic (10%) surgeries. Ninety-nine percent of patients claimed to enjoy music, and half of surveyed patients (50%) expressed that they would benefit from listening to music more than any other preoperative waiting activity. Specifically, 43% of patients believed that they could most benefit from recorded music listening while only 7% claimed live music listening would be most valuable. Other preferences included watching television (11%), listening to relaxation recordings (9%), talking (8%), sitting in silence (6%), reading (6%), and a combination of the listed activities (9%). Most patients reported feeling anxious (71%) and believed that hearing music might reduce their current anxiety level (86%). In considering music listening before, during, and after surgery, patients felt that it would be most beneficial in the period just before surgery (48%), followed by the period just after surgery (24%) and during surgery (15%). In the preoperative stage, the majority of patients expressed that they would enjoy listening to preferred recorded music through headphones (76%) and/or quiet live music listening (71%). Sixty-four percent of patients believed they would enjoy preferred music listening via headphones during surgery (see Figure 1). Figure 1. View largeDownload slide Overall, participants were mostly welcoming of intraoperative music listening (77%), recorded preoperative music listening (84%), and quiet, live preoperative music listening (74%). Figure 1. View largeDownload slide Overall, participants were mostly welcoming of intraoperative music listening (77%), recorded preoperative music listening (84%), and quiet, live preoperative music listening (74%). Patients believed the greatest benefits of music listening (see Figure 2) would be: “being less anxious” (73%), “refocusing my mind on something positive” (55%), and “occupying my time as I wait for surgery” (39%). Figure 2. View largeDownload slide Participants from all four groups agreed that reducing patient anxiety would be the greatest benefit of music listening in a surgical context. Figure 2. View largeDownload slide Participants from all four groups agreed that reducing patient anxiety would be the greatest benefit of music listening in a surgical context. Patient’s chief concerns for music listening were (see Figure 3): “headphone discomfort” (35%), “audio equipment getting in the way” (31%), and “not being able to hear staff” (29%), although the most popular answer was “no concerns” (36%). Figure 3. View largeDownload slide Greatest concerns about music listening during the surgical experience varied between groups. Patients mostly expressed no concern (36%), family was concerned that patients would not hear the staff (32%), and surgeons (44%) and nurses (55%) were mainly concerned that music would disturb other patients. Figure 3. View largeDownload slide Greatest concerns about music listening during the surgical experience varied between groups. Patients mostly expressed no concern (36%), family was concerned that patients would not hear the staff (32%), and surgeons (44%) and nurses (55%) were mainly concerned that music would disturb other patients. Forty-one percent of patients revealed that they sang or played a musical instrument themselves, 91% of surveyed patients felt they could benefit from music listening (see Figure 4), and 88% reported that they would be willing to participate in music listening if it was offered to them as part of surgical care. Figure 4. View largeDownload slide Overall, the majority of participants (93% total) believed music listening to be a beneficial practice. Figure 4. View largeDownload slide Overall, the majority of participants (93% total) believed music listening to be a beneficial practice. Singing or playing a musical instrument was positively correlated to acceptance of music in surgery (P = .01). Using an exact test, an association was found between patient age range and willingness to participate in surgical music (P = .04). Although acceptance of music during the surgical experience was high across all ages, in this study, those aged 45–54 were found to be more willing to participate, while those aged 35–44 and 75+ were less likely to accept music during the surgical experience. Family Members A total of 293 accompanying family members were offered a questionnaire and 251 family members (86%), accepted it, with 248 (99%) returning it after completion. Median age range of family members was 45–54, and more females (73%) than males (27%) volunteered to take the survey. Most participants were Caucasian 76% or Black/African American (20%) (see Table 1). Family members described themselves mostly as spouses (43%), adult children (20%), parents (12%), partners (9%), or siblings (8%). A majority of participants felt anxious as their loved one prepared for surgery (64%) and felt that hearing live music might reduce their own anxiety level (75%). Ninety-nine percent of family members admitted to enjoying music. Most questioned family members reacted favorable to the possibility of the following music-in-surgery experiences being offered to their relative: recorded music listening via headphones before surgery (89%), quiet, live music listening before surgery (82%), and preferred recorded music listening via headphones during surgery (87%) (see Figure 1). When asked how witnessing live music being played for their loved one might affect them personally, over half of surveyed family members (55%) responded, “It would relax me,” while 41% stated, “It would take my mind off things” and 41% responded with “it would offer a comforting presence.” The majority of family members (61%) felt that music listening could be most beneficial for their loved one in the period just before surgery. Family members believed that the greatest benefits to music listening during the surgical experience would be (see Figure 2): “decreased patient anxiety” (76%), “refocusing the patient’s mind on something positive” (66%), and “occupying the patient’s time as he/she waits for surgery” (37%). Biggest concerns were: “patient not hearing staff” (32%), “audio equipment getting in the way” (24%), “preoperative music disturbing other patients (22%), and “headphone discomfort” (22%). A substantial group of family members (28%) voiced that they had “no concerns” (see Figure 3). When asked what they would think about a facility that offered music listening to their loved one, family members revealed that it would make them view the institution as: one that “offers unique services” (69%), “cares about patients” (67%), and/or “a top facility” (35%). A majority of family members admitted that they would be happy to have their family member experience music (93%), believed the patient could benefit from music listening (94%) (see Figure 4), and agreed that they would be more likely to recommend a surgery center that offered music services (76%). Surgeons A total of 288 surgeons were sent an electronic questionnaire, and 93 (32%) took the survey. Using an exact test and chi-squared test when applicable, we found that our surgeon sample was representative of the population in terms of gender (P = .8), but not age (P = .02). The majority of surgeons completed the survey online (n = 71, 76%), while the remainder (n = 22, 24%) completed a paper questionnaire. Median age range was 55–64. More men than women took the survey (67% vs. 33%), and participant race was largely Caucasian (81%) and Asian (13%) (see Table 1). Surveyed surgeons specialized in a wide array of surgeries, the most common being orthopedic (23%), obstetrics (15%), and otolaryngology (9%). Almost all surgeons (98%) reported enjoying music listening, with 35% singing or playing a musical instrument themselves. Most surgeons (84%) revealed that they listened to music while performing surgery “always” (36%), “often” (27%), or “sometimes” (21%). Ninety-eight percent of questioned surgeons believed their patients could benefit from music listening (see Figure 4), with the three greatest reasons being (see Figure 2) “decreased patient anxiety” (87%), “raised patient satisfaction” (46%), and “refocusing the patient’s mind to a positive stimulus (40%).” They believe music listening could be most beneficial preoperatively (77%). Surgeons were receptive of music practices, stating that they would specifically welcome preoperative recorded music listening via headphones (87%), preoperative live music listening (68%), and/or intraoperative music listening via headphones (73%) (see Figure 1). Biggest concerns with perioperative music were “preoperative music disturbing other patients” (44%), “patient not hearing staff” (37%), and “music listening delaying surgery schedule” (29%) (see Figure 3). When asked if they would be willing to collaborate in making music listening a usual part of surgical care, 76% of surgeons answered affirmatively. Surgeon age (P = .90) and gender (P = .22) were not associated with willingness to collaborate, as was evaluated through exact and chi-squared tests, respectively. Nurses Thirty-nine of the 43 nurses invited to take the survey completed it (91%). Twenty-one surveys (53%) were taken electronically, while 18 nurses (47%) filled out paper documents. Median age range was 55–64. More woman than men completed the survey (85% vs. 15%). Nurse participant race was mostly relayed as Caucasian (90%) and Black (8%) (see Table 1). One hundred percent of surveyed nurses enjoy music, and 80% would like to hear it in their work environment. Forty percent of nurses sing or play a musical instrument. Ninety-seven percent feel their patients could benefit from music listening (see Figure 4) and that it could have the greatest benefit in PACU (53%), then preoperative care (40%). The majority of surveyed perianesthesia nursing staff would welcome recorded preoperative music listening via headphones (87%), quiet live music listening in preop (56%), and intraoperative recorded music listening via headphones (95%) (see Figure 1). There was no interaction between nurses’ age and acceptance of live music (P = .3). Greatest perceived benefits of music listening by perioperative nursing staff were “decreased patient anxiety” (68%), “refocusing the patient’s mind on a positive stimulus” (47%), and “raised patient satisfaction” (42%) (see Figure 2). Biggest concerns were “preoperative music disturbing other patients” (55%), “ward becoming overcrowded” (42%), and “patient not hearing staff” (40%) (see Figure 3). Seventy-four percent of questioned perioperative nurses would be willing to collaborate in creating a surgical music program. Using exact tests, it was found that neither age (P = .38) nor gender (P = .10) was associated with perioperative nursing staff’s willingness to collaborate in making music practices a usual part of surgical care. Genre Preferences Participants were questioned about their preferred music genres, both generally and in a surgical context. Generally, patients claimed to prefer popular (21%), country (17%), and rock (15%) music genres. Surgeons mostly enjoyed popular (35%), rock (32%), and classical (9%) genres (see Figure 5). Nurses showed preference for country (26%), popular (23%), and rock (23%) music. Other genres written in by participants as favorites were: alternative, bluegrass, folk, hiphop, musicals, Motown, and oldies. Figure 5. View largeDownload slide What is your most preferred style of music to listen to? Figure 5. View largeDownload slide What is your most preferred style of music to listen to? Intraoperatively, patients expressed a preference for popular (14%), classical (12%), or gospel (11%) music, yet most claimed it wouldn’t matter because they’d be asleep (32%). Surveyed surgeons mostly prefer listening to rock (39%), popular (36%), and classical (14%) genres while preforming surgery. Nurses expressed a preference for classical (48%), popular (19%), or country (13%) music (see Figure 6) in their work environment. Other genres mentioned by participants as most preferred during surgery were: Celtic, Christian, folk, and oldies. Figure 6. View largeDownload slide What would be your most preferred style of music to be played during surgery? Figure 6. View largeDownload slide What would be your most preferred style of music to be played during surgery? Discussion To the best of the investigators’ knowledge, this is the first study to examine and compare preferences, perceptions, and concerns regarding music and music therapy in surgical contexts by the four populations affected by its practice. We found that the vast majority of surveyed surgeons, nurses, patients, and family members were supportive of music in the perioperative arena and regarded music listening in surgery as a beneficial practice, supporting both live and recorded perioperative music engagement. Music listening appears to be a welcome addition for practitioners and patrons alike. Eighty-four percent of surgeons choose to listen to music in the operating room, and 50% of patients similarly found merit in listening to music much more than any other pre-surgical activity. These findings support earlier studies, which suggest that both surgeons and patients have a preference for music listening during the surgical experience (Hyde, Bryden, & Asbury, 1998; Ullmann et al., 2008). The popularity and affinity for music listening across the spectrum may relate to the desired and varied effects it may promote (Bosanquet, Glasbey, & Chavez, 2014). For patients, preferred music listening may not only lessen anxiety, but also introduce comfort, normalization, and familiarity during a time of uncertainty (Thorgaard, Ertmann, Hansen, Noerregaard, & Spanggaard, 2005). In this study, researchers found that the desire to include music in surgery may be significantly heightened if the patient has some musical skill, training, or ability. This aligns with related research suggesting that those with musical experience are more likely to be impacted by music (Pelletier, 2004). Additionally, patient age significantly affects one’s willingness to participate (P = .04), with middle-aged patients, aged 45–54, most accepting of music in surgical contexts. Importantly, over half of surveyed family members believed that witnessing live music with their loved one during the surgery process would help relax them personally. This reflects the findings of past research, which found music therapy to improve family satisfaction (Gooding, Yinger, & Iocono, 2015), mood, and communication (Gallagher, Lagman, Walsh, Davis, & LeGrand, 2006). Having a less anxious visitor may allow guests to be more manageable for staff and calmer for the patients who need their support. Because patient and family satisfaction ratings can be components of the progressively important focus of quality care (Hartog & Jensen, 2013), offering an enjoyable, beneficial, and welcome complementary medicine modality such as music therapy may help surgery units prioritize satisfaction and, thus, improve quality care. Surgeons, on the other hand, may choose music listening for themselves to promote motivation, alertness, and focus in addition to offering a joint music listening experience to fortify team spirit and create camaraderie among staff (Özalp, 2016). While nurses were also generally supportive of recorded perioperative music listening, only 56% of surveyed nurses welcomed quiet live music listening for patients preoperatively and, unlike the other populations, largely believed music to be most beneficial after surgery. This contrast may be due to the implication that live preoperative music listening would impact a perioperative nurse’s standard routine and environment (Palmer, Lane, & Mayo, 2016) more than the other groups questioned. Genre Preferences When asked about favorite music genres, patients, surgeons, and nurses differed in music preferences, both generally and perioperatively, overall expressing a wide range of partialities. While popular music was the most preferred music genre by patients, both in and out of surgical contexts, participants also favorited country and rock music in general, while conversely expressing a preference for classical and gospel music intraoperatively. During a randomized trial, mechanically ventilated patients also selected a wide range of music preferences when choosing self-directed music (Heiderscheit, Breckenridge, Chlan, & Savik, 2014), thus corroborating our findings that patients have distinct and differing preferences when empowered to select their own music for listening during a stressful medical circumstance. Recommendations for Music Therapists While this study reinforced the lack of clarity surrounding music listening interventions and music therapy, it also provided information that music therapists may find helpful in their practice, particularly those concerned with approaching, assuring, and working with patients and staff in the surgical arena. In approaching potential clients, music therapists may wish to begin by explaining exactly what music therapy is, followed by its differential benefits. Next, music therapists can inquire if the patient has ever sung or played an instrument, since there is a greater chance of buy-in for those who are musical themselves. For those who are not musical, therapists can reassure patients that experience isn’t necessary. Music therapists may also wish to address possible concerns by reassuring the patient that participation will not have negative consequences such as being bothersome to others or impeding the patient’s ability to hear surgeon or nurse instruction. By approaching patients in this fashion, patients may better understand the nature of participating in a session. Music therapists may be referred to pediatric surgical patients as well as those adult patients living with dementia, developmental disability, psychological diagnosis, or pain. In this survey, patients believed anxiety reduction might be the greatest benefit of music therapy. Because surgery and anesthesia may be anxiety provoking (Clarke et al., 2013, Mavridou, Dimitriou, Manataki, Arnaoutoglou, & Papadopoulos, 2013), music therapists can offer an intervention to any patient expressing fear before surgery. This can be accessed via a visual analog scale (patients draw a vertical line over a horizontal line to rate severity of anxiety), Likert scale (patient self-rating of 1–10), face representation scales (patient self-rating of distress via face drawing associations), or simply by observing patient behavior and vital signs (e.g., shaking, crying, hypomania, high heart rate, or high blood pressure). Music therapy may also help those who are generally dissatisfied with services. Dissatisfaction may arise from long wait times, and music therapists may be able to help patients manage stressful surgery delays in a way that is supportive of their overall emotional state. Nurses and physicians can refer patients to music therapy services on surgery day or in advance, if possible. Music therapists may also assess patients waiting in the preoperative stage to ascertain who is appropriate for music therapy intervention. This study also found that patients were accepting of music, both live and recorded, in all stages of surgery. The scope of practice for music therapists in the surgical arena includes using both modes of live and recorded music listening to reduce anxiety, allow verbal expression, manage pain, and provide support to patients and their families. As suggested by patients in this survey, music therapists can likely be most beneficial prior to surgery, by providing preferred live music to patients, as an intervention of just one preferred song was found to reduce preoperative anxiety by 42% (Palmer, Lane, Mayo, Schluchter, & Leeming, 2015). Yet, for those patients preferring audio recordings, music therapists may still help patients by assisting them in organizing personalized playlists, choosing appropriate genres, processing any potential emotions that may arise from the music listening, and offering a comforting presence to manage their feelings before, during, and after surgery. Music therapists may also positively alter a patient’s sound environment intraoperatively when his or her preferences differ from that being played by staff in the operating room, especially during monitored anesthesia care (where patients often remain awake). With such a wide range of preferred genres, the employment of a music therapist may help make the surgery experience more pleasant, helping patients navigate toward the most appropriate aural experience for the situation. For those patients not wanting to make music decisions, music therapists may offer headphones and MP3 players programmed with music and genres specifically chosen by the therapist for surgery. Therapist-selected music can also be therapeutic (Pelletier, 2004), chosen with regard to evidence-based parameters such as steady tempos and consistent dynamics (Gooding, Swezey, & Zwischenberger, 2012). The addition of music therapist–guided recorded music listening may also benefit a patient intraoperatively and during postoperative recovery. The benefit of a board-certified music therapist is his/her ability to discern and choose from a variety of interventions that create an experience unique to each client and his/her situation. The aforementioned points are possible needs that music therapists are trained to handle and that music listening alone does not encompass. Music medicine interventions, typically facilitated by nurses, often consists of only the addition of audio equipment with surgery, and not interaction with a music therapist who can adapt, tailor, discuss, and process music interventions based on the varied needs of the patient. While music listening without the presence of a music therapist may also prove beneficial, music therapy, which always involves a relationship between a trained music therapist and patient, allows for interventions to meet the ever-changing needs of a patient and the surgery environment. While only 7% of patients admitted that live music listening would be most beneficial to them before surgery (over television, reading, talking, silence, or recorded music), 88% of patients reported that they would indeed accept music during the surgical experience and 71% would welcome live music listening specifically if it were offered to them preoperatively. Though mostly accepted, the lack of priority associated with live music in this survey may be due to the fact that survey respondents may associate live music listening with past experiences such as choir concerts, rock shows, marching bands, and other performance-based music-making, and not the therapeutic potential contained with a live music therapy experience. Without prior involvement with music therapy, survey participants may not be able to distinguish it from other kinds of live music they may have encountered. Appropriate education and experience with music therapy may increase acceptance of live music practices in surgery. While participants embraced music and the term “music therapy” during this study, they may not have understood exactly what music therapy is when completing the survey. Because of this, one of the key outcomes researchers found in this study was the need for advocacy. Since many may not understand or differentiate music therapy apart from music listening, surgical patients and their families would benefit from learning about music therapy prior to their operations. Letters or phone calls to patients prior to surgery could help introduce music therapy services. In a recent study conducted by Palmer, Lane, Mayo, Schluchter, & Leeming (2015), music therapists called patients to offer and explain music therapy a few days prior to surgery. With proper education and personalization, 94% of patients accepted the addition of music therapy to their surgery experience. When music therapists are not able to call patients prior to surgery, flyers may be handed out to patients during their pre-surgery doctor’s appointment or additional verbiage may be included during the patient-scheduling phone call to help educate patients about music therapy services. All survey groups indicated support for the concept of music listening during the surgery experience; however, each group identified specific concerns with perioperative music. While “no concern” was the most frequent answer given from patients in regard to surgical music, the three items most worrisome to this group all concerned audio equipment. The greatest concern voiced by both surgeons and family groups was the possibility of muting staff instruction. Additionally, nurses largely feared that music may disturb neighboring surgical patients while also expressing concerns about patient headphone discomfort. Music therapy may solve these chief concerns, since board-certified music therapists are trained to consider all aspects of a changing medical setting in order to discern and adapt interventions to the individual and environment. Live preoperative music therapy, for example, avoids the possibility of headphone discomfort or audio equipment obstruction, and also allows for intelligent volume management that ensures that patients can hear staff instruction and are respectful of neighboring patrons, ultimately addressing all major concerns voiced by the four parties. A music therapist can also work to provide emotional support and anxiety reduction to patients while simultaneously supporting family members in a manner that is mindful to staff and neighboring patients. To capture medical staff’s attention, music therapists can hold in-services, attend staff meetings, create demonstration projects, and invite nurses and doctors to shadow them on rounds to clarify the role music therapy is taking (and could take) in the surgical arena. In-services for medical staff can include videos, testimonials, examples, and information about how a music therapist can support patients, nurses, and physicians without complicating their unit procedures. Because nurses showed the greatest concern with music in the preoperative setting, music therapists should especially work with nurse allies to determine how the two professions can be utilized without infringing upon standard medical practices and protocols. Limitations This study has several limitations. While the overall response rate was sufficient, the moderate response rate from surgeons may lend itself to non-response bias and threaten the validity of the findings with this particular group in comparison to the others surveyed. Additionally, since patients did not receive a music intervention, questions related only to the possibility of music listening, which may have affected the responses. Finally, many of the survey items were answered within the context of the term “music therapy,” but there was no way to discern if participants had any understanding of music therapy when answering the questions. Future research, especially across institutions and regions, including larger surgeon response rates, and clearer articulation of music therapy interventions, is needed to clarify these study findings. Conclusion Patients, their family members, surgeons, and perianesthesia nurses are largely supportive of the presence of music during the surgical experience and cognizant of the potential benefits. Those with music ability and experience may be especially receptive. Both live and recorded music listening practices are welcome and viewed as beneficial by all surveyed surgical populations. While apprehension exists in regard to music listening in and around surgery, employment of a music therapist may provide optimum benefit while solving the chief concerns of these study participants. Funding This work was supported by the Kulas Foundation, grant award J0251. Deforia Lane is Associate Director of Seidman Cancer Center and Director of Art and Music Therapy at University Hospitals in Cleveland, Ohio. Jaclyn Bradley Palmer holds a master’s degree in music therapy from Colorado State University and specializes in developing and researching music therapy in surgical contexts. Yanwen Chen is a biostatistician with the Case Comprehensive Cancer Center. Acknowledgments We are extremely grateful to the following contributors: Marsha Vaughn, Diane Mayo, MSN, CRNA, Celeste Brewer-Edwards, George Stamatis, Maryjo Rutkowski, Brooke Beringuel, BSN, RN, Stephan Zyzanski, PhD, Lindsey Rians, Laurie Canala, and Libby Gill, MT-BC. References American Music Therapy Association (AMTA) . 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Music Therapy PerspectivesOxford University Press

Published: May 15, 2018

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