ORI GI NAL ARTI CLE

Minimising preoperative anxiety with music for day surgery patients a

randomised clinical trial
Cheng-Hua Ni, Wei-Her Tsai, Liang-Ming Lee, Ching-Chiu Kao and Yi-Chung Chen
Aims and objectives. The objective of this study was to evaluate the effects of musical intervention on preoperative anxiety and
vital signs in patients undergoing day surgery.
Background. Studies and systematic meta-analyses have shown inconclusive results of the efcacy of music in reducing pre-
operative anxiety. We designed a study to provide additional evidence for its use in preoperative nursing care.
Design. Randomised, controlled study.
Method. Patients (n = 183) aged 1865 admitted to our outpatient surgery department were randomly assigned to either the
experimental group (music delivered by earphones) or control group (no music) for 20 minutes before surgery. Anxiety,
measured by the State-Trait Anxiety Inventory, and vital signs were measured before and after the experimental protocol.
Results. A total of 172 patients (60 men and 112 women) with a mean age of 4090 (SD 1180) completed the study. The largest
number (357%) was undergoing elective plastic surgery and 767% of the total reported previous experience with surgery. Even
though there was only a low-moderate level of anxiety at the beginning of the study, both groups showed reduced anxiety and
improved vital signs compared with baseline values; however, the intervention group reported signicantly lower anxiety [mean
change: 583 (SD075) vs. 172 (SD 065), p < 0001] on the State-Trait Anxiety Inventory compared with the control group.
Conclusions. Patients undergoing day surgery may benet signicantly from musical intervention to reduce preoperative anxiety
and improve physiological parameters.
Relevance to clinical practice. Finding multimodal approaches to ease discomfort and anxiety from unfamiliar unit surroundings
and perceived risks of morbidity (e.g. disgurement and long-term sequelae) is necessary to reduce preoperative anxiety and
subsequent physiological complications. This is especially true in the day surgery setting, where surgical admission times are often
subject to change and patients may have to accommodate on short notice or too long a wait that may provoke anxiety. Our
results provide additional evidence that musical intervention may be incorporated into routine nursing care for patients undergoing
minor surgery.
Key words: CAM, musical intervention, nurses, nursing, preoperative anxiety, State-Trait Anxiety Inventory, Taiwan
Accepted for publication: 20 July 2010
Introduction
A high level of preoperative anxiety is common among
patients undergoing surgery (Augustin & Hains 1996).
Anxiety over loss of control, unfamiliarity with hospital or
unit settings and perceived morbidity and mortality contrib-
ute to increased intra-operative anaesthetic requirements and
postoperative complications (Maraneta & Kain 1999, Kain
Authors: Cheng-Hua Ni, MSc, Instructor, School of Nursing, College of
Nursing, Taipei Medical University and Head Nurse of Operating
Room, Department of Nursing, Taipei Medical University, Wan Fang
Hospital; Wei-Her Tsai, PhD, Assistant Professor, Department of Health
Care Management, National Taipei University and Health Science;
Liang-Ming Lee, MD, Assistant Professor and Chief of Urology
Department, School of Medicine, College of Medicine, Taipei Medical
University, Wan Fang Hospital; Ching-Chiu Kao, MSc, Instructor,
School of Nursing, College of Nursing, Taipei Medical University and
Director, Nursing Department, Taipei Medical University Hospital,
Taipei; Yi-Chung Chen, MSc, Attending Physician, Internal
Medical Department, Da-Chien General Hospital, Miaoli, Taiwan
Correspondence: Yi-Chung Chen, Attending Physician, Taipei Medical
University, Wan Fang Hospital, No. 111. Section 3, Hsing-Long Rd,
Taipei 116, Taiwan. Telephone: +886 2 27296603.
E-mail: m600105@yahoo.com.tw
2011 Blackwell Publishing Ltd
620 Journal of Clinical Nursing, 21, 620625, doi: 10.1111/j.1365-2702.2010.03466.x
et al. 2000, Ozalp et al. 2003). Even patients with a low
predisposition to anxiety may become apprehensive in the
anticipation of surgery and show physical and psychological
changes, including increased heart rate (HR), blood pressure,
palpitations, vasoconstriction, nausea, vomiting and gastric
stasis (Simpson & Stakes 1987, Jacquet et al. 2006). In day
surgery, where preoperative nursing care is limited and
waiting times for surgery are unnervingly long and subject to
change, traditional pharmacological anxiolysis may fail to
reduce preoperative anxiety (Gilmartin 2004). Nursing
interventions including preoperative psychological prepara-
tion, timely provision of information and symptom manage-
ment are necessary to limit anxiety and stress and to facilitate
a fast and painless discharge and aftercare.
The therapeutic value of music in various clinical settings
has been recognised for its ability to modify the limbic system
to provide pain relief, relaxation and reduction in psycho-
physiological stress. This depends on the nature and rhythm
of the music and the personal associations generated while
listening (Thaut 1990). Increases in HR and vasoconstriction
because of stress are modulated by the autonomic nervous
system; music acts on the autonomic nervous system by
occupying several neurotransmitters from the auditory centre
of the temporal lobe, which then signals the hypothalamus,
medulla, amygdala, pons, midbrain and thalamus (Thaut
1990). The result is an anxiolytic diversion from negative
stimuli and an integrated hypothalamic relaxation response
resulting in reduced HR and blood pressure. These benets
have led to considerable research on the effect of music on
preoperative anxiety for minor surgery, bronchoscopy, col-
onoscopy, cardiac catheterisation and transurethral resection
of the prostate (Nilsson 2008), mostly with mixed results.
The object of this study was to evaluate the effectiveness of
musical intervention in reducing preoperative anxiety in
patients undergoing day surgery as measured by the State-
Trait Anxiety Inventory (STAI). We also assessed the effect of
music on the physiological parameters of anxiety, including
HR and systolic and diastolic blood pressures (SBP and DBP).
Background
The effects of music on preoperative anxiety
The effect of music on preoperative anxiety has been a subject
of ongoing investigation in Western/European countries
(Evans 2002, Nilsson 2008) and, to a lesser extent, in Eastern
countries: (Szeto & Yung 1999, Taylor-Piliae & Chair 2002,
Yung et al. 2002, Mok & Wong 2003, Lee et al. 2004).
Research on musical intervention in Taiwan is limited, with
only a few studies reported domestically (Hwang et al. 1996,
Good & Chin 1998, Huang 2003, 2005, Wu & Chou 2008)
and none reported internationally. Systematic meta-analysis
conducted by Nilsson (2008) revealed that 50% of studies
(12 of 24) published between January 1995January 2007
found signicant reductions in anxiety scores as measured by
STAI. Others have reported minor but insignicant reduc-
tions in physiological indices. These mixed results have been
attributed to small sample size, lack of a control group, lack
of randomisation, selection bias, previous surgical experi-
ence, non-objective outcome measures, inconsistent duration
of musical intervention and non-standardised protocols. In
this study, we sought to overcome these limitations with a
randomised, controlled study design.
The importance of the type of music
Cooke et al.s (2005a) of 12 studies found that the effective-
ness of musical intervention did not appear to be inuenced
by genre or type of soothing music selected, although slow
rhythm and other descriptions of the music were often
undened. All Chinese studies conducted thus far have
included a choice of soothing Western or Eastern music
provided by the investigators (Szeto & Yung 1999, Taylor-
Piliae & Chair 2002, Yung et al. 2002, Mok & Wong 2003,
Lee et al. 2004); Szeto and Yung (1999) and Yung et al.
(2002) reported a lack of difference in musical preference
among patients but mentioned that patients preferred their
own personal selections. Cooke et al. (2005b) also found that
patients had specic musical preferences. In all cases,
soothing, non-lyrical music with a tempo of 6080 beats,
delivered at a maximum volume level of 60 dB, has been
recommended (Staum & Brotons 2000). Musical intervention
generally lasts 1530 minutes.
Methods
Design
This randomised, controlled study was conducted with
patients aged 1865 admitted to our outpatient surgery
department from 20042007. The exclusion criteria were
(i) patients with cognitive decits or who were illiterate in
Chinese; (ii) patients with hearing impairments or who had
difculty wearing earphones; (iii) patients who received
preoperative sedatives; (iv) patients who did not have
sufcient time to participate in the study waiting time
of <3045 minutes; (v) patients who were undergoing
ophthalmic surgery or major surgery; and (vi) patients with
psychological illnesses or life-threatening diseases. Permuted-
block randomisation was used to assign participants to either
Original article Music effect on anxiety in preoperative patients
2011 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 620625 621
experimental (music delivered by earphones) or control group
(no music); routine nursing care was performed for both
groups. The primary outcome was anxiety level as measured
by STAI. Vital signs (blood pressure and HR) were also
measured before and after musical intervention. This study
was approved by the institutional review board, and
informed consent was obtained from all participants.
The STAI is a two-part 20-item self-report measure
developed by Spielberger (1983). It contains 40 items rated
on a Likert scale (one being not at all and four being very
much so) measuring feelings of apprehension, tension,
nervousness and worry. Total scores range from 2080, with
higher scores indicating greater anxiety (low anxiety: 2039;
moderate anxiety: 4059; and high anxiety: 6080). The
Chinese STAI (Shek 1993) used in this study has been
previously validated and exhibited high internal consistency
(090094) (Taylor & Deane 2002). The STAI takes fewer
than ve minutes to complete and can be scored quickly.
Data collection
Patients who were admitted to the hospital 3045 minutes
prior to surgery received the same procedural instructions
from an investigator. Consent to participate and detailed
demographic information were obtained at that time. After
preoperative registration, a registered nurse took vital signs
and administered the STAI following standardised instruc-
tions. A computer-generated list then randomised the patients
to receive either musical intervention or control. Music
consisted of an investigator-selected mini library that
included soothing popular Chinese and Minan Taiwanese
Pop songs (low-tone, slow-rhythm ballads only) in compact
disc format delivered by headphones and a compact disc
player. The patients were free to select from the musical
menu. Control patients engaged in relaxing activities in the
waiting room. After 20 minutes, anxiety and vital signs were
measured again. Patients then underwent standard preoper-
ative anaesthetic and surgical management.
Statistical analysis
Categorical variables were analysed by the use of Chi-square
analysis/Fishers exact test. Paired t-tests in both groups were
employed to analyse the results of differences in improvement
after intervention. Independent two-sample t-tests were used
to detect group differences in baseline-to-postintervention
changes. Continuous data were presented as mean stan-
dard deviation, while categorical data were represented by a
number and a percentage. All statistical assessments were
two-tailed and considered signicant at the 005 level.
Statistical analyses were performed using SPSS SPSS 15.0 statistics
software (SPSS Inc., Chicago, IL, USA).
Results
One hundred and eighty-three patients were selected for our
study between 20042007 in the Taipei Municipal Wan
Fang hospital (Taipei, Taiwan); however, three failed to
meet inclusion criteria and six did not complete the
questionnaire. The remaining 174 patients were randomly
assigned, with 87 in the music group and 87 in the control
group. Of these patients, 112 (651%) were women. One
patient in the music group and one patient in the control
group did not complete the study. Figure 1 is a ow chart of
the trial that presents the reasons for early patient termi-
nation. The groups were comparable in baseline character-
istics (Table 1). The STAI scores and vital signs did not
show signicant differences between the two groups
(p > 005).
The primary endpoint, the mean change in STAI score
from baseline after intervention, is shown in Table 2.
Signicant decreases in STAI scores from baseline were
observed in both groups (both p < 0001). In addition, there
was a statistically signicant difference between the music
and control groups (p < 0001). The STAI score decreased
by means of 583 and 172 in the music and control groups,
respectively. The secondary endpoints, the mean changes in
vital signs from baseline after intervention, are also shown in
Table 2. Decreases in HR, systolic and diastolic blood
pressures from baseline were observed in both groups.
Discussion
Although Lee et al. (2004) found signicant changes in self-
reported anxiety but no signicant changes in physiological
indices postintervention, four other Chinese studies on the
effect of music on preoperative anxiety found changes in both
(Szeto & Yung 1999, Taylor-Piliae & Chair 2002, Yung
Patients randomised
n = 174
Patients screened
n = 183
Control group
n = 87
Music group
n = 87
Completed
n = 86
Withdrawn
n = 1
Screening failures:
- Criteria (3)
- Time is not enough to
complete questionnaire (6)
Completed
n = 86
Withdrawn
n = 1
Figure 1 Patient ow chart.
C-H Ni et al.
2011 Blackwell Publishing Ltd
622 Journal of Clinical Nursing, 21, 620625
et al. 2002, Mok & Wong 2003). In their study, Cooke et al.
(2005b) found a signicant reduction in state anxiety level
but did not measure physiological changes. The design and
sample size of this study afrm both the anxiolytic effects of
music on preoperative anxiety and its ability to reduce
physiological indices.
Patients in both the intervention and control groups
showed a reduction in HR, SBP and DBP, but the
differences were not signicant except for SBP that was
actually lower in the control group. Variable changes in
physiological outcome measurements are common (Davis &
Thaut 1989, Strauser 1997, Taylor-Piliae & Chair 2002,
Wang et al. 2002) and have been explained by trait-related
differences in sympathetic system response to stress (Wang
et al. 2002), cultural expectations regarding the public
display of emotion (Taylor-Piliae & Chair 2002) and
previous experience with the stressor. The latter may have
also been a confounding factor in our study, as a majority
(767%) had had previous experience with surgery and
many were undergoing elective plastic surgery (357%) that
they felt positive about.
While this study demonstrated positive results, there are
also several limitations to the research. It is possible that a
20-minute musical intervention may have been insufcient to
produce physiologically measurable effects, and the relaxing
Table 1 Basic demographic parameters
and baseline characteristics of study
population (n = 172)*
Total
(n = 172)
Music group
(n = 86)
Control group
(n = 86) p-value
Age (years)

4090 1180 4159 1097 4021 1260 0444

Gender

Male 60 (349%) 31 (360%) 29 (337%) 0749

Female 112 (651%) 55 (640%) 57 (663%)
Education

Elementary school 18 (105%) 8 (93%) 10 (116%) 0861

High school 102 (593%) 51 (593%) 51 (593%)
University 52 (302%) 27 (314%) 25 (291%)
Surgery

Neurosurgery 29 (170%) 12 (140%) 17 (200%) 0225

Obstetrics & Gynaecology 32 (187%) 13 (151%) 19 (224%)
General Clinic 19 (111%) 9 (105%) 10 (118%)
ENT Department 13 (76%) 8 (93%) 5 (59%)
Urology 14 (82%) 5 (58%) 9 (106%)
Plastic Surgery 61 (357%) 38 (442%) 23 (271%)
Cardiovascular 3 (18%) 1 (12%) 2 (24%)
Experience of surgery

132 (767%) 70 (814%) 62 (721) 0149

Smoking

37 (216%) 16 (188%) 21 (244%) 0694

Drinking

25 (146%) 14 (163%) 11 (129%) 0424

Heart rate (beat/min) 7997 1252 8124 1241 7869 1258 0187
Systolic pressure (mmHg) 13161 2059 12921 1948 13404 2151 0128
Diastolic pressure (mmHg) 8374 1191 8336 1196 8412 1193 0682
STAI 4392 933 4283 999 4502 854 0124
*Data are presented as

mean SD and
,
number (percentage).
STAI, State-Trait Anxiety Inventory.
p-values based independent two-sample t-test (

), p-values based independent chi-square test (

),
p-values based independent Fishers exact test (

).
Table 2 Comparative primary endpoint (mean change of anxiety
score from baseline) and secondary endpoints (mean change in vital
signs from baseline) between the two groups (n = 172)*
Mean change
from baseline
Music group
(n = 86)
Control group
(n = 86) p-value
Primary endpoint
STAI 583 075

172 065

<0001

Secondary endpoints
Heart rate (beat/min) 501 079

376 063

0216
Systolic pressure
(mmHg)
772 116

1289 116

0002

Diastolic pressure
(mmHg)
426 087

423 078

0976
*Data are presented as mean SE.

Signicant difference between pre- and postintervention using paired

t-test, p < 005.

Signicant difference between two groups using independent two-

sample t-test, p < 005.
STAI, State-Trait Anxiety Inventory.
Original article Music effect on anxiety in preoperative patients
2011 Blackwell Publishing Ltd
Journal of Clinical Nursing, 21, 620625 623
effect of the investigators selections may not have been as
great as it might have been if the patient had brought his own
music from home. The use of an interviewer to administer the
questionnaire may have introduced a positive bias in scores
(more data about anxiety), but that bias would have been the
same for both groups. The individuals who collected post-
intervention data were aware of who was in each group and
this may have biased the results. We did not gather
information about preoperative pain or other adverse events
and did not examine other potential determinants of preop-
erative anxiety such as bedside manner, responsiveness to
patient needs or adequacy of information. Finally, the
ndings may not be generalised beyond a day surgery setting
in a medical centre.
Future studies might incorporate more sophisticated out-
come measurements such as galvanic skin response, epineph-
rine, norepinephrine, cortisol and prolactin levels in urine
and blood before and after musical intervention. Another
meaningful area of study would be the association between
preoperative anxiety and postoperative patient satisfaction to
see whether reduction in the former produced an increase in
the latter.
Conclusions
The results of this study indicate that patients scheduled to
undergo elective day surgery may benet from musical
intervention in terms of reduced preoperative anxiety levels
and physiological indicators of anxiety. The ndings suggest
that nurses can make a positive contribution to quality of
care through such an intervention.
Relevance to clinical practice
Finding multimodal approaches to ease discomfort and
anxiety from unfamiliar unit surroundings and perceived
risks of morbidity (e.g. disgurement and long-term sequelae)
is necessary to reduce preoperative anxiety and subsequent
physiological complications. This is especially true in the day
surgery setting, where surgical admission times are often
subject to change and patients may have to accommodate on
short notice or too long a wait that may provoke anxiety.
Our results provide additional evidence that musical inter-
vention may be incorporated into routine nursing care for
patients undergoing minor surgery.
Acknowledgements
We acknowledge all staff members in the Departments of
Nursing Service and Surgery, Taipei Medical University, Wan
Fang Hospital, for their assistance in the smooth completion
of this study. The study was supported by grants from Taipei
Medical University, Wan Fang Hospital, 96wf-eva20.
Contributions
Study design: C-HN, Y-CC; data collection and analysis:
C-HN, W-HT, L-ML, C-CK, Y-CC and manuscript prepa-
ration: C-HN, W-HT, L-ML, C-CK, Y-CC.
Conict of interest
None.
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Journal of Clinical Nursing, 21, 620625 625
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