The results of several studies show that preoperative anxiety is associated with negative postoperative outcomes. These studies were conducted on men, women and children, all undergoing surgery for various diagnoses. A study conducted in Singapore on school aged children found a statistically significant correlation between preoperative anxiety and pain intensity 24 hours postoperatively (Chieng, Gu, & Chan, 2012). A broader study on 241 children, that lasted four years, concluded that not only was preoperative anxiety associated with postop pain, but with sleep problems, emergence delirium, and slower return to eating habits, (Kain, Mayes, Caldwell-Andrews, Karas, & McClain, 2006). This research also showed that children with higher anxiety consumed significantly more codeine and acetaminophen through the third day postop. A 2003 study, on 99 women diagnosed with breast cancer, concluded that there was a significant correlation between higher preoperative anxiety levels, postop pain, and analgesic consumption (Ozalp, Sarioglu, Tuncel, Aslan, & Kadiogullari, 2003). Anxiety has also been shown to affect the immune system, causing a pro-inflammatory response and decreased immunity which prolong healing (Pittman & Kridli, 2011).
Currently, the hospital I work at uses education as the primary means to alleviate preoperative anxiety. The nurse in the preoperative unit educates the patients on the procedures before surgery, reinforces the surgeons’ explanation of the surgery, and explains what the patient can expect postoperatively. The patient is also allowed to have one person of their choosing to wait with them in the preoperative holding area. Nursing staff encourages the patient to ask questions and voice concerns and addresses these concerns as needed. Pastoral care is also provided upon request to patients who wish to speak with a chaplain. Each room has a television, as well, to provide distraction if the patient wishes to watch it. A2a, b & c: Basis, Rationale & Explanation
The Policy and Procedure Committee makes decisions regarding hospital protocols. This committee is made up of the president of nursing services, several physicians, the head surgeon, director of quality control and administrative personnel. I would have to present the recommended intervention to this committee for approval, including all evidence supporting it, for their review. According to Susan Suiter, President of Nursing Services, the current standard of nurses providing preoperative education and emotional support has been in place for at least the last ten years. Policies regarding this practice are based on the best available research, and recommendations of The Joint Commission, Centers for Medicare and Medicaid, and The National Health Institute. This hospital also aligns its policies with the parent university hospital, and medical university, which conduct their own research. Current research continues to suggest that preoperative education, emotional support and family support are effective in alleviating anxiety (Pritchard, 2009). Mrs. Suiter contends that this policy is based in evidence and has provided desired results of decreasing preoperative anxiety but could possibly be improved upon by music intervention. A3a: Reference List
Binns-Turner, P., Wilson, L., Pryor, E., Boyd, G., & Prickett, C. (2011). Perioperative music and its effects on anxiety, hemodynamics, and pain in women undergoing mastectomy. AANA Journal, 79(4), 21-27. El-Hassan, H., McKeown, K., & Muller, F. (2009). Clinical trial: Music reduces anxiety levels in patients attending for endoscopy. Alimentary Pharmacology and Therapeutics, 30(7), 718-724. Gooding, L., Swezey, S., & Zwischenberger, J. (2012). Using music interventions in perioperative care. Southern Medical Journal, 105(9), 486-490. Ni, C., Tsai, W., Lee, L., Kao, C., & Chen, Y. (2012). Minimizing preoperative anxiety with music for day surgery patients – a randomized clinical trial. Journal of Clinical Nursing, 21(5/6), 620-625. Pittman, S., & Kridli, S. (2011). Music intervention and preoperative anxiety: An integrative review. International Nursing Review, 58, 157-163.
A4and A5: Clinical Implications & Procedural Changes
Current studies on preoperative anxiety suggest that music is a non-invasive, non-pharmaceutical, and low cost intervention for relieving patient anxiety (Binns-Turner et al., 2011). The relief of this anxiety may reduce postoperative complications of vomiting, pain, surgical complications and prolonged healing (Gooding, Swezey, & Zwischenberger, 2012). Music has also been found to increase patient satisfaction by addressing the emotional, spiritual and psychological needs of the patient ( (Gooding, Swezey, & Zwischenberger, 2012).
The clinical implications for pre-surgical staff would involve their education on the effects of preoperative anxiety on postoperative outcomes and how music can relieve some of these effects. Staff would then be required to convey this information to patients and their families and encourage them to take advantage of the benefits of this intervention. This should be done verbally and with written materials at the pre-surgical appointment. If patients do not prefer to bring their own music, they should be offered a facility owned media player by a staff member on admission.
A nurse on the perioperative staff should be educated on the types and tempo of music to be included on the media players, and assigned to find suitable music for use. Media players with headphones that can be easily sanitized would have to be ordered by central supply and the cost would have to be included in the surgical unit’s budget. Overall, the cost of this intervention is low and the time required by staff to implement it is minimal, especially compared to the benefits it provides. In studies of preoperative music intervention, many patients experienced more effective pain control, consumed less analgesics and began out of bed activities earlier than those who did not (Gooding, Swezey, & Zwischenberger, 2012). These benefits result in lower costs to patient and facility and decreased length of stay (Pittman & Kridli, 2011). A6: Stakeholders
The manager of the surgical unit, nurses, anesthetists, and surgeons would be considered key stakeholders, as well as, the patients themselves. I would be considered the initiating sponsor, as the recommendation for intervention is mine. The key sponsor who provides immediate authority over the staff would be the unit manager. He or she would be provided with potential cost information and the expected outcomes to justify the expense. The unit manager would be provided with all relevant research and an initial roll out plan for study. He or she would be asked for opinions on how the recommendation would affect practice, changes to the plan, and obstacles to change. The unit manager would also set up meetings for nurse and support staff education. During these meetings, recommendations, opinions and obstacles to implementation would be noted and addressed.
The anesthetists and surgeons would be provided with education on the benefits of music therapy to their practice. This would include the possible reduction in anesthesia necessary for patients, and the improved patient outcomes that could be expected. Emphasis for all staff would be placed on improved patient outcomes, satisfaction, and the benefits to staff of having less anxious clients. Patients as target stakeholders would be provided with information in lay terms beginning at the pre-surgery appointment. This information would be provided in written form, as well as, verbal question and answer conversations. Patients would again be educated on this intervention on the day of surgery and offered a music player if they did not bring their own. B1: Translation of Research
Gathering evidence to support a change in practice is time consuming and requires education on the types of research, credibility, validity, and applicability, among other things. The nature of nursing research limits the ability to generalize results to large populations, therefore studies on the same intervention must be found for different populations. The majority of nurses performing patient care have not been exposed to research terminology, let alone the requirements of a valid study or literature review. Lack of the understanding of research requires new evidence to be translated into generally understood information that must then be disseminated to staff. Ideally this information would be tailored to the many different occupations the change would affect. This translation of evidence can become costly as it requires not only material resources, but the time of all employees involved in the proposed change. B2 & B3: Barriers and Strategies
Many barriers to change exist in any organization. The disparity and distrust between management and work force is a common causative factor when a proposed change fails. The feeling by nursing staff that their unit manager is out of touch with patient care or only considers administrative consequences is common in hospital settings. Staff nurses often fail to commit to change because they feel their opinions and work load are not appreciated by their managers. One strategy to overcome this barrier is to have management reflect on their leadership styles. Engaging staff and becoming less authoritative can help to build trust. Providing opportunities for everyone to participate in the process and help tailor the implementation will help employees become vested in the change. It is also helpful to identify and recruit informal or opinion leaders among the staff. Educating opinion leaders on the implementation gives other staff members someone to go to with questions and opinions that does not intimidate them.
Another common barrier to change is the psychological/emotional resistance of employees. Any change whether, positive or negative, creates some amount of turmoil because it demands corresponding change on a personal level. Employees often experience a sense of loss of control over their environment, and that their level of competence is threatened. Providing staff with timely and accurate information will help ease these feelings. Also, allowing employees to take part in decision making processes gives them a feeling of control and that their opinions are valued. Positive feedback on the implementation process and results should also be used to keep employees vested, as it provides a sense of accomplishment. B4: Application of Findings
My recommendation to include music in preoperative nursing practice is as follows: 1. All surgical staff should be educated on the benefits of introducing music into the preoperative period. This should include studies detailing anxiety’s correlation to postop pain and studies showing the efficacy of these interventions in improving postop outcomes. 2. At the pre-op appointment- Patients should be informed of the possible benefits of using music interventions to relieve anxiety and decrease postop pain severity. This information should be explained verbally and written information should be provided as well. Written information could be added to the standard pre-op instructions or provided as separate information. The patient’s should be encouraged to bring their own IPods/CD players with earphones on the day of surgery. Soothing music, of the patient’s choosing, should be suggested to listen to preoperatively.
3. On the day of surgery- Patients who have not brought their own media players should be offered one owned by the facility. Choices of different genres of soothing non-lyrical music should be offered on a prerecorded playlist (Ni et al., 2012). Patients should be encouraged to begin listening to music at least 30 minutes prior to scheduled surgery time to provide maximum benefits (Binns-Turner et al., 2011). Facility owned media players should be set to a maximum volume of 70db, to avoid hearing damage (Binns-Turner et al., 2011). As this intervention is non-invasive and non-pharmaceutical, patients do not have to be monitored for adverse effects. In my opinion, the only disadvantage of implementing this intervention would be the low cost of the printed materials, media players and CDs. Educating patients on the benefits of the interventions would only take a few minutes, and retrieving a media player or CD for the patient a few minutes more. Overall the possible benefit to patient outcomes outweighs these issues.
Binns-Turner, P., Wilson, L., Pryor, E., Boyd, G., & Prickett, C. (2011). Perioperative music and its effects on anxiety, hemodynamics, and pain in women undergoing Mastectomy. AANA Journal, 79, 21-27. Chieng, S., Gu, H., & Chan, S. (2012, Jan-Mar). Research in brief- An exploratory study of preoperative level of anxiety and postoperative pain in school-aged children undergoing surgey. Singapore Nursing Journal, 39(1), 50-51. El-Hassan, H., McKeown, K., & Muller, A. (2009). Clinical trial: Music reduces anxiety levels in patients attending for endoscopy. Alimentary Pharmacology and
Therapeutics, 30(7), 718-724. Gooding, L., Swezey, S., & Zwischenberger, J. (2012). Using music interventions in perioperative care. Southern Medical Journal, 105(9), 486-490. Kain, Z., Mayes, L., Caldwell-Andrews, A., Karas, D., & McClain, B. (2006, August). Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics, 118(2), 651-658. doi:10.1542/peds.2005-2920 Ni, C.-H., Tsai, W.-H., Lee, L.-M., Kao, C.-C., & Chen, Y.-C. (2012, March). Minimising preoperative anxiety with music for day surgery patients – a randomised clinical trial. Journal of Clinical Nursing, 21, 620-625. doi:10.1111/j.1365-2702.2010.03466.x Ozalp, G., Sarioglu, R., Tuncel, G., Aslan, K., & Kadiogullari, N. (2003). Preoperative emotional states in patients with breast cancer and postoperative pain. Acta Anaesthesiol Scandinavica, 47(1), 26-29. Pittman, S., & Kridli, S. (2011). Music intervention and preoperative anxiety: An integrative review. International Nursing Review, 58, 157-163. Pritchard, M. (2009). Identifying and assessing anxiety in pre-operative patients. Nursing Standard, 23(51), 35-40. Wang, S., Kulkarni, L., Dolev, J., & Kain, Z. (2002, June). Music and preoperative anxiety: a randomized, controlled study. Anesthesia And Analgesia, 94(6), 1489-1494.