Older adults face many challenges as they transition toward the final stages of life. As people age, they are at increased risk for disease, depression, social isolation, and cognitive and functional impairment (Linden, 2001). It is estimated that approximately 25% of adults older than age 65 have some level of depression and that 75% of older adults experience pain on a weekly basis (Morone & Greco, 2007). These impairments can create difficulties in independent functioning for older adults, which can increase feelings of anxiety and social isolation. Providing an environment that is conducive to maximum functional ability by decreasing stress, anxiety, and confusion may help older adults remain independent longer, thus reducing the burden of depression, social isolation, and disease in this group.
Understanding and creating environments that are healing and promote well-being is one of the most important roles of nursing. Providing healing environments for older adults includes attention to the functional, emotional, and cognitive stability within which healing can occur. Therefore, nurses should be aware of and know how to implement beneficial interventions within the environment that may help older adults remain independent and minimize morbidity and depression.
This article presents evidence that music listening can improve the environment for older adults and reviews research specifically related to the ways in which music can reduce pain and confusion, as well as improve functional ability. In addition, information to help nurses implement a music listening program in a therapeutic setting are provided.
Music is sound organized into an artistic form of auditory communication. Music allows individuals to express feelings and ideas about themselves and their place in the world (McCaffrey & Locsin, 2002). Music listening is a passive activity that allows listeners to take in musical sound through the ear, process that sound in the mind, and allow the sound to evoke an emotional and/or physical response (Khalfa, Isabelle, Jean-Pierre, & Manon, 2002). Therefore, the basis of music’s effect within an environment is the relationship between the musical sound, the body, and the mind.
Music is a fundamental form of personal and cultural expression that can create responses to capture the unique and elusive essence of each individual. In ancient civilizations, music did not signify merely the harmony of sounds but actually embodied the idea of the inner harmony of the spirit, and it was thought that the soul responded in harmonic rhythm (Lang, 1997). Throughout history, music has been an integral part of rites of passage—graduations, weddings, funerals, and healing and religious ceremonies. Encoded in the language of melody, harmony, and rhythm are the patterns of emotional intelligence that are stored in the ancient structures of the limbic system where emotions reside (McCaffrey & Locsin, 2002).
Although music can evoke emotion, it can also form emotional habits such that when one hears certain kinds of music, one’s emotions come to the surface without any other stimulus. This is what Aristotle referred to when he wrote “by music a man becomes accustomed to feeling the right emotions” (Marshall, 1953, p. 229). Using music to create healing environments may assist in promoting mental and physical health and well-being. Just as music is a universal language that promotes understanding among cultural and ethnic groups, it may be that music is a universal language within the body to promote health and well-being (Gardner, 1990).
In recent nursing studies, music listening has been shown to affect health and well-being physiologically, psychologically, and cognitively. The body of evidence that music listening can be a helpful and effective nursing intervention continues to grow. Physiological changes that occur when individuals listen to music include reductions in blood pressure and pulse and heart rates, as well as increases in oxygen saturation (Chan, 2007). Allen (2007) studied the effect of music on the physiological response to stress of 60 patients undergoing surgery. In the study, plasma levels of cortisol and natural killer lymphocytes during surgery decreased in the groups that listened to music but increased in those in the control group.
Positive psychological effects of music include reduction of anxiety and stress. Music listening has been shown to have a positive effect on anxiety in patients undergoing gastrointestinal procedures, such as colonoscopy (Hayes, Buffum, Lanier, Rodahl, & Sasso, 2003). Twiss, Seaver, and McCaffrey (2006) studied 60 patients undergoing coronary artery bypass surgery to determine the effect of music on anxiety and length of intubation time after surgery. These researchers found that those patients who listened to music during and after surgery had lower scores on anxiety measures than did those who did not listen to music. Patients in the study who listened to music were able to be removed from the ventilator at an average of 6 hours, whereas those who did not listen to music were able to be removed from the ventilator at an average of 9 hours. The results of these studies demonstrate that music listening can decrease stress, which is known to impede healing and well-being.
In patients with dementia, music listening has proven to be a powerful tool in reducing anxiety and agitation. Hicks-Moore (2005) studied nursing home patients with dementia who became agitated during mealtimes and found that music listening during meals decreased agitation and improved food consumption among participants. Goodall and Etters (2005) investigated the therapeutic use of music on agitated behavior in adults with dementia. These researchers found that singing, music listening, and other music activities reduced aggression, agitated behavior, and confusion in addition to decreasing wandering.
Providing a musical environment within the hospital setting can lead to improved patient satisfaction. The Mayo Clinic found that although clinical outcomes were excellent in cardiovascular surgical patients, patient satisfaction with the hospital experience was not rated as satisfactory (Cutshall et al., 2007). They explored several mind, body, and spirit therapies to determine their effect on patient satisfaction and found that listening to music had the greatest effect on patient satisfaction because it promoted relaxation, decreased anxiety, and distracted patients from unpleasant experiences, such as pain.
McCaffrey and colleagues conducted several studies using the theoretical framework proposed by Florence Nightingale who believed it was nurses’ responsibility to control the environment to put the patient in the best environment for healing to occur (McCaffrey & Freeman, 2003; McCaffrey & Good, 2000; McCaffrey & Locsin, 2004). The first study demonstrated the ways in which music was used by older adults to reduce pain, improve physical function, and reduce episodes of acute confusion postoperatively (McCaffrey & Good, 2000). Using van Manen’s approach to phenomenology, 9 older adults were interviewed to determine the lived experience of listening to music while recovering from surgery (McCaffrey & Good, 2000). Participants were provided with the means to listen to music whenever they wished during their recovery. Multiple audio-recorded interviews elicited a saturation of information from each participant on the lived experience.
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Interviews were conducted with all participants on each postoperative day. The interviews were transcribed, read, and reread by the researchers, and during this process, three themes emerged. The first theme was Feeling Comfort in a Discomforting and Frightening Situation (McCaffrey & Good, 2000). Participants stated that the hospital environment was frightening because there were many uncomfortable tests and procedures, the atmosphere was noisy and frenetic, and they had no control of what happened to them or when it happened. The participants indicated that the music provided a feeling of comfort, rest, and decreased anxiety because it was soothing, calming, familiar, and reassuring (McCaffrey & Good, 2000).
The second theme was Distraction from Pain (McCaffrey & Good, 2000). Participants indicated that when they experienced pain, they focused on the musical sounds rather than on the pain. Focusing on the music decreased pain perception for participants and allowed them to have some control over their pain. This was especially true when they had to wait for pain medication.
The third theme was A Feeling of Being at Home (McCaffrey & Good, 2000). This theme was derived from statements made by participants describing the ability to close their eyes, listen to familiar music, and be transported to their own homes. One participant indicated that when she listened to the music, she closed her eyes and returned to a favorite chair in her living room. This provided comfort and a feeling of safety for participants, which had a positive effect on their well-being. Nursing implications from the findings of this study were that nurses can use music to help patients who are recovering from surgery and that music is an inexpensive, easy-to-use, safe, evidence-based intervention to improve the recovery environment after surgery (McCaffrey & Good, 2000).
The effect of music listening on the chronic osteoarthritis pain of 66 community-dwelling older adults was studied by McCaffrey and Freeman (2003). Osteoarthritis is the most common disease in human beings and presents a significant obstacle to maintaining function and independence due to pain and deformity (Brown, Johnston, Saltzman, Marsh, & Buckwalter, 2006). An experimental group of 33 participants listened to a prepared audiocassette of 20 minutes of light classical music daily for 14 days. A control group of 33 participants was asked to sit quietly for 20 minutes daily for 14 days and were asked not to listen to music but to read or rest. The short form of the McGill Pain Questionnaire (Melzack, 1975) was used to evaluate pain perception before and after the intervention of sitting or sitting and listening to music on days 1, 7, and 14 of the study.
Results indicated that those in the experimental group had significantly less pain after the music intervention on all 3 days in both the pain rating index and the visual analogue pain rating scales (McCaffrey & Freeman, 2003). This study demonstrated ways in which music was used to provide an environment that decreased osteoarthritis pain in community-dwelling older adults. This has implications for nurses in their responsibility to promote comfort and well-being and to recognize pain management as a priority in the care they provide.
A study on osteoarthritis pain in community-dwelling older adults was undertaken to determine the effect of music on pain and acute confusion in older adults after elective hip or knee surgery (McCaffrey & Locsin, 2004). A review of the literature confirmed that acute confusion is common in older adults and is a comorbid marker of impaired recovery from surgery in older adults. It is estimated that up to 50% of older adults experience an episode of acute confusion after hip or knee surgery and that that percentage increases with age (McCaffrey & Locsin, 2004, 2006). The researchers found that those who listened to music postoperatively had less pain on nursing assessment and received fewer dosages of pain medication than did a control group. Those who listened to music also had fewer episodes of acute confusion than did the control group (McCaffrey & Locsin, 2004).
This study demonstrated that music can be used to create a healing environment, decreasing pain and episodes of acute confusion in older adults undergoing hip or knee surgery (McCaffrey & Locsin, 2004). Postoperative patients who exhibit signs of acute confusion are less able to ambulate after surgery, are more prone to postoperative complications, and are at high risk for falls. Reducing postoperative confusion is essential to promote healing after surgery, and in this study, music provided a calming and anxiety-reducing atmosphere in which patients could begin the healing process.
Nilsson (2008) completed a systematic review of the effects of music in reducing anxiety and pain. Forty-two randomized controlled trials studying 3,936 participants were reviewed. In the majority of studies, music was demonstrated to have an effect on reducing pain and anxiety. Generally, the studies described listening to music as altering the meaning of the negative sensation, thereby promoting a sense of autonomy and an ability to cope. The author found that the positive effects of music intervention may be likened to patient-controlled analgesia, and music could be called audioanalgesia, audioanxiolytic, or audiorelaxation. The implications of this review for nursing include nurses’ ability to create a healing environment by using music to reduce pain and anxiety.
As mentioned above, Hicks-Moore (2005) studied the effects of music on agitated behavior in nursing home residents with dementia. In this quasi-experimental study, 33 participants with severe cognitive impairment from Alzheimer’s disease were observed for agitation during mealtime using the 29 indicators of dementia-induced agitation found in the Cohen-Mansfield Agitation Inventory. After the music listening intervention, there were significantly fewer episodes of agitated behavior in the group studied. In addition, the researcher noted a more relaxed and harmonious atmosphere in the dining room when music was played. Everyone in the dining room smiled more, and less restlessness was observed. Between courses, some participants would sway and clap their hands to the music. Hicks-Moore noted that during the music intervention, participants were more social and looked more directly at each other and that an increase in conversation took place. This study demonstrated the effect of music on a nursing home environment, such that playing gentle and calming music is beneficial to nursing home residents with dementia.
Mok and Wong (2003) completed a randomized controlled trial to study the effects of music on anxiety in the perioperative and postoperative environments. Eighty participants older than age 65 who were to undergo minor surgery were studied. The experimental group listened to music during surgery and in the immediate postoperative recovery period. The control group did not listen to music postoperatively. Not only did the experimental group have significantly lower anxiety during and after surgery, as measured by the state anxiety inventory and lower blood pressure and pulse rates, but they also indicated that the music listening was helpful to them during recovery. The nursing implication here is that providing music during and after surgery may speed recovery and reduce postoperative complications, such as hypertension and tachycardia.
Discussion and Nursing Implications
One important aspect of the nursing role is to establish and maintain healing environments for those who have health problems. Music listening is a passive activity that does not require the person’s attentiveness but rather facilitates a nonthreatening atmosphere and provides an environment for healing (McCaffrey & Good, 2000). The outcomes of the research studies presented in this article demonstrate that music can positively affect the healing environment. Conclusions drawn from all of the studies demonstrate that music has a positive influence on the healing environment for older adults by increasing feelings of comfort; distracting them from postoperative pain, as well as chronic osteoarthritis pain; and improving cognition while reducing acute confusion in older adults after hip or knee surgery.
If music is able to reduce anxiety and decrease confusion, it might be useful for patients with psychiatric diagnoses, such as bipolar disorder, depression, and psychosis. Psychiatric syndromes are often accompanied by anxiety, aggressive behaviors, depression, or other problems that music might effectively relieve. Further research to determine the effect of music on people with psychiatric syndromes other than dementia would be beneficial to provide evidence for practice.
Music is a safe, evidence-based intervention nurses may use independently to improve the environment of older adults, thereby promoting health and well-being. The use of music listening in a clinical situation does not require special knowledge. The researchers in these studies selected a broad range of music for listening. Participants in the studies changed the kind of music they listened to during the day, depending on their mood.
People have very definite preferences toward kinds of music on the basis of past experiences of musical listening, cultural and ethnic preferences, and personality type. Providing many different kinds of music to patients will enable them to choose music that helps create a personal healing space. With the popularity of new technologies, such as the iPod® or other such devices, music can be easily downloaded to satisfy individual preferences. Family members should be encouraged to bring music from home that is familiar to the patients. The Sidebar on page 42 presents a list of some of the composers and CDs used by the researchers in the music listening studies described in this article. This may serve as the basis for developing a music library so music listening interventions may be implemented by nurses.
Agnus Dei II: Music to Soothe the Soul, Choir of New College Oxford
An Ancient Muse, Loreena McKennitt
Awake, Josh Groban
Be Still My Soul: The Ultimate Hymns Collection, various artists
Beautiful America, Tim Janis
Big Band Magic: The Sound of the Fabulous ’40s, various artists
Deep Within a Faerie Forest, Gary Stadler and Wendy Rule
The Essential Kenny G, Kenny G Lullaby: A Windham Hill Collection, various artists
The Mozart Effect: Music for Babies: Nighty Night, various artists
Nurses should be encouraged to develop music listening as an intervention for older adults after hip or knee surgery; further research should be undertaken in this area to strengthen nursing knowledge in the area of music listening and healing environments. The global position toward health promotion and illness prevention emphasizes the value of conscious healing from within, an appreciation of the wholeness of human beings, and the importance of environment in the healing process. Providing music as part of the healing environment promotes learning how to breathe and relax. Using music listening to perceive the inner landscapes of the body, mind, and spirit can lead to health and wholeness.
Yehudi Menuhin (1972), the famous conductor and musician, stated, “Music creates order out of chaos for the rhythm imposes unanimity upon the divergent, melody imposes continuity upon the disjointed, and harmony imposes compatibility upon the incongruous” (p. 139). On the basis of the results of these studies identifying the use of music as a positive factor in creating a healing environment that facilitates the healing process, nurses should be encouraged to use music as an intervention. Educational sessions to help nurses better understand the use of music in different settings and decide how to arrange music listening interventions are also recommended.
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