validity of research methodology

validity of research methodology
Selection of the appropriate sample is critical to the reliability and validity of research methodology. The sample must be representative of the population that is being studied. Researchers often report both the inclusion and exclusion criteria for the sample. There are many different methods for selecting a sample and random sampling provides the high control of outside variables but is often difficult to utilize in many studies.

For this Discussion, please review the following:

For this assignment, read the article by Labrague, L. & McEnroe-Petitte, D. (2016). Influence of music on preoperative anxiety and physiological parameters in women undergoing gynecologic surgery. Clinical Nursing Research, 25(2), 157-173, listed in the resource section for this week.
By Day 3

Prepare a 250-300-word post discussing the strengths and weaknesses of the sampling method used in this study and if the sampling method promoted reliable and valid results. Include in the discussion if there is anything the researcher could have done to improve the sampling process.

Note: Post a three paragraph (at least 250–350 words) response. Be sure to use evidence from the readings and include in-text citations. Utilize essay-level writing practice and skills, including the use of transitional material and organizational frames.

File #1
validity of research methodology
Selection of the appropriate sample is critical to the reliability and validity of research methodology. The sample must be representative of the population that is being studied. Researchers often report both the inclusion and exclusion criteria for the sample. There are many different methods for selecting a sample and random sampling provides the high control of outside variables but is often difficult to utilize in many studies.

For this Discussion, please review the following:

For this assignment, read the article by Labrague, L. & McEnroe-Petitte, D. (2016). Influence of music on preoperative anxiety and physiological parameters in women undergoing gynecologic surgery. Clinical Nursing Research, 25(2), 157-173, listed in the resource section for this week.
By Day 3

Prepare a 250-300-word post discussing the strengths and weaknesses of the sampling method used in this study and if the sampling method promoted reliable and valid results. Include in the discussion if there is anything the researcher could have done to improve the sampling process.

Note: Post a three paragraph (at least 250–350 words) response. Be sure to use evidence from the readings and include in-text citations. Utilize essay-level writing practice and skills, including the use of transitional material and organizational frames.

File #1

Clinical Nursing Research
2016, Vol. 25(2) 157–173
© The Author(s) 2014
Reprints and permissions:
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DOI: 10.1177/1054773814544168
cnr.sagepub.com
Article
Influence of Music on
Preoperative Anxiety
and Physiologic
Parameters in Women
Undergoing Gynecologic
Surgery
Leodoro J. Labrague, MAN, BSN, RN1 and
Denise M. McEnroe-Petitte, PhD, MSN, BSN, RN2
Abstract
The aim of this study was to determine the influence of music on anxiety levels
and physiologic parameters in women undergoing gynecologic surgery. This
study employed a pre- and posttest experimental design with nonrandom
assignment. Ninety-seven women undergoing gynecologic surgery were
included in the study, where 49 were allocated to the control group
(nonmusic group) and 48 were assigned to the experimental group (music
group). Preoperative anxiety was measured using the State Trait Anxiety
Inventory (STAI) while noninvasive instruments were used in measuring
the patients’ physiologic parameters (blood pressure [BP], pulse [P], and
respiration [R]) at two time periods. Women allocated in the experimental
group had lower STAI scores (t = 17.41, p < .05), systolic (t = 6.45, p < .05)
and diastolic (t = 2.80, p < .006) BP, and P rate (PR; t = 7.32, p < .05) than
in the control group. This study provides empirical evidence to support
the use of music during the preoperative period in reducing anxiety and
unpleasant symptoms in women undergoing gynecologic surgery.
1Samar State University, Catbalogan City, Philippines
2Kent State University Tuscarawas, New Philadelphia, OH, USA
Corresponding Author:
Leodoro J. Labrague, Associate Dean, College of Nursing and Health Sciences, Samar State
University, Brgy. Guindapunan, Catbalogan, Samar, 6700, Philippines.
Email: Leo7_ci@yahoo.com
544168 CNRXXX10.1177/1054773814544168Clinical Nursing ResearchLabrague and McEnroe-Petitte
research-article2014
158 Clinical Nursing Research 25(2)
Keywords
anxiety, gynecologic surgery, music therapy, physiologic parameters, State
Trait Anxiety Inventory
Introduction
Patients generally experience high levels of anxiety when hospitalized to
undergo surgery and other invasive procedures. Anxiety is an emotional state
consisting of a set of behavioral manifestations, which occurs in 11% to 80%
of adult surgical clients prior to surgery regardless of the scope and extent of
surgery (Caumo et al., 2001; Starkweather, Witek-Janusek, Nockels, Peterson,
& Mathews, 2006). Women, in particular, experience high levels of anxiety
during surgery when compared with men (Caumo et al., 2001; Mitchell,
2003). Many factors are thought to contribute to surgical patients’ anxiety:
preoperative waiting time, fear of postoperative pain, disfigurement, disruptions
of their personal and professional lives, and even financial burdens
(D. Lee, Henderson, & Shum, 2004; Mitchell, 2003; Poleshuck et al., 2006;
Shelby, Taylor, Kerner, Coleman, & Blum, 2002). Although considered as a
common phenomenon and accepted as a normal response in anticipation of a
surgical event, high levels of anxiety affects patients’ postoperative outcome
and overall well-being (Hook, Songwathana, & Petpichetchian, 2008;
McCance & Huether, 2006; Starkweather et al., 2006). Therefore, the challenge
for perioperative nurses is to maintain physiological and psychological
well-being of patients by reducing anxiety and fear.
Background
Anxiety is defined as a state of uneasiness or apprehension resulting from the
anticipation of a real or perceived threatening event or situation. This state
commonly occurs among preoperative patients and ranges from low to high
in intensity depending on the individual’s perception of the event (Arslan,
Ozer, & Ozyurt, 2008; Pritchard, 2009). Anxiety related to surgery is thought
to be related to fear of the outcome of the surgery, separation from friends and
family, fear of death and disfigurement, coping with postoperative pain and
treatment regimens, fear of losing independence, and surgical recovery time
from surgery burdens (D. Lee et al., 2004; Mitchell, 2003; Poleshuck et al.,
2006; Shelby et al., 2002). It usually appears during the planning phase
including scheduling of the surgical procedure and peaks during the day of
admission. (Carr, Brockbank, Allen, & Strike, 2006; Pritchard, 2009).
Women, in particular, experience high levels of anxiety during surgery when
Labrague and McEnroe-Petitte 159
compared with men (Caumo et al., 2001; Mitchell, 2003). Although studies
on prevalence of anxiety in women undergoing gynecologic surgery are
scarce, Carr et al. (2006) found that rates reach 67%; 45% during the night
before surgery, 53% in the morning of surgery, and 67% just prior to administration
of anesthetic agents.
Although considered a normal phenomenon and highly anticipated during
the preoperative period, anxiety that exceeds an individual’s tolerance may
have harmful physiological and psychological effects to the human body.
During the preoperative period, surgery-related anxiety affects the functioning
of the sympathetic nervous system and hypothalamic–pituitary–adrenal
axis. This in turn triggers the release of biological substances that cause physiological
and psychological manifestations of anxiety (McCance & Huether,
2006; Pritchard, 2009), which can affect surgical outcomes. High levels of
anxiety are attributed to poor surgical outcomes. This will additionally affect
the immune system by significantly decreasing cellular immunity, which can
subsequently prolong the time for healing (McCance & Huether, 2006;
Starkweather et al., 2006). It will alter the individual’s postoperative pain
response by decreasing pain tolerance and threshold, which will lead to prolonged
recovery time and hospital discharge (Hook et al., 2008). In response
to the various adverse effects of anxiety, it is imperative that interventions for
managing anxiety be explored to reduce postoperative complications.
Substantial research had been undertaken to identify anxiety-reduction interventions
and strategies such as therapeutic relationships and providing surgicalspecific
preoperative information and education (Erci, Sezgin, & Kacmaz, 2008;
Kain et al., 2007; Ng, Chau, & Leung, 2004; Spaulding, 2003; Stirling, 2006).
Other interventions such as application of essential oils, relaxation techniques,
and parental presence were also found to be effective in reducing anxiety (Kain
et al., 2007; Stirling, 2006). However, it can be noted that most of the strategies
and interventions available provide limited evidence for managing preoperative
anxiety and stabilizing vital signs among preoperative patients. Given this constraint,
evidence-based, nonpharmacological approaches in managing preoperative
anxiety during the immediate preoperative period is essential. One
innovative approach is the use of music intervention.
Music intervention, which is defined as utilization of music for restoration,
maintenance, and improvement of diseases and defects (Kemper & Danhauer,
2005) has been studied and used in a variety of populations and settings primarily
to reduce pain and anxiety and induce relaxation (Bringman, Giesecke,
Thörne, & Bringman, 2009; Cooke, Chaboyer, Schluter, & Hiratos, 2005;
Kemper & Danhauer, 2005; Labrague, Rosales, Rosales, & Fiel, 2013; D. Lee
et al., 2004; K. C. Lee, Chao, Yiin, Chiang, & Chao, 2011; K. C. Lee et al.,
2012; Ni, Tsai, Lee, Kao, & Chen, 2012; Sendelbach, Halm, Doran, Miller, &
160 Clinical Nursing Research 25(2)
Gaillard, 2006; Twiss, Seaver, & McCaffrey, 2006). The act of listening to
music has been proven to be effective in reducing anxiety and pain. Music
additionally induces relaxation and plays an important role in the provision of
comfort for patients by decreasing activity in the sympathetic nervous system
(Arslan et al., 2008; Boso, Politi, Barale, & Emanuele, 2006; Cooke et al.,
2005; Gillen, Biley, & Allen, 2008). In a randomized controlled study conducted
by Ni et al. (2012) in a group of patients undergoing minor surgery,
those patients who were provided with musical interventions reported a significantly
lower level of anxiety on the State Trait Anxiety Inventory (STAI) compared
with the nonmusical group. Cooke et al. (2005) introduced music into a
group of adult surgery patients in Australia. The study’s findings supported the
hypothesis that listening to music prior to surgery is associated with a decrease
in preoperative anxiety. Music also showed a significant reduction in anxiety in
the immediate preoperative period when having procedures performed in the
daytime hours (D. Lee et al., 2004). Music listening also decreases preoperative
anxiety in a preoperative setting to a greater extent when compared with the use
of preoperative midazolam (Bringman et al., 2009).
Music can also have positive effects on vital signs of preoperative patients
(Buffum et al., 2006; Hamel, 2001; D. Lee et al., 2004; Wang, Kulkarni,
Dolev, & Kain, 2002; Wong, Lopez-Nahas, & Molassiotis, 2001; Yung, ChuiKam,
French, & Chan, 2002). In a quasi-experimental study conducted by
Hamel (2001) with 101 subjects prior to cardiac catheterization, music significantly
reduced physiologic parameters. After listening to music, systolic
blood pressure (BP) was lower than baseline measurements and the mean
heart rate decreased after 20 min in the music group. Yung et al. (2002) also
found significant reduction in systolic and diastolic BP and mean heart rate
following music interventions. Similarly, a significant reduction in heart rate
and respiratory rate (RR) was also observed by Wong et al. (2001) in their
study using crossover repeated measures design with random assignment.
However, in other studies conducted, music provided no significant changes
in vital signs (Buffum et al., 2006; D. Lee et al., 2004).
For centuries, music has been used as a modality in health care and as an
adjunct in treating varied health problems (Bringman et al., 2009; Buffum et al.,
2006; Cooke et al., 2005; Hamel, 2001; Kemper & Danhauer, 2005; Labrague
et al., 2013; D. Lee et al., 2004; Yung et al., 2002). However, little is known in
the literature highlighting the use of music in alleviating anxiety among women
who are known to experience high levels of anxiety prior to a surgical procedure.
Furthermore, a thorough review of the literature identified that this topic
has never been previously researched in the Philippines. For this current study,
the researchers are interested in identifying influence of music on the anxiety
level and vital signs among women undergoing gynecologic surgery.
Labrague and McEnroe-Petitte 161
Aim of the Study
The aim of this study was to determine the influence of music on anxiety
levels and vital signs of women undergoing gynecologic surgery. More specifically,
this study aimed
1. to compare the anxiety levels of the control and experimental group
after exposure to music and
2. to compare the physiologic parameters (RR, BP, pulse rate [PR]) of
the control and experimental group after exposure to music.
Method
Research Design
This study utilized a pre- and posttest experimental design with nonrandom
assignment to determine whether music decreases anxiety levels in women
undergoing gynecologic surgery and to examine whether it has effects on
their physiologic parameters.
Study Subjects
Subjects in this study were recruited from a 150-bed capacity government
hospital in Samar Province, Philippines during the months of September to
November 2013. This study used a purposive sampling of women who were
undergoing gynecologic procedures. To be eligible to participate in the study,
subjects were required to (a) have no hearing difficulties, (b) be at least 18
years old, (c) have no presurgical morbidities, (d) be informed and have
signed consent form, and (e) be undergoing gynecologic surgery.
In this study, gynecologic surgery refers to surgery that involves the
female reproductive system to include minor and major operative procedures.
One hundred five subjects were originally recruited to participate in
the study. However, eight women withdrew for the following reasons: Four
were referred to highly specialized facility, three revealed having hearing
difficulties, and one refused to wear the required headset. Finally, 97 women
were included in the study. Forty-nine women were allocated to the control
group (nonmusic group) and 48 women were assigned in the experimental
group (music group). The number of subjects both in the control and experimental
group were equivalent to the number of subjects in previous studies
conducted (Arslan et al., 2008; Hamel, 2001; D. Lee et al., 2004; K. C. Lee
et al., 2012).
162 Clinical Nursing Research 25(2)
Music
Three types of prerecorded music were used in this study consisting of classical,
country, and nature sounds with slow and flowing tempos. The music
tempo was primarily chosen (with the help of a music expert) to mimic the
human heart beat. This would be considered appropriate in reducing anxiety
as it has a slow tempo, a middle low pitch, low volume, and has a simple and
steady melody. In a systematic review of recent studies describing the clinical
effects of music intervention preoperatively, it has been suggested that music
used therapeutically should have the following characteristics: (a) slow and
flowing music, (b) approximately 60 to 80 beats per minute, (c) is nonlyrical,
(d) consists predominantly of low notes, (e) is comprised mostly of strings
with minimal brass or percussion, and (f) has a maximum volume level at 60
decibels (dB; Cepeda, Carr, Lau, & Alvarez, 2006; Nilsson, 2008). Preselected
music was recorded in four multimedia players (MP3s) with the utilization of
accompanying headphones.
Measurement
Anxiety
Preoperative anxiety was measured using the STAI. It is a 20-item report
instrument developed by Spielberger (2010) and was designed to evaluate
patients’ feeling of apprehension, tension, nervousness, and worry. Patients
rated their responses on the scale of 1 (not at all) to 4 (very much so), the
intensity of the feelings being asked about. The instrument has been extensively
utilized with a high level of reliability and validity. The state anxiety
score can range from 20 to 80 with higher scores indicating higher levels of
anxiety. The STAI was translated into the individual country’s language using
the American English version, using a forward and back translation process.
The translated version was discussed with a group of experts to determine
content validity.
The Cronbach’s alpha of the STAI was calculated. The 20-item inventory
scale yielded a Cronbach’s alpha of .92, which is comparable with previous
studies (Arslan et al., 2008; Buffum et al., 2006; Spielberger, 2010).
Physiologic Parameters
Noninvasive instruments were used in measuring patients’ vital signs. BP and
heart rate were measured with an automatic BP monitor (Japan, OMRON
HEM 7111). The RR was obtained by the researchers counting one full
Labrague and McEnroe-Petitte 163
minute the number of times the chest rose and fell. To ensure an accurate
measurement of physiologic measures, the researcher underwent intensive
training in vital signs monitoring.
Music Intervention Protocol
After seeking an informed, signed consent from the participants, eligible
women who agreed to participate were assigned to the control and experimental
group. The music intervention took place in the preoperative waiting
room. Both groups did not receive anxiety medications during the course of
the study. The experimental group received and was exposed to music intervention
for 20 min prior to admission to the operating room, whereas the
control group only received standard nursing care. In most studies conducted,
listening durations ranged from 15 min to 40 min, however, a minimum of 15
to 20 min of listening to music was shown to be effective in minimizing preoperative
anxiety (Pittman & Kridli, 2011). Measures of anxiety with the use
of the STAI and physiologic parameters (RR, BP, PR) were obtained before
and after 20 min of exposure to music in the experimental group and 20 min
after taking physiologic parameters (RR, BP, PR) in the control group. To
block environmental noise that may heighten anxiety or may distract participants,
headphones were used to deliver the music. In most studies conducted,
headphones were used to provide music to the subjects (Arslan et al., 2008;
Cooke et al., 2005; D. Lee et al., 2004; Nilsson, 2008). Subjects were also
given the freedom to adjust and readjust the volume of music during the
entire listening experience. In addition, to avoid unnecessary disturbances in
the preoperative waiting rooms, subjects were assigned by group either into
the control group or experimental group on a weekly basis. For instance,
patients who were scheduled for surgery on the first week were assigned in
the control group and those who were assigned in the following week were
assigned in the experimental group. See Figure 1 for the flow diagram through
the phases of the trial.
Statistical Analysis
The data were coded and entered into a computerized database and analyzed
using the SPSS (version 19). Descriptive statistics such as the mean, frequency,
and standard deviation were used to quantify the participants’ demographic
profile. To test for the homogeneity and normality of the two groups,
chi-square and Fisher’s exact test were used. Paired t tests were utilized to
examine any significant difference between the pre- and posttest STAI, and
physiologic parameters for each group. To compare the control and
164 Clinical Nursing Research 25(2)
experimental group, the unpaired t test was used. The level of significance
was set at p < .05.
Ethical Considerations
Approval for the study was granted by the Ethical Committee of Samar State
University prior to the actual study. The principal researcher sought the permission
of the hospital director and chief nurse of the hospital prior to conduction
of the study. Consent forms from the subjects were also secured upon
approval to participate in the study.
Results
Ninety-seven women were recruited in this study. Forty-nine women were
allocated in the control group, and 48 women were assigned in the music
group. The mean age was 42.10 years (SD = 5.02) and 42.31 years (SD =
4.89) in the control group and experimental group, respectively. When compared,
no significant differences were identified between the two groups in
their demographic characteristics such as civil status, education, history of
previous surgery, and type of surgery. The majority of the subjects chose classical
music (53.61%, n = 52) whereas the rest chose nature (26.80%, n = 26)
and country music (19.59%, n = 19; Table 1).
Baseline scores of the two groups on the STAI and physiologic measures
were compared using inferential statistics. Results of five independent t tests
indicate that the two groups were not significantly different on STAI scores
Women undergoing
gynecologic procedures
(105)
4 were referred to highly specialized;
3 revealed having hearing difficulties;
1 refused to wear the required
headset
Allocated to
experimental Group
(n = 48)
Allocated to control
Group
(n = 49)
Analyzed (n = 49) Analyzed (n = 48)
Figure 1. Flow diagram of the trial.
Labrague and McEnroe-Petitte 165
(t = 1.02, p = .3085), systolic BP (t = 1.48, p = .1407), diastolic BP (t =
0.99, p = .3202), PR (t = 0.61, p = .5445), and RR (t = 1.33, p = .1877). The
result showed that there is normality and homogeneity of samples on both
groups.
With the use of the dependent t test (one-tailed test), STAI scores and
physiologic measures of both groups were examined separately for any
changes at Period 1 and Period 2 (Table 2). Statistically significant decreases
in the STAI scores (t = 11.89, p < .05), systolic BP (t = 7.99, p = < .05), diastolic
BP (t = 4.16, p = < .05), and PR (t = 5.33, p < .05) were observed except
for the RR (t = 0.17, p = .8579) in the experimental group. For the control
group, there were no significant changes noted on the systolic BP (t = –0.37,
p = .7130), diastolic BP (t = 1.28, p = .2041), and RR (t = 0.25, p = .7991).
However, significant increases in the STAI scores (t = –8.78, p < .05) and PR
(t = –6.01, p < .05) were noted.
Table 1. Characteristics of the Subjects in Two Groups.
Variable
Control group
(n = 49)
M (SD)/n (%)
Experimental
group (n = 48)
M (SD)/n (%) t/?2 p
Age
Mean age (year) 42.10 (5.02) 42.31 (4.89) 0.208 .835
Civil status
Single 8 (16.32) 5 (10.42) 3.078 .214
Married 38 (77.55) 35 (72.92)
Separated 3 (6.12) 8 (16.67)
Education
Primary 10 (20.41) 8 (16.67) 0.560 .755
Secondary 16 (32.65) 19 (39.58)
Tertiary 23 (46.94) 21 (43.75)
History of previous surgery
No 42 (85.71) 40 (83.33) 0.105 .745
Yes 7 (12.28) 8 (16.67)
Types of surgery
Partial Hysterectomy 3 (6.12) 2(4.17) 1.333 .987
Dilatation and curettage 5 (10.20) 4 (8.33)
Completion curettage 9 (18.37) 12 (25)
Tubal ligation 12 (24.49) 10 (20.83)
Total Hysterectomy 4 (8.16) 3 (6.25)
Breast mastectomy 5 (10.20) 6 (12.5)
Breast lumpectomy 6 (12.24) 7 (14.83)
166
Table 2. Means, Standard Deviations, t Values, and p Values After Music Intervention.
Experimental group (n = 48) Control group (n = 49)
Scale/parameter Before M/SD After M/SD t value p value Before M/SD After M/SD t value p value
STAI 40.75 ± 1.97 36.43 ± 1.86 11.89 <.05* 41.18 ± 2.16 43.30 ± 2.02 -8.78 <.05*
Systolic BP 127.60 ± 5.20 123.04 ± 4.25 7.99 <.05* 129.30 ± 6.03 129.48 ± 5.49 -0.37 .7130
Diastolic BP 75.93 ± 5.15 73.81 ± 4.91 4.16 <.05* 77.08 ± 6.13 76.67 ± 5.11 1.28 .2041
Pulse rate 75.39 ± 4.87 71.39 ± 4.28 5.33 <.05* 74.82 ± 4.35 77.51 ± 3.95 -6.01 <.05*
Respiratory rate 18.39 ± 1.51 18.35 ± 1.56 0.17 .8579 18.75 ± 1.14 18.73 ± 1.15 0.25 .7991
Note. STAI = State Trait Anxiety Inventory; BP = blood pressure.
*p < .05.
Labrague and McEnroe-Petitte 167
An important finding focused on whether the experimental group had significantly
lower STAI scores and physiologic parameters (Table 3). Five
independent t test analyses were conducted to compare the two groups after
ensuring homogeneity of the samples used. Women in the experimental group
had lower STAI scores (t = 17.41, p < .05) than the control group. No significant
difference in the RR (t = 1.36, p = .17) was noted in both groups.
Discussion
Patients during the preoperative period may have stress and anxiety heightened
due to the unknown environment and unfamiliar staff. During this
period, the sympathetic nervous system is aroused resulting in increased
body processes leading to undesirable surgical outcomes (Hook et al., 2008;
McCance & Huether, 2006; Pritchard, 2009; Starkweather et al., 2006).
Developing effective anxiety-reduction interventions based on empirical evidence
is essential to optimize nursing care. Music intervention may be particularly
effective for patients experiencing physical and psychological
distress. With that, this study determined the influence of music on the anxiety
level and physiologic parameters in women who will undergo gynecologic
surgery.
Key finding of this study indicated that exposure to music intervention
during the immediate preoperative period was effective in reducing anxiety
levels in women undergoing gynecological surgery. Subjects in the experimental
group (allocated to music group), after listening to music, reported
significant reduction in their anxiety level compared with those women allocated
in the control group. This result further supports previous findings of
Table 3. Difference on the Posttest Scores of the Control and Experimental
Group After Music Intervention.
Scale/parameter
Experimental
(n = 48)
M/SD
Control
(n = 49)
M/SD 95% CI t value p value
STAI 36.43 ± 1.86 43.30 ± 2.02 [-7.65, -6.08] 17.41 <.05*
Systolic BP 123.04 ± 4.25 129.48 ± 5.49 [-8.42, -0.83] 6.45 <.05*
Diastolic BP 73.81 ± 4.91 76.67 ± 5.11 [-4. 88, -0.83] 2.80 .0060*
Pulse rate 71.39 ± 4.28 77.51 ± 3.95 [-7.78, -4.46] 7.32 <.05*
Respiratory rate 18.35 ± 1.56 18.73 ± 1.15 [-0.93, 0.17] 1.36 .1747
Note. CI = confidence interval; STAI = State Trait Anxiety Inventory; BP = blood pressure.
*p < .05.
168 Clinical Nursing Research 25(2)
the use of music in the reduction of anxiety during the immediate preoperative
period. For instance, in a recent systematic review conducted by Bradt,
Dileo, and Shim (2013), results indicated that listening to music may help
reduce anxiety in patients awaiting surgery. Similarly, Hamel (2001) and
El-Hassan, McKeown, and Muller (2009) also concluded that listening to
music, regardless of age and type of procedures, may be an effective intervention
for decreasing preoperative anxiety. The same result was obtained in
randomized controlled studies of previous authors (Arslan et al., 2008;
Bringman et al., 2009; Cooke et al., 2005; D. Lee et al., 2004; K. C. Lee et al.,
2012; Wang et al., 2002). Preoperative STAI scores in patients undergoing
day surgery such as orthopedic, cystoscopy, biopsy, urology, and endoscopy
had significantly lower scores with posttest than in the control group.
Significant reductions in the anxiety levels were also obtained in the experimental
studies conducted by Twiss et al. (2006) and Sendelbach et al. (2006)
among a wide range of surgical patients. Interestingly, subjects in the control
group reported increased STAI scores and PRs during the posttest. This suggests
that as the surgical schedule time approaches, preoperative anxiety
increases. With the proven anxiety-reducing effects of music, perioperative
nurses may consider this intervention as part of their routine nursing care for
surgical patients during the immediate preoperative period as anxiety and
stress is heightened in this period (Hamel, 2001).
Findings also revealed significant changes in the physiologic parameters.
Women in the experimental group demonstrated a significant reduction in
their BPs (systolic and diastolic BPs) and heart rates but not the RR. This is
in keeping with the previous studies conducted in a variety of populations
and settings. For instance, Hamel (2001) provided music intervention to cardiac
patients prior to surgery. After exposure to music, systolic BP and heart
rate lowered significantly in the music group. Similarly, Yung et al. (2002)
proved that music notably reduced BP and heart rate in patients undergoing
transurethral resection of the prostate. In a systematic review conducted by
Nilsson (2008) concerning the effects of music intervention on anxiety and
pain reduction, it was indicated that music has both physiological (changes in
heart rate, BP, and RR) and psychological (reduction in anxiety and pain)
benefits. However, Wang et al. (2002) and Buffum et al. (2006) observed no
significant changes in the heart rate and respiratory pattern in the music group
when compared with nonmusic group.
The majority of the studies conducted utilizing music as an intervention
for preoperative anxiety utilized primarily male subjects (Arslan et al., 2008;
Buffum et al., 2006; Cooke et al., 2005; Hamel, 2001; Kemper & Danhauer,
2005; D. Lee et al., 2004; K. C. Lee et al., 2011; Yung et al., 2002) who are
known to experience comparably lesser anxiety than women (Caumo et al.,
Labrague and McEnroe-Petitte 169
2001; Mitchell, 2003). In the present study where subjects are female, music
proved to be beneficial in the reduction of anxiety and vital signs. This result
implicates that music intervention may produce significant and beneficial
effects on the physiologic parameters and anxiety regardless of gender
differences.
Theoretically, during the preoperative period, music acts in several ways
to reduce anxiety and cause changes in the physiologic parameters. The act of
listening to music distracts patients and diverts feelings of anxiety and fear to
a more positive, stress-free experience (Cooke et al., 2005). Soothing music
lowers heart rate and BP by reducing catecholamine levels (Gillen et al.,
2008; Mok & Wong, 2003). The act of listening to music influences the limbic
system of the brain by reducing neurotransmitters’ ability to relay uncomfortable
feelings and triggers the release of body’s natural mood-altering
substances called encephalins and endorphins (Boso et al., 2006; Gillen et al.,
2008). Music, aside from anxiolytic effects, may also affect the sympathetic
nervous activity and, in turn, decreases in heart rate, RR, and BP (Arslan
et al., 2008).
With the above findings, and with the abundance of the results of the value
of music during the preoperative period, the present study may add to the
existing body of knowledge regarding the use of music in health care and
may further support the use of music as an effective intervention option that
promotes the physical and psychological well-being of the patient. In light of
the current global climate in nursing, it is important that health care providers
in general and perioperative nurses in particular are able to support the needs
of the patient by creating an environment that maintains relaxation and promotes
overall well-being. Although music yielded favorable effects on the
anxiety level in women undergoing gynecologic surgery, it should not be
utilized as a replacement for medical treatments and regimens. Music interventions
may be introduced to patients as an adjunct to produce more desirable
anxiolytic effects and be incorporated as part of nursing care.
Furthermore, hospital administrators may consider establishing “music centers”
in the hospital facility as a way of reducing patients’ experiences of
discomfort and unpleasant symptoms. With the current constraints on health
care budgets, providing soothing music in the preoperative environments in
patients who are scheduled for surgery is highly feasible.
While this study is essential, as it is one of the few studies conducted utilizing
women as subjects, nevertheless it has some limitations. First, awareness
of the subjects regarding the study protocol might have affected their
responses. Second, in the present study, prerecorded music was provided to
the patient, thus limiting the optimal effect of music on the anxiety levels. It
could also be possible that they might have different responses not reflective
170 Clinical Nursing Research 25(2)
of their real feelings or emotions. Previous studies suggested that for the
music to be therapeutic in reducing stress and inducing relaxation, it must be
the preference of the subject. D. Lee et al. (2004) stressed that beneficial
effects of music on anxiety reduction are associated with the music preference
of the listener. However, in a recent systematic review conducted, the
genre of soothing music appeared not to influence the effectiveness of music
interventions (Cepeda et al., 2006; Nilsson, 2008). Third, the use of headsets
rather than speakers might have caused different listening experiences that
may impact music intervention effects. Fourth, considering that the subjects
were taken from a single hospital facility, the researchers cannot make generalization
based on the result. Furthermore, this study may be conducted comparing
different types of music with varied listening duration time to
determine the extent to which music would result in maximum anxiety reduction.
Research studies are also needed to determine therapeutic effects of
self-selected music versus researcher-selected music in anxiety reduction
among surgical patients in varied populations.
Clinical Implications
As a noninvasive intervention, music intervention is safe, low risk with no
apparent deleterious effects, cost-effective, and easy to administer. Music
may be used as a complementary intervention by health care practitioners in
general and perioperative nurses in particular to promote comfort and relaxation
as well as to reduce preoperative anxiety among surgical patients.
Conclusion
Perioperative nurses are always challenged to provide holistic care to surgical
patients by providing comfort and safety during the entire perioperative
experience. Findings of this study provide empirical evidence to support the
use of music during the preoperative period in reducing anxiety and stabilizing
physiologic parameters in women undergoing gynecologic surgery.
Acknowledgment
The authors would like to express their heartwarming thanks and gratitude to all the
women who participated in the study.
Authors’ Note
Both authors contributed equally in study design, data collection and analysis, manuscript
preparation, and literature review.
Labrague and McEnroe-Petitte 171
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication
of this article.
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Author Biographies
Leodoro J. Labrague, MAN, BSN, RN, is a clinical instructor at Samar State
University, College of Nursing and Health Sciences, Philippines.
Denise M. McEnroe-Petitte, PhD, MSN, BSN, RN, is an assistant professor at Kent
State University Tuscarawas, USA.

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