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Experiences and perceptions of music therapy in critical illness.

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The setting for this study was the general intensive care unit (ICU) in a district general hospital serving a multicultural community. The unit promotes a holistic, multidisciplinary approach.

Abstract

VOL: 101, ISSUE: 45, PAGE NO: 34

Tina Stubbs, BSc, RGN, is practice development facilitator, intensive care unit, Homerton University Hospital, London

The setting for this study was the general intensive care unit (ICU) in a district general hospital serving a multicultural community. The unit promotes a holistic, multidisciplinary approach.

 

 

At the time of the study rest periods for patients were an established and respected part of care. This involves closing the unit to visitors for two hours during which the lights are turned down and the patients are not disturbed unless in an emergency. The layout of the unit allows for a light-operated telephone system, which means that patients do not have to endure ringing telephones as well as various machine alarms. A sleep promotion standard has been developed and is in place.

 

 

Music therapy was suggested as a natural addition to these measures as it was thought it might help promote the psychological well-being of patients.

 

 

Aim
The objectives of the study were to gain insight into patients’ and nurses’ perception of the benefits of music therapy during critical illness and to add to the body of knowledge in nursing around the use of therapies complementary to medicine.

 

 

In particular the study aimed to discover if the patients had any recollection of listening to music when they had been sedated, ventilated and unresponsive and if the use of the patients’ favourite music made a difference to their response or memory of the music therapy intervention.

 

 

Literature review
The following databases were searched: MEDLINE, CINAHL and PSYCHLIT. Journals were hand searched for articles and their references used.

 

 

It became apparent that there was little qualitative data on the psychological benefits of music as a therapy to support or refute the quantitative physiological findings to date.

 

 

In his study Hazzard (2002) found the most significant theme in interviews with patients post intensive care was the emotional pain of prolonged stress. Therefore, critical care nurses should plan care to alleviate stress as much as possible.

 

 

The very nature of intensive care, where physiological parameters are changing from one moment to the next and can be influenced by a multitude of factors, means that it can prove difficult to measure them as an outcome. Medications can and do have a profound effect on physiological parameters and, unless the researcher controls for these, results have to be viewed with caution.

 

 

All the studies found relating to intensive care patients have been on patients who were not sedated. Only two studies concerned patients who were mechanically ventilated but not unresponsive or sedated (Chlan, 1998; 1995).

 

 

The physiological measurements recorded were heart rate and respiration (Chlan, 1998; 1995; and White, 1992) and the findings suggested that music intervention helped to reduce these autonomic nervous system indicators, which are strongly suggestive of a relaxation response. Chlan’s (1998) was the only study that mentioned taking medications into consideration and found a reduction in heart rate and respiration for the music group.

 

 

Guzetta (1989) found a reduction in heart rate in both her relaxation and music therapy groups but music therapy was more effective than relaxation alone in increasing peripheral skin temperature - another indicator of the relaxation response.

 

 

Updike’s 1990 study was the only one to look at music therapy in intensive care patients using a semi-qualitative approach. As well as physiological measurements she used an open-ended questionnaire to gather data on emotional states before and after music therapy. The findings were that all 20 patients felt calm, relaxed or comforted post music intervention while around half had felt ‘lousy’, ‘terrible’ or ‘frustrated’ pre-intervention.

 

 

In summary the research has demonstrated that physiologically music has a positive effect on the relaxation response of patients who are awake and weaning off a ventilator but there is no research on the use of music therapy in patients who are critically ill, unresponsive and ventilated.

 

 

The intervention
The patients received music therapy on two prescribed occasions for 30 minutes each day. This time had been used in previous quantitative studies (Updike, 1990; Chlan, 1998; 1995).

 

 

No authors mentioned how they decided on this time, but for music to be a ‘therapeutic noise’ there has to be a limit to the length of time it is applied to prevent it becoming a nuisance. The first music therapy interval led into the rest period and the second was after the evening bedbath as the lights were dimmed.

 

 

The music was chosen from a library of CDs held on the ICU or from music brought in by the patients’ relatives or friends. This had the effect of increasing family and friends’ involvement in care thus reducing the sense of helplessness many of them experience (Dyer, 1991). It also meant the patients had access to music familiar to them, which could help elicit beneficial effects of music therapy.

 

 

Music therapy was carried out on all patients even when they were unresponsive secondary to sedation because, as Hudak et al (1990) state, when a patient is unresponsive they may not necessarily lack sensory awareness as denoted by an unconscious patient.

 

 

Method of investigation
For this study, a qualitative exploratory study approach was chosen, using unstructured interviews with five patients and four nurses. These were analysed according to Burnard’s framework (1991).

 

 

Ethical approval was given by the local research and ethics committee.

 

 

The patients were interviewed in the general ward area before their discharge home or as outpatients. Granberg at al (1998) suggest that by doing this the interviews would be deemed to be genuine as the participant was no longer reliant on intensive care for their medical care.

 

 

To enable full exploration, the interviews with the participants were loosely structured. The author used probes or questions to elicit information, such as: ‘What does music mean to you in health?’, ‘What are the sounds of intensive care you remember most?’ and ‘Do you recall wearing headphones while you were a patient in intensive care?’

 

 

Results
Patients’ experience

 

 

A common theme quickly emerged. When patients were informed the interview related to music therapy they had received on the ICU, they all denied they had listened to music. The nursing staff had kept a timetable of the music therapy interventions the patients had received. This served as a memory jogger. The music was played at the time of interview.

 

 

Two participants recalled imagery. One said:

 

 

‘I remember imagining in my mind’s eye a fountain and lots of greenery, lots of hedges and quite watery. I do remember sort of moving my mouth as well, the moisture was quite appealing… ’

 

 

Another participant, commenting on the CD being played, said:

 

 

‘Maybe this is why I thought I was in Africa, hey?’

 

 

Three participants talked about being somewhere else or being reminded of somewhere else. One said: ‘It was a little bit of home I suppose… umm… in that very grey place.’

 

 

Another participant said:

 

 

‘It made me feel like I was at home. I felt like I was in my own surroundings, in my bedroom… the hospital hadn’t come into it. I didn’t realise I was on intensive care - that’s what that did for me.’

 

 

A third, who had thought she was in Africa, said:

 

 

‘I went to Africa to buy melons.’

 

 

Spies-Pope (1995) discusses how a patient’s perception can be altered by music and this proved true for one of the participants, who said:

 

 

‘Oh dear, I must have been in a lot of pain at the time. This helped a lot. It was very unexpected having the music put on… but this was spot on at the time.’

 

 

Aldridge (1994) found evidence that music had an effect not only on the emotional aspect of pain but also the actual sensation of pain reduced.

 

 

When asked if the music helped him to sleep and relax, one participant said:

 

 

‘Yes, all of those and to pass the time… it’s a form of escape, escape into the music if you like… It is probably the best invention man ever made, everybody likes some form of music.’

 

 

One participant recalls having musical dreams:

 

 

‘I do remember some kind of musical dreams, I call it… which was fairly out there and that was very cloud-like, cushioned me a little bit - I remember that.’

 

 

The music also recalled memories of the intensive care stay and one participant became quite emotional. When asked if it was an uncomfortable response, he replied:

 

 

‘No, it’s not. I think it puts me back there a little which obviously isn’t too comfortable but kind of the music’s there it’s just a memory… I am OK about remembering it, but it’s just about what it is doing to me now is remember… and impress upon me how much in a bad way I really was… and how this music for this brief moment really, really helped a lot.’

 

 

He added later:

 

 

‘I’m glad we are listening to it again as well because it has evoked pooled memories and I think that’s a good therapy to me because as you know everything has been a bit scant.’

 

 

The same participant felt that the music was a ‘happy memory’ among so many bad memories of intensive care.

 

 

The use of the patients’ own music gave them reassurance and they recognised it as familiar.

 

 

‘This music is about life carrying on, your life is carrying on and again it’s very comforting and very sort of like… yes… things aren’t all good but you are going to persist, you are going to carry on and stuff like that… This matched the mood that, like, OK you are in this bed and you’re pretty low but that life is going on, an eternity kind of thing, the persistence of life, so I remember this as well.’

 

 

The same participant, on listening to one of the CDs being played, said:

 

 

‘I definitely remember being carried away by this and thinking it was going to be OK and I suppose feeling a lot happier.’

 

 

Recognising her own music being played gave reassurance to one of the participants, who said:

 

 

‘I found it comforting [to hear] this tune I knew really well.’

 

 

This participant had in the past played the tune in anger. When asked if this emotion returned on hearing it in intensive care, she felt she had got over the stage of playing it in anger and felt:

 

 

‘Comfortable… it’s like ‘Yes!’ I’d played the tune so often I knew exactly what CD it was.’

 

 

During one interview the researcher inadvertently played a CD that the participant had not listened to. The patient was not informed at the time of the interview that another CD had been substituted for the one on his timetable. He did not recall the first piece of music but did recall the next CD played, which was one he had listened to.

 

 

This inadvertent addition added to the validity of the interviews because it proved the participant had not been trying to please the interviewer but was being honest about his recall of the music.

 

 

Nurses’ experience

 

 

None of the nurses interviewed felt there were any disadvantages and found positive results. One said:

 

 

‘… and they clearly settled and slept on it… they definitely seemed to be relaxed by it.’

 

 

Another nurse reported:

 

 

‘I do find that it helps generally, especially when you are trying to reduce sedation, trying to get the patient off it completely and I think their music helps to keep them calm.’

 

 

Discussion
In this study music therapy was started as soon as the patient was admitted to intensive care when she or he was still unresponsive. Relatives were asked about musical preferences and whether the patient would mind wearing headphones.

 

 

Psychological care should start at the same time as physical care. One participant recalled a piece of music that had been played according to her timetable very early in her ICU admission when she would have been sedated and ventilated. Sedation regimes have changed in recent years; patients are given as little sedation as possible to get them ‘tube tolerant’ awake and weaning off the ventilator as early as possible. Music therapy can be a useful adjunct to calm patients and focus them on weaning and tolerating the endotracheal tube.

 

 

Of particular note to nurses and their practice is that patients recall the music and it can bring back memories of intensive care. It is important that the music is played at specific times and individually to the patient and not as background working noise for the nursing staff. Otherwise there is a risk of patients having flashbacks to certain pieces of music, especially if they were undergoing an unpleasant procedure while it was being played.

 

 

Conclusion
This study revealed that music therapy could have a role in the care of patients in the ICU setting.

 

 

Further research into this area of practice is needed. A study to look at the effects on the stress response of a critically ill patient could be performed by looking at measurements of stress hormone levels during and after music therapy (Watkins, 1997). A further study could include a control group (patients who do not receive music therapy) compared with a music intervention group with evaluation of their memories and recall of their intensive care experience.

 

 

Psychological care is as important as physiological well-being. Music therapy is one intervention that, used appropriately, can be used confidently to relax, reassure and distract a patient. On occasions such therapy can even ‘relocate’ patients temporarily from their critical illness, assisting them psychologically in their recovery.

 

 

This article has been double-blind peer-reviewed.

 

 

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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