Music Intervention
Linda L. Chlan
Annie Heiderscheit
Music has been used throughout history as a treatment modality (Haas & Brandes, 2009). From the time of the ancient Egyptians, the power of music to affect health has been noted (Davis, Gfeller, & Thaut, 2008). Nursing pioneer Florence Nightingale recognized the healing power of music (1860/1969). Today, nurses can use music in a variety of settings to benefit patients and clients.
DEFINITIONS
The American Heritage Dictionary of the English Language (2011) defines music as “the art of arranging sounds in time so as to provide a continuous, unified and evocative composition, as through melody, harmony, rhythm, and timbre.” Crowe (2004) identifies several elements that serve as the building blocks of music.
Rhythm is the timing in music and is a phenomenon that is universal to all music. Rhythm includes: tempo, beat, meter, and the duration of tones. It is what provides the movement in music. Rhythm influences motor skills and activates muscles. Slow rhythms can invoke a sense of peace and calm. Strong and intense rhythms can foster a sense or feelings of energy or power.
Melody is the movement of pitches and tones in time. Melody is the relationship between the pitches. The movement and frequency of these pitches impacts our experience. Frequency and pitch are produced by the number of vibrations of a sound—the highness or lowness of a
musical tone, noted by the letters A, B, C, D, E, F, G. Higher pitches have more rapid vibrations that tend to act as a stimulant, whereas lower pitches have slower vibrations that can bring about relaxation. Melody is often the element in music a listener follows that can serve to engage or distract the mind.
Harmony is related to melody in that it is the sound produced when pitches are played or sung simultaneously. Harmony communicates a sense of relationship, how the notes connect or relate to one another. Harmony often conveys the emotions in music. When harmony is consonant or pleasing in sound, there is a feeling of calm connection. Harmony that is dissonant creates a sense of tension, conflict, and unpleasantness. It is important to note that cultural norms determine what a listener deems enjoyable and pleasant. Different cultures use different tonal systems.
Timbre is the characteristic sound of the instrument playing the music or the voice singing. The construction, shape, materials, and the technique of the player impact timbre of an instrument. Timbre of a voice is impacted by the body and technique of the vocalist. The psychological significance of timbre includes the associations with feelings, memories, and events.
Form is the structure or design of music. It can be considered the container within which music is organized. For example, symphonies follow a form of four movements, whereas in a song there will be lyrics and a chorus. The organization in form provides a sense of comfort and predictability.
Dynamics in music are the change in sound intensity or volume. Dynamics range from loudness to softness. The intensity in dynamics can impact our experience with music. Softer or quieter music can create a sense of calm, closeness, and intimacy; louder music can create a feeling of energy and power.
Music therapists are well versed in using and implementing the healing elements of music to meet the specific and individualized needs of patients. In the United States and around the world, music therapists are employed in a wide variety of health care settings and facilities. Although music therapists are specifically trained to use music in various therapeutic ways, there are many situations in which nurses can implement music intervention into a patient’s plan of care. So as not to confuse the practice of music therapy with the use of music from a nursing perspective, the term music intervention will be used in this chapter.
SCIENTIFIC BASIS
Music is a complex auditory stimulus that affects the physiological, psychological, and spiritual dimensions of human beings. Individual responses to music can be influenced by personal preferences, experiences, demographic characteristics, the environment, education, and cultural factors.
Entrainment, a physics principle, is a process whereby two objects vibrating at similar frequencies tend to cause mutual sympathetic resonance, resulting in their vibrating at the same frequency (Dissanayake, 2009). Entrainment also refers to the synchronization of body rhythms to an external rhythm (Crowe, 2004; Hodges & Sebald, 2011). Music and physiological processes (including heartbeat, blood pressure, brain waves, body temperature, digestion, and adrenal hormones) involve rhythms and vibrations that occur in a regular, periodic manner and consist of oscillations (Crowe, 2004). Rhythm and tempo of music can be used to synchronize or entrain body rhythms (e.g., heart rate and respiratory pattern) with resultant changes in physiological states. Certain properties of music (less than 80 beats per minute with fluid, regular rhythm) can be used to promote relaxation by causing body rhythms to slow down or entrain with the slower beat and regular, repetitive rhythm (Robb, Nichols, Rutan, Bishop, & Parker, 1995).
Likewise, music can decrease anxiety by occupying attention channels in the brain with meaningful, distractive auditory stimuli (Bauldoff, Hoffman, Zullo, & Sciurba, 2002). Music intervention provides a patient/client with a familiar, comforting stimulus that can evoke pleasurable sensations while focusing the individual’s attention onto the music (distraction) instead of on stressful thoughts, pain, discomfort, or other environmental stimuli.
INTERVENTION
Determining a patient’s music preferences through assessment is essential; among the tools developed for this purpose is an assessment instrument by Chlan and Heiderscheit (2009) that elicits information on how frequently music is listened to; the type of music selections, artists, groups, and genres preferred; and the individual’s reasons for listening to music. For some people, the purpose of listening to music may be to relax, whereas others may prefer music that distracts, stimulates, and invigorates. After assessment data have been gathered, appropriate techniques with specific music can then be devised and implemented.
Techniques
The use of music for intervention can take many forms, such as (passive) listening to selected compact discs (CDs) or individual music downloads from the Internet, as well as actively singing or drumming. A number of factors should be kept in mind when considering the specific technique: the type of music and personal preferences, active music making versus passive listening, individual versus group involvement, length of time
involved with the music, and desired outcomes. Two of the more commonly used music-intervention techniques are discussed here: individual listening and group music making.
involved with the music, and desired outcomes. Two of the more commonly used music-intervention techniques are discussed here: individual listening and group music making.
Individual Music Listening
Providing the means for patients to listen to music is the intervention technique most frequently implemented by nurses. CDs or MP3 downloads from a reputable Internet source (such as www.MyMusicInc.com or iTunes) make it easy to provide music intervention for patients in a wide range of health care settings. CD/MP3 players are relatively inexpensive; they are small and can be used in even the most crowded confines, such as critical care units. CD/MP3 players have superior sound clarity and track seeking that enables immediate selection of a desired piece of music. Comfortable headphones allow patients private listening that does not disturb others. Equipment selected for music intervention should be easy for patients to use with minimal effort. Small MP3 players, like the Apple iPod® or Apple iPad®, are more expensive than CD/MP3 players and should be reserved for patients with intact dexterity and sufficient visual acuity to operate these units.
Nurses can encourage patients and their family members to bring in their own music from home to use while hospitalized. Patients may already have own their preferred music available via a mobile or digital device. With only a very modest outlay of money, a nursing unit can establish a music library containing a wide variety of selections to suit various musical preferences. The Public Radio Music Source (www. prms.org) offers diverse music for purchase. It is also easy to individualize CDs or MP3 files to accommodate the preferences of each client. Attention to copyright laws is necessary when reproducing CDs or downloading music from Internet sites (for guidance refer to www.copyright.gov).
Although various musical genres are available on the radio or Internet radio (Pandora), commercial messages and talking are deterrents to using these sources for music intervention. Likewise, one cannot control the quality of the radio signal reception or the specific music selections.
Group Music Making
Music can be used for patient groups as a powerful integrating force. Music creates and fosters connection and interrelationships among the members as well as between the listener and the music. One method of group music making is drumming, a form of rhythmic auditory stimulation. Drumming has been found to reduce posttraumatic stress disorder (PTSD) symptoms in a small group of soldiers, both by serving as
an outlet for rage and for regaining a sense of control (Bensimon, Amir, & Wolf, 2008). Drumming circles can induce relaxation by entraining theta and alpha brain waves, leading to altered states of consciousness by activation of the limbic brain region with the lower brain (Winkelman, 2003) and by increasing natural killer (NK) cell activity (Bittman et al., 2001; Wachi et al., 2007). Group drumming has been used effectively to reduce burnout and improve mood in nursing students (Bittman et al., 2004), decrease employee burnout and improve mood states of staff working in long-term-care settings (Bittman, Bruhn, Stevens, Westengard, & Umbach, 2003), foster creativity and body movement in long-term-care residents (Bittman et al., 2004), and enhance recovery from a variety of chemical addictions (Winkelman, 2003).
an outlet for rage and for regaining a sense of control (Bensimon, Amir, & Wolf, 2008). Drumming circles can induce relaxation by entraining theta and alpha brain waves, leading to altered states of consciousness by activation of the limbic brain region with the lower brain (Winkelman, 2003) and by increasing natural killer (NK) cell activity (Bittman et al., 2001; Wachi et al., 2007). Group drumming has been used effectively to reduce burnout and improve mood in nursing students (Bittman et al., 2004), decrease employee burnout and improve mood states of staff working in long-term-care settings (Bittman, Bruhn, Stevens, Westengard, & Umbach, 2003), foster creativity and body movement in long-term-care residents (Bittman et al., 2004), and enhance recovery from a variety of chemical addictions (Winkelman, 2003).
Before implementing this type of group music making, nurses should consult with experts trained in the use of group drumming. The American Music Therapy Association website (www.musictherapy.org) can provide assistance in locating a music therapist for consultation. Interested nurses can visit the HealthRhythms website at Remo.com to locate an endorsed HealthRhythms facilitator in a specific area or to learn more about HealthRhythms training. HealthRhythms is a group-drumming protocol developed by Remo, Inc.; training is offered throughout the United States each year. Further, diversity in the preferences, interests, and abilities of individuals in a group or the difficulties of securing an appropriate site for a group session may necessitate handling music on an individual basis; group sessions also require more planning than individual sessions.
Types of Music for Intervention
Careful attention to the selection of the music contributes to its therapeutic effect. For example, music to induce relaxation has a consistent and steady rhythm (less than 80 beats per minute); melody that is smooth, flowing, and predictable, with a small range of interval dynamics; and harmonic structure that is consonant and pleasing, with instrumentation that the individual enjoys (Grocke & Wigram, 2007). It is important to note that past experiences can influence one’s response to music and that music can elicit a powerful emotional response or reaction at times.
Older adults may enjoy patriotic and popular songs from an earlier era (often music from their late teens to early twenties) or hymns with slower tempos played with familiar instruments (Moore, Staum, & Brotons, 1992). Religious music may be preferred and welcomed by those unable to attend spiritual services, and for whom faith is important.
New Age or contemporary music may be preferred by some people. This kind of music differs from traditional music, which is characterized by tension and release. However, some experts think that this type of synthesized music is not appropriate for relaxation because of the novelty of the stimulus and the absence of the usual forms found in more
conventional music (Bonny, 1986; Hanser & Thompson, 1994). Music perceived as unfamiliar will cause an orienting response that may undermine goals for intervention (Maranto, 1993).
conventional music (Bonny, 1986; Hanser & Thompson, 1994). Music perceived as unfamiliar will cause an orienting response that may undermine goals for intervention (Maranto, 1993).
Guidelines
Music intervention for the purpose of relaxation uses music as a pleasant stimulus to block out sensations of anxiety, fear, and tension and to divert attention from unpleasant thoughts (Thaut, 1990). A minimum of 20 minutes of music is necessary to induce relaxation, along with some form of diversion exercise, such as deep breathing, prior to initiating music intervention (Guzzetta, 1995).
Although the definition of relaxing music may vary by individual, factors affecting response to music include musical preferences, familiarity of selections, and cultural background. Relaxing music should have a tempo at or below a resting heart rate (less than 80 beats per minute); predictable dynamics; fluid melodic movement; pleasing harmonies; regular rhythm without sudden changes; and tonal qualities that include strings, flute, piano, or specially synthesized music (Robb et al., 1995). One of the most widely used classical music selections for relaxation is Pachelbel’s Canon in D Major, which is frequently included in commercially available diversion CDs. In the last several years, many music companies have been producing recordings specifically packaged as music for relaxation. There is a wide array of recordings available in various genres and styles that can also include various instrumentation and environmental sounds. Exhibit 7.1 outlines the basic steps for handling music intervention for promoting relaxation.
Measurement of Outcomes
The outcome indices for evaluating the effectiveness of music intervention vary, depending on the purpose for which the music is used. Results may be physiological and/or psychological alterations and include a decrease in anxiety or stress arousal, promotion of relaxation, increase in social interaction, reduction in the need for medications, and increase in overall well-being. The nurse should carefully consider the goals of intervention and select outcome measurements and appropriate instruments accordingly.
Precautions
It is imperative that music preferences be assessed prior to initiating a musiclistening intervention. Everyone has “musical memories” and listening to a piece of music can bring up negative emotions that can be detrimental to an individual’s well-being and also negatively impact the goals of intervention.
Exhibit 7.1. Guidelines for Music Intervention for Relaxation
1. Ascertain that patient has adequate hearing
2. Ascertain patient’s like/dislike for music
3. Assess music preferences and previous experience with music for relaxation
4. Provide a choice of relaxing selections; assist with CD/MP3 selections as needed
5. Determine agreed-upon goals for music intervention with patient
6. Complete all nursing care prior to intervention; allow for a minimum of 20 minutes of uninterrupted listening time
7. Gather equipment (CD or MP3 player, CDs, headphones, fresh batteries) and ensure all are in good working order
8. Test volume and comfort of volume level with patient prior to intervention
9. Assist patient to a comfortable position as needed; ensure call-light is within easy reach and assist patient with equipment as needed
10. Enhance environment as needed (e.g., draw blinds, close door, and turn off lights)
11. Post a “Do Not Disturb” sign to minimize unnecessary interruptions
12. Encourage and provide patient with opportunities to practice relaxation with music
13. Document patient responses to music intervention
14. Discuss feelings of patient after using music intervention. Identify whether client encountered any challenges or problems with the equipment
15. Revise intervention plan and goal(s) as needed
Initiating music intervention without first assessing a person’s likes and dislikes may produce deleterious effects. Because of music’s effect on the limbic system, it can bring about intense emotional responses. Use of portable players with headphones may be inappropriate or prohibited for patients in psychiatric settings, who may use the equipment cords for self-harm.
Likewise, using music for diversion in patients with tenuous or unstable cardiovascular status should be done with extreme caution. Patients should be closely monitored for any untoward cardiovascular responses.
Age-Related Implications or Adjustments Needed for Optimal Implementation
Older adults may require additional precautions prior to using music for therapeutic listening purposes. For instance, volume and bass may need to be adjusted to match hearing acuity. Headphones are ideal
for masking background noise that can interfere with hearing acuity. Careful selection of equipment for music-listening interventions requires special attention to dexterity and/or vision impairments. Diminishing dexterity or vision may impact the frequency or use of individual music listening.
for masking background noise that can interfere with hearing acuity. Careful selection of equipment for music-listening interventions requires special attention to dexterity and/or vision impairments. Diminishing dexterity or vision may impact the frequency or use of individual music listening.
USES
Music has been tested as a therapeutic intervention with many different patient populations; a majority of the nursing literature focuses on individualized music listening. Exhibit 7.2 shows those patient populations and the numerous therapeutic purposes that music has served. Two frequent uses are highlighted here.
Exhibit 7.2. Uses of Music Intervention
Orientation/Minimizing Disruptive Behaviors
Decreasing Anxiety
Pediatrics (Barrera et al., 2002; Kemper et al., 2008)
Surgical patients (Johnson, Raymond, & Goss, 2012; Kain, Sevarino, Alexander, Pincus, & Mayes, 2000; Lee, Henderson, & Shum, 2004; Yung et al., 2002)
Cancer patients (Clark et al., 2006; Ferrer, 2007)
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