Honors and the creative arts in nursing: music therapy to decrease anxiety in critical care patients.
Buckner, Ellen B. ; Leach-Fuller, Cynthia
In nursing education, we strive for a delicate balance between the
science and the art of nursing. While curricular objectives address
standards of practice assuring competencies in pathophysiology,
pharmacology, clinical fundamentals, medical nursing, surgical nursing,
and other domains of health science, we also purport to produce a
practitioner with sensitivity and compassion. The honors in nursing
option, begun in 2000 at UAB, has allowed us to push the creative side
of nursing to a higher level. Honors students have clearly taken this
opportunity with enthusiasm. Our first nursing honors graduate, Ms.
Cynthia Leach-Fuller, investigated an application of music therapy in
nursing while she was a student in our program. The research she
completed, a discussion of which follows, exemplifies the creative
process in a scientific setting.
Ms. Leach-Fuller joined our inaugural class of honors students in
nursing as an experienced registered nurse. She had begun the process of
completing requirements for the BSN. From her initial interview, it was
obvious that she possessed both great knowledge and creativity. She was
seeking to reach the highest levels of accomplishment in the profession
to which she was already committed. The honors program represented both
the culmination of long-held dreams and a legitimately earned position.
In our initial interview, Ms. Leach-Fuller recounted the
observation that would become the basis of her honors project. A teen
patient in intensive care following a motor vehicle accident was
semi-comatose, responding to stimuli not with words but with gestures
and motion. He was clearly anxious, restless, and hard to manage without
significant medication. Ms. Leach-Fuller had noticed that, when music
was played, the patient seemed to relax, becoming more cooperative and
at ease. She asked his mother to bring in tapes he enjoyed at home and
found that with this "music therapy" he could be more calm, be
more appropriately responsive, and heal more easily.
When Ms. Leach-Fuller joined the honors program, her questions were
those of an academic novice who was unfamiliar with the methods of
research, but they were also questions of a clinical expert who knew
what questions to ask. Coming from a community hospital, she had never
heard of anyone else interested in music therapy. What she found at UAB
was a rich literature in music therapy and numerous supportive
resources. She located and completed her mentorship with a certified
music therapist and initiated her honors project as an application of
music therapy. Her intuitive, creative energies were channeled through
her honors work into a developed working knowledge, manifold skills, and
the application of a novel approach to nursing.
Background in Music Therapy
Music can affect moods, spark memories, and foster associations.
Many people believe that these abilities make music uniquely helpful in
relieving the effects of mental or physical disability or illness, and
this belief has led to the use of music as a therapeutic intervention
(Marwick, 2000). Music is now used as a non-invasive treatment modality to help patients relax and cope with the uncomfortable issues of
illness. Ever since ancient times, though, music has been acknowledged
as having therapeutic value.
The literature regarding music therapy shows that music therapy has
been organized as a professional activity since the 1950's. The
American Music Therapy Association sponsors educational training for
licensure by the Certification Board for Music Therapists. Currently,
there are 8000 certified music therapists in the United States and
Canada. Music therapists are now utilized in a variety of settings
including nursing homes, geriatric and psychiatric units, hospitals, and
physical rehabilitation programs. Regardless how convincing anecdotal
accounts and individual observations about music therapy may seem, this
procedure will begin to enjoy widespread success only if it can be
validated by systematic studies providing consistent proof of its
effectiveness. The two most important current issues in music therapy
have to do with reimbursement and research. Evidence-based research will
provide the basis for future development.
Music has been shown to have more than entertainment value. If the
appropriate selection is made, it can stop the cycle of ceaseless
thinking and produce relaxation (Sammon, 1997). One study suggested that
the use of intra-operative music decreased patient-controlled
requirements for sedatives and analgesics (Koch, Kain, Ayoub &
Rosenbaum, 1998). Music has also been shown to decrease infant pain.
Babies listening to music during surgery displayed significantly less
pain by the end of the procedure than babies who weren't listening
to music during surgery. The group that did not listen to music
displayed an increase in heart rate and pain intensity (Kech &
Gerkensmeyer, 2000).
Methodology of the Honors Project
The purpose of the study conducted by this first honors graduate
was to decrease levels of anxiety and help patients relax with music
therapy. The sample consisted of critical care adults whose sensory
acuity level was within normal limits. The study variables were pre- and
post-therapy blood pressure, heart rate, respiratory rate, and emotional
disposition as evidenced by muscle tension/relaxation, facial
expressions, and anxiety levels. One research question guided this
study: will there be a decrease in level of anxiety in critical care
patients receiving music therapy?
Patients were invited to participate in the study as part of their
scheduled music therapy sessions, which were provided daily by a
certified music therapist. This intervention had been in place in the
university medical center for several years. The intervention may be
initiated by the patient's or a family member's request or
upon recommendation by the nurse or physician. For the patient who is a
candidate for the therapy, the music therapist offers a selection of
music from gospel to rock and that can include taped selections or live
vocal or instrumental works. Approval of the study for use of human
subjects was granted by the Institutional Review Board of the
university. Individuals who agreed to participate were asked their own
level of anxiety before and after the music session. Their vital signs
including blood pressure, heart rate and respiratory rate were taken
every five minutes.
Results
Five patients met the criteria for participation in the study. Four
of the subjects were female, and one was male, and ages ranged from 45
to 73. Music selections included gospel, folk, and classical.
Anxiety was present by self-report in 3 of 5 subjects prior to the
session. Based on a 1-5 scale of "not anxious" to "highly
anxious," the pre-session mean score was 3.3. At the end of the
session, 4 of 5 reported that they were "not anxious" and the
mean anxiety score decreased to 2.6. Because the sample size was so
small, these findings were not statistically significant.
Heart rate dropped during the session from a mean value of 94.2
pre- to 91.4 mid- to 91.2 post-session. Change in blood pressure was
less consistent: systolic pressure dropped mid-session but increased by
the end for an overall slight decrease. Diastolic pressure peaked mid
session, post-session being overall lower than pre-session. Findings
within individuals varied from this pattern, and the music may have
stimulated some neurologically mediated circulatory mechanisms.
Dispositions were rated on a scale of happy-to-sad and of
comfortable-to-restless.
Discussion
Overall results of this study demonstrated a reduction of anxiety
levels and vital signs during and after music therapy. There was one
participant whose vital signs increased, although this subject reported
a lessened level of anxiety and a happy disposition. In another case, a
participant's caregiver reported lowered levels of her own anxiety,
which she attributed to her having been present during the
patient's session. Therefore, there seem to be benefits for
caregivers as well as for their patients.
Results from this study support the opinion that music therapy can
reduce levels of anxiety in critically ill patients. As there is yet
little published data on the physiological effects of music therapy,
continued research should be directed toward further investigation into
this area. The systematic investigation of nurses into methods of
healing previously considered to be intuitive but to lack support from
the scientific community may reveal new procedures that are essential to
the holistic care of persons during both illness and health. The use of
the creative arts may hold great potential for new developments in the
practice of nursing.
Honors and the Creative Arts in Leadership Development in Nursing
Music therapy is growing in popularity with recent articles
detailing the benefits of this intervention in areas of pediatric nursing (Berlin, 1998), childbirth (Olson, 1998), and oncology/cancer
nursing (Lane, 1992). Through honors educational opportunities, students
may develop the creative art of nursing care as they discover, explore,
and integrate innovative modalities as an essential component of
practice.
Nursing has been described as a fine art, whether explicitly or
implicitly, by scholars ranging from Florence Nightingale to those of
the present day (Donahue, 1985). In his report "Scholarship
Revisited," Earnest L. Boyer (1990) defines four processes integral
to the scholarship of undergraduate education: discovery, integration,
application, and teaching. Through discovery of existing resources in
music therapy and their integration and application into the science of
nursing practice, our first nursing honors graduate, Ms. Leach-Fuller,
effectively demonstrated Boyer's definition of scholarship.
Additionally, because nursing is an interpersonal discipline, student
development in the affective domain (not just in the domain of
understanding) is or ought to be a goal of professional nursing
education. B. S. Bloom's taxonomy of educational objectives gives a
framework for exploring four levels of affective development (Krathwohl
et al., 1964). In the first level (attending to another person's
needs), Ms. Leach-Fuller recognized the effect of music therapy on her
patient's well-being and implemented procedures to utilize this
therapy as part of his care. She evidenced the second level of affective
development (valuing) by treating music therapy as an important practice
component and by pushing her ideas about it to even higher levels of
understanding and application in the honors course. As an intensive care
nurse, Ms. Leach-Fuller plans to use this modality whenever possible to
benefit her patients; it is thus part of her organization of practice,
the third level (in Bloom's terminology) of affective development.
Finally, Ms. Leach-Fuller was able, through mentorship, project
development, and dissemination, to reach the fourth level of affective
development: characterization by the value. For her, the art of nursing
can and should be practiced concurrently with the science in a manner
benefiting both the profession and the patient.
It is well recognized in nursing education that the profession is
demanding not only cognitively but also emotionally. Nurses use
emotional intelligence, defined as personal competence (self management)
and social competence (capacity for relating to others), to provide care
to patients and family members (Bellack, 1999). Bellack argues further
that nursing curricula, while teaching cognitive and psychomotor competence, fail to allow for development of these personal and social
competencies so essential to practice. Inundated by the memorization and
learning of baseline concepts essential to nursing care, the
undergraduate student can lose the basics of showing active interest and
concern for others, recognizing and responding to client needs, and
listening effectively. These skills, she notes, are both desirable and
valued in a relationship-intense and service-based profession such as
nursing. Bellack goes on to advocate non-traditional and novel learning
experiences as a necessary element to building a student's
emotional intelligence. Among those novel learning experiences are
mentorships and innovative projects such as those made possible through
honors education.
E. R. Bruderle (1994) discusses the importance of using the
creative arts to develop nurse leaders. She first recognizes that
leadership is an inherent quality in those who aspire to the profession.
Creativity and openness to new ideas is a characteristic of leaders, and
mentoring is one approach to developing such characteristics. Bruderle
sees the humanities as fostering the ability to integrate feelings,
ideas, and experience with one's personal (and professional)
experiences. She argues that leadership is better learned than taught
and that leaders must cultivate self-awareness, imagination, creativity,
and sensitivity to the uniqueness of individuals.
Did our honors student become a better leader, enhance her
creativity, and learn to apply humanistic content to the practice of
nursing through the integration of honors and the creative arts? Her
chosen innovation was an integrative therapy, a modality that functions
as an integrative whole, interacting with multiple processes and
systems. However, it is also a modality whose effects have not been
measured or evaluated systematically. In her three-month internship with
the music therapist, Ms. Leach-Fuller experienced a breadth and range of
music therapy applications for a variety of client conditions and ages.
Her knowledge of and sensitivity to the beneficial effects of this
intervention were strengthened. In choosing to evaluate this
methodology, she sought to find ways to describe the benefits of the
seemingly immeasurable effects she was observing. Her initial
observations were strengthened through systematic study. The project met
criteria outlined by the National Institutes of Health for evaluating
research in non-traditional therapies in that her primary question was
(a) asked by a researcher knowledgeable in the experience and practice
of the modality, (b) answerable, explicit, and practical, and (c)
important in the alleviation of suffering (Smith, 1998). The application
of scientific methodology through the honors project then provided the
bridge between the art and the science of nursing. By developing her
personal competencies in the modality and recognizing not one but
numerous effective applications to human responses in illness, Ms.
Leach-Fuller clearly developed her abilities as a leader in the practice
of acute care nursing.
References
Bellack, J.P. (1999). Emotional intelligence: A missing ingredient?
Journal of Nursing Education, 38(1), 3-4.
Berlin, K. (1998). Pediatric Update: Music Therapy with children
during invasive procedures, our emergency department's experience.
Journal of Emergency Nursing, 24(6), 607-608.
Bruderle, E.R. (1994). The arts and humanities: A creative approach
to developing nurse leaders. Holistic Nursing Practice, 9 (1), 68-74.
Boyer, E. L.(1990). Scholarship Reconsidered: Priorities of the
Professoriate. Princeton, N.J.: The Carnegie Foundation for the
Advancement of Teaching.
Donahue, M. P.(1985). Nursing: The Finest Art, An Illustrated
History. St. Louis: C.V. Mosby Company.
Kech, J., & Gerkersmeyer, J., (2000). Music shown to decrease
infant pain. Excellence in Clinical Practice, 7, 2.
Kock, M., Kain, Z., Ayoub, C., & Rosenbaum, S. (1998). The
sedative & analgesic sparing effect of music. Anesthesiology, 89(2),
300-336.
Krathwohl, D.R., Bloom, B.S., & Masia, B.B. (1964). Taxonomy of
Educational Objectives, Handbook II: Affective Domain. New York: David
McKay Company, Inc.
Lane, D. (1992). Music therapy: A gift beyond measure. Oncology
Nursing Forum, 19 (6), 863-867
Marwick, C., (2000). Music therapists chime in with data on medical
results. JAMA: The Journal of the American Medical Association, 283(6),
731-733.
Olson, S.L. (1998). Bedside musical care: Application in pregnancy,
childbirth and neonatal care. JOGNN: Journal of Obstetric, Gynecological Neonatal Nursing, 27 (5) 569-575.
Sammon, J., (1997). March music: A piece of my mind. JAMA:The
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Smith, M. (1998). Researching integrative therapies: Guidelines and
application. Journal of Emergency Nursing, 24 (6), 609-613.
ELLEN B. BUCKNER AND CYNTHIA LEACH-FULLER
UNIVERSITY OF ALABAMA AT BIRMINGHAM
The authors may be contacted at:
Ellen Buckner
204 School of Nursing
University of Alabama at Birmingham
1530 3rd Avenue South
Birmingham, AL, 35226
e-mail: bucknere@uab.edu
