Radiography (2008) 14, 184e188

ava i lab le at www.sc iencedi rect .com

journa l homepage: www.e l sev ie r.com/ locate/rad i

The use of music to aid patients’ relaxation ina radiotherapy waiting room

Laura Cooper a,*, Irene Foster b

a Oncology Department, Cheltenham General Hospital, Sandford Road, Cheltenham, Glos. GL53 7AN, UKb Faculty of Health and Social Care, University of West of England, Glenside Campus, Blackberry Hill,Stapleton, Bristol BS16 1DD, UK

Received 29 September 2006; accepted 29 January 2007Available online 3 April 2007

KEYWORDSRadiotherapy waitingarea;Environmental factors;Environmental stress;Anxiety;Cancer treatment;Relaxation;Stress reduction;Patient well-being;Music therapy

* Corresponding author. Tel.: þ44 8E-mail addresses: ljtrooper@h

irenejfoster@hotmail.com (I. Foster).

1078-8174/$ - see front matter ª 200doi:10.1016/j.radi.2007.02.001

Abstract Patient-centred practice and increasing user involvement adds impetus to built en-vironmental research within the health care setting. Much work has been centred around stressreduction initiatives for improving health outcomes for patients and staff.

This study examined the influence of music choice on patients’ anxiety levels whilst seatedin a radiotherapy waiting area. Patients’ stress levels and perceptions were assessed in the ab-sence/presence of music. The opinions of patients were elicited through a questionnaire fol-lowing exposure to a range of music types. Music therapy was shown to have clear benefitswhen individuals enjoyed the music to which they listened. Although clear preferences wereindicated, the results were skewed by the negative effects of music not enjoyed by patients.Further investigation needs to take account of the impact of personal variables and the valueof ‘quiet areas’.ª 2007 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction

The effects of music on human behaviour have beenrecognised since the times of ancient Greeks and Romans.1

However, music is more likely to have positive effect on in-dividuals if they enjoy the type of music to which they arelistening.2 The positive effects expressed as a source ofcomfort and an outlet for emotional expression have beenexploited therapeutically.3e6 These effects of music havebeen used as a tool to bring about positive changes in the

45 422 4043.otmail.com (L. Cooper),

7 The College of Radiographers.

behaviour and emotional well being of individuals, thuscoining the term ‘music therapy’. Recognised as a ‘universallanguage’, music therapy is successfully used in reducingfeelings of stress and isolation3, management of physicalsymptoms such as increasing the distraction from pain,and is instrumental in the management of emotional andbehavioural afflictions (Fig. 1).5,6

A search of the literature shows much work during the1970s and 1980s centred around the use of music therapywithin the healthcare setting, for enabling the enhance-ment of coping strategies of individuals. This was especiallyevident during the first and second World Wars, whenmusicians would go into the hospitals and perform for thephysically and emotionally injured soldiers.7 The continuedsearch for alternative and complementary therapies that

Published by Elsevier Ltd. All rights reserved.

Increasesocial

interaction

Increaseexpression ofthought and

feelings

Relaxation

Distractionfrom pain or

anxiety

Guidedimagery

MusicTherapy

Figure 1 Varying uses of musical intervention.

The use of music to aid patient’s relaxation 185

benefit patients’ well being in this way, has resulted in therecent resurgence of interest in the subject of musictherapy.

Evidence has shown that the calming effect of musichelped to reduce states of stress and anxiety. Patients arethus better able to take control and become engaged inactive coping strategies.8 Choice of music type is howeverimperative, since music will be relaxing only if it is enjoyed,but may have an undesirable effect if not enjoyed.2

The four main areas of research into approaches forreduction of stress and anxiety (Table 1), have informed thework of many therapists. A mounting body of evidencedemonstrates the positive effects of music therapy as anaid to relaxation.9,10 This is especially apparent in patientswho also experience feelings of isolation. They relate tomusic as a ‘universal language’ which eases both anxietyand distracts the patients attention from internalising.11

Whether the patients participate in the music or listen toit, the music will usually have an effect on their thoughtsas well as emotions.12

The effect of music on the anxiety levels of patientswere similarly examined within oncology. Since anxietyamongst cancer patients is the most common form ofdistress,13,14 the use of music therapy within the oncology

Table 1 Main research areas of stress reduction in patients (ad

Information provision The patient is given information abouRelaxation Involves many techniques which aid rCognitive-behavioural

approachesTeaching the body and mind to deal wThis could mean that the patient hasthrough the situation

Modelling Based on a view that exposure to a msuccessfully with a particular experiecoping strategies

setting was considered beneficial in aiding relaxation anddecreasing levels of anxiety.15,16

Smith et al.16 examined the anxiety of radiotherapy pa-tients receiving daily treatment. Those in the first subjectgroup that took part in this study were able to listen toa type of music of their choice during their simulation ap-pointment and daily treatments through headphones. Thesecond group, the control group, was not exposed to anymusic within this environment.

The State-Trait Anxiety Inventory16 was completed bythe subjects at pre-determined intervals:

� immediately following the simulation procedure;� at the end of the first week of treatment;� at the end of the third week;� at the end of treatment.

The study results showed no statistically significantdifferences between the group that listened to the musicand those that did not. However, the study did indicatea pattern and dynamics of patient anxiety during thecourse of treatment. State anxiety scores for both groupsreduced over time during the course of treatment. Thestudy concluded that music may fulfil a therapeutic roleduring pre-treatment planning and the early stages oftreatment.16

Methodology

A pilot study identified the waiting room as the area wherepatients felt most anxious. Prominent relaxation methodswere listed as being time spent with friends and family,watching television and listening to music. Based on thisoutcome, the study examined the patient’s level of anxietywhilst seated in the waiting room and the effective changeof music on their status.

The study was conducted within a single oncologycentre. Recruitment for this purpose considered all pa-tients for follow-up clinics, chemotherapy and radiother-apy. From this group of patients, 250 were randomly chosento complete the questionnaire. Every third patient report-ing to the reception desk for one of the three allocationswas invited to participate. The questionnaire sought toelucidate opinions on patients’ degree of comfort andanxiety status whilst seated in the waiting room.

The study was conducted over five consecutive days. Day1 was the control without any music being played. Prede-termined selection of music categories were played onsubsequent days (Fig. 2).

apted from Messer and Meldrum8)

t the procedure they are to undergoelease of tension or clears the mindith stressful situations in a different manner.to give themselves ‘self-help’ talks to get them

odel (e.g. a video) of an individual copingnce. This can teach the patient to utilise similar appropriate

No Music(white)

Classical Music(green)

Easy listening Music(pink)

Jazz Music(orange)

Pop Music(yellow)

Day 1

Day 2

Day 3

Day 4

Day 5

Figure 2 Design of the study.

Television9%

Radio19%

Books3%

Music66%

Playingcards3%

Figure 3 Suggestions for increasing degree of relaxation inwaiting area.

Treatment67%

TreatmentPlanning

1%

Chemotherapy18%

Follow-up14%

Figure 4 Reasons for attendance at the oncology centre.

186 L. Cooper, I. Foster

Colour coded questionnaires that corresponded with themusic type were handed to every third patient as indicatedabove. It was considered pertinent that patients settledthemselves in the waiting room for a while before answer-ing the questions. This time adjustment was considerednecessary to allow adjustment to the environment and thusgo some way towards improving reliability and validity ofthe study.

Time of arrival and departure from the waiting room wasnoted at the top of each completed questionnaire, andposted into a box sited on the reception desk as the patientleft the department.

Results

A response rate of 32.8% was received and analysed. Inresponse to the questionnaire on day 1 of how theenvironment could be made more comfortable and aidtheir feeling of relaxation, patients indicated overwhelm-ingly in favour of listening to music (Fig. 3). Sixty-nine per-cent of these patients arrived at the centre feeling relaxedand at ease, whilst 17% reported feeling anxious. In both in-stances, these were patients attending for treatment, che-motherapy and follow-up clinic (Fig. 4).

Responses to the categories of music being playedvaried with age and gender, although easy listening musicproved to be the most popular and jazz the least popular.The peak age range of the respondents was in 51e60-year-old category, with 87.8% being female. Thefemales showed a preference for easy listening music,whilst the males mostly favoured pop music. The easylistening and classical music induced a sense of increased

calm, whilst easy listening and pop music engenderedpositive feelings.

Patients surveyed spent an average of one hour in thewaiting room. At the end of this time 57% indicated a feelingof calmness. The time spent in this environment may haveenabled participants to respond to and enjoy the musicenough to experience this positive outcome. This result washowever distorted by the numbers of patients who tooka disliking to the music played on a particular day, thusincreasing their level of discomfort (Fig 5). It could be sur-mised that levels of discomfort may also have been in-creased by extended waiting beyond appointment times.Levels of stress may increase if patients have time con-straints due to other commitments, or feel anxious abouttheir treatment.

Discussion

Research into the impact and influence the environmenthas on individuals is gathering pace, not least within thehealthcare arena. Functionality of hospital design should

0

10

20

30

40

50

60

70

80

Resp

on

den

ts R

esp

on

se (%

)

Classical Easy Listening JazzMusic Category

YesNoNot Sure

Pop

Figure 5 Increased levels of relaxation.

The use of music to aid patient’s relaxation 187

essentially include consideration of the comfort levels of alluser groups.17 Much research has examined the influence ofenvironmental factors such as noise, colour, lighting, smelland general ambience within hospital areas.18e24 This envi-ronment should facilitate reduced stress levels for staff andpatients, for improved outcomes and overall healthcarequality.17 Whilst most of these aesthetic effects areimposed or constrained by extraneous factors, practitionersare well placed to positively influence the therapeuticenvironment to the benefit of their patients23,25,26 andthemselves.

Therapeutic intervention is much more effective whenthe emotional, spiritual, cognitive, social and physicalneeds of the patients are being met.5 Research showsthat music can influence a wide range of physiologicaland psychological effects. These effects can trigger therelease of hormones which can alter body temperaturebecause of its influence on pulse rate, breathing, sweatingand blood circulation3 and positively contribute to a lessen-ing of those factors that enhance the disease process.27

However, these experiences are more likely to be positivewhen individuals are exposed to music of preferredchoice.27 The music that appealed to most patients withinthis study, was the gentle melodic type categorised as being‘easy listening’. Patients were seated in the waiting roomfor an average of one hour. Those who enjoyed the musicthey were listening to during this time period, reportedfeelings of calmness and increased relaxation. The studyconfirmed that patients’ level of comfort and relaxationcould be influenced by the music being played in the wait-ing room. Although smaller proportions of patients indi-cated positive responses to pop music, jazz and classicalmusic, these numbers were too small to provide any mean-ingful inferences. Supposition within this study regardingmusic choices has been confirmed elsewhere2; classicalmusic used within coronary care reported benefits beingsimilar to the effects of vallium.28

Although no formally accredited assessment tool wasused to gauge the patients’ levels of anxiety whilst seatedin the waiting room, this study does concur with othersimilar research undertaken.15,16,27e30 Other studies29,30

indicating the use of music within the health care settingfailed to identify the types of music being used or

preferences, but did suggest that levels of stress and anxi-ety were effectively reduced.

Many studies10,11,15,23,28 have indicated the use of musicduring therapeutic intervention. Although this has a placewithin oncology practice, the patients within this study in-dicated that higher levels of anxiety were experienced inthe waiting room, rather than the treatment rooms. Whilstthe vast majority of patients questioned indicated that theenvironment of the waiting room could be improved by hav-ing music being played, others also indicated addition ofthe radio or television should be considered (Fig. 3). Care-ful consideration should be given to the introduction of theaudio/visual medium, since similar preferences to radiostation or television channels, as music type, will prevail.

The limitation inherent within this study failed torecognise that background noise may contribute to levelsof anxiety.31 Although patients were invited to make anyadditional comments regarding the music and other envi-ronmental factors within the waiting area, there was nooption to indicate the preference of a ‘quiet area’. Patientsexperiencing pain and discomfort, as in the case of somecancer patients, are more likely to have a restricted toler-ance of noise.31,32 Music intended to relax patients maythus inadvertently exacerbate anxiety levels under thesecircumstances.

Hospital waiting areas, by their very nature, have anassociation with stress and anxiety. Rofe et al.33 suggestthat a vast majority of patients would prefer to avoid otherpatients, and thus a waiting room filled with ‘sick’ people.Patients do not want to be confronted with ongoing healthconditions and threats of progressive disease.34 Attemptsshould therefore be made to make waiting rooms as pleas-ant as possible. Calming environments which are conduciveto patients’ well being need not incur huge costs.35 Practi-tioners are well placed in recognising and helping to reduceaspects of common stress factors, such as the quality ofinformation giving,36 signposting,37 waiting times, and tidi-ness and comfort of waiting areas.17 Failing to address someof these issues may invalidate other attempts of creatinga calming and relaxing environment.

Conclusion

Cost effectiveness in hospital design has had detrimentaleffects on the ambience of patient areas. Research into theenvironmental stressors and the subsequent negative im-pact on health outcomes for patients may have begun toinfluence change. Small changes within the clinical envi-ronment could significantly improve the health and wellbeing of patients and staff. The provision of subtlebackground music is one such initiative. The choice ofmusic should wherever possible appeal to the range ofpatients attending the department. There is recognitionthat the confounding personal variables may not have beenfully accounted for within this study. These variables arepotentially wide ranging within a radiotherapy department,especially since perceptions of stress and coping are verysubjective, as are the perceptions of and responses toenvironmental stressors. It may therefore appear to becounter-productive to introduce the playing of soothingmusic within the waiting areas in an attempt to facilitate

188 L. Cooper, I. Foster

increased relaxation, when patients are not able to reapthe full benefit. Providing patients with additional facilitiesfor personal coping strategies would increase the efficacyof harmonised environmental stressors.

Although test tools were not used to measure anxiety ormood states in patients, responses to the questionnairewere considered valid reflections of their perceived emo-tional status at that particular time. The study has provideda useful insight into changes that could improve theambience of patient areas within the department at lowcost, and highlighted other areas for further research.

References

1. Rooke A. Searching for the Last Chord: ancient uses and mod-ern trends, Sunshine Magazine. Theosophical University Press;1985.

2. O’Connor T. What is relaxation music? http://www.tonyoconnor.com.au/sounds.html [Accessed on 04/07/06].

3. Campbell D. The Mozart effect. New York: Avon Books; 1997.4. McGuire D, Yarbro C, Ferrell B. Cancer pain management. Lon-

don: Jones and Bartlet; 1995.5. Hillard RE. Music therapy in hospice and palliative care. Evi-

dence-based Complementary and Alternative Medicine 2005;2(2):173e8.

6. Mandel SE. The role of the music therapist on the hospice/palliative care team. Journal of Palliative Care 1993;9:37e9.

7. Hallam S. The power of music report. http://www.thepowerofmusic.co.uk [Accessed on 04/7/06].

8. Messer D, Meldrum C. Psychology for nurses and health careprofessionals. Hertfordshire: Prentice Hall/Harvester Wheat-sheaf; 1995.

9. Thault MH, Smeltekop RA. Psychological and neurophysical as-pects of music therapy interventions. New York: Schirmer; 1990.

10. Hicks F. The power of musicdcan the soothing effects of musicreduce patient and staff stress and tension in theatre? TheNursing Times 1992;88(41):72e4.

11. Herth K. The therapeutic use of music. Supervisor Nurse; Oct1978;22e3.

12. Davis B. Caring for people in pain. London: Routledge.13. Greer S, Moorey S, Baruch JDR, Watson M, Robertson B,

Mason A, et al. Adjuvant Psychological therapy for patientswith cancerda prospective randomised trial. The British Med-ical Journal 1992;304:675e80.

14. Watson M, Greer S, Rowden L, Gorman C, Robertson B, Bliss J,et al. Relationships between emotional control, adjustment tocancer and depression and anxiety in breast cancer patients.The Journal of Psychological Medicine 1991;21:51e7.

15. Cook JD. Music as an intervention in the oncology setting. Can-cer Nursing Journal 1986;9:23e8.

16. Smith M, Casey L, Johnson D, Gwede C, Riggin O. Music asa therapeutic intervention for anxiety in patients receivingradiation therapy. Journal of Oncology Nursing Society 2001;28(5):855e62.

17. Ulrick R. Architects help make hospitals better, www.tamu.edu/univrel/tamunews/Facspotlight/stories/06/fsaprc.html;2006 [Accessed on 12/7/06].

18. Frasca-Beaulieu K. Interior design for ambulatory care facili-ties: how to reduce stress and anxiety in patients and

families. Journal of Ambulatory Care Management 1999;22(1):67e73.

19. Topf M, Thompson S. Interactive relationships between hospi-tal patients’ noise-induced stress and other stress with sleep.Heart and Lung 2001;30(4):237e43.

20. Schweitzer M, Gilpin L, Frampton S. Healing spaces: elementsof environmental design that make an impact on health.Toward Optimal Healing Environments in Health Care: 2ndAmerican Samueli Symposium. Journal of Alternative andComplementary Medicine 2004;10(1):S71e83.

21. Ainsworth RA, Simpson L, Cassell D. The effects of three colorsin an office interior on mood and performance. Perceptual andMotor Skills 1993;76(1):235e41.

22. Coryell JA. The therapeutic use of color in a clinical environ-ment. Dissertation Abstracts International: Section B: The Sci-ences and Engineering, vol. 64(3B). USA: The Wright Institute;2003.

23. Lehrner J, Eckersberger C, Walla P, Potsch G, Deecke L. Ambi-ent odor of orange in a dental office reduces anxiety and im-proves mood in female patients. Physiological Behaviour2000;71(1e2):83e6.

24. Galrajani RP. Physical environmental factors affectingpatients’ stress in the accident and emergency department.Accident and Emergency Nursing 1995;3:22e7.

25. Renz M, Schutt M, Cerny T. Spirituality, psychotherapy andmusic in palliative cancer care: research projects in psycho-oncology at an oncology centre in Switzerland. SupportiveCare in Cancer 2005;13(12):961e6.

26. Smolen D, Topp R, Singer L. The effect of self-selected musicduring colonoscopy on anxiety, heart rate and blood pressure.Applied Nursing Research 2002;15(3):126e36.

27. Bartlett D, Kaufman D, Smeltekop R. The effects of musiclistening and perceived sensory experiences on the immunesystem as measured by interleukin-1 and cortisol. Journal ofMusic Therapy 1993;30:194e209.

28. Ostrander S, Schroeder L, Ostrander N. Superlearning. NewYork: Delacorte Press; 2000.

29. Kaempf G, Amodei M. The effect of music on anxiety. Asso-ciation of Operating Room Nurses Journal (AORN) 1989;50:112e8.

30. Winter MJ, Paskin S, Baker T. Music reduces stress and anxietyof patients in the surgical holding area. Journal of Post Anaes-thesia Nurses 1994;9(4):340e3.

31. Topf M. Hospital noise pollution: an environmental stressmodel to guide research and clinical interventions. Journalof Advanced Nursing 2000;31(3):520e8.

32. Babisch W. Noise and health. Environmental Health Perspec-tives 2005;113(1):A14e5.

33. Rofe Y, Lewin I, Hoffman M. Affiliation patterns among cancerpatients. Psychological Medicine 1987;17(2):419e24.

34. Palmer SC, Kagee A, Coyne JC, DeMichele A. Experience oftrauma, distress, and posttraumatic stress disorder amongbreast cancer patients. Psychosomatic Medicine 2004;66(2):258e64.

35. Biley F. Creating a healing patient-environment. Nursing Stan-dard 1993;8(5):31e5.

36. Browning G, Warren NA. Unmet needs of family members in themedical intensive care waiting room. Critical Care NursingQuarterly 2006;29(1):86e95.

37. Nicoll S. The art of good signage. (Use of art and design in hos-pital signposting). Hospital Development 1995;26(6):24e5.