Evaluating Pictures of Nature and Soft Music on Anxiety and Well-Being During Elective Surgery

1. INTRODUCTION

Patients undergoing surgery often have a sense of anxiety and stress [1, 2]. A higher level of preoperative anxiety has been associated with increased postoperative pain [3], prolonged recovery [4], increased hypotension after spinal anesthesia [5], and a greater risk of in-hospital mortality or major morbidity [6].

Spinal, epidural, or local anesthesia offers many advantages for the patient because it is less risky as compared to general anesthesia. However, these anesthesia options may be stressful and anxiety inducing because the patient is awake during surgery, so it is important to establish and maintain the patient’s comfort [7, 8]. The patient needs security during this exposed situation and can communicate with the nurse anesthetist or physician during the procedure [9]. Mediating a sense of comfort and keeping the patient focused are achieved by continuously giving the patient information, which is important for establishing the reassurance the patient needs [10]. In addition to reducing anxiety through establishing trust between the patient and the nurse anesthetist, different interventions have been tested for distracting patients to reduce the anxiety and stress [11-13] related to the surgery.

Nursing intervention to relieve unpleasant experiences has long relied on music. Music can also be used as a pleasant distraction to keep the patient from thinking about the situation they are in while undergoing surgery [14, 15]. The experience and effect of listening to music may be influenced by the choice of music as well as the patient’s earlier experience of it. Patient age, gender, and cultural background may also affect responses [16]. The music can be listened to using speakers or earphones, and it is preferred that the patient can change the volume at will [17].

Instrumental music with a rhythm of about 60–80 beats per minute has positive relaxing effects on anxiety, pain, and stress [18] and also positively influences circulation and respiration [15, 16]. Furthermore, relaxing music in a preoperative setting decreases anxiety preoperatively [19, 20] more than sedative oral premedication does [21]. In one study, patients listening to music while undergoing mastectomy had decreased mean arterial blood pressure, anxiety, and pain compared to patients in a control group [22]. Likewise, anxiety was reduced among patients listening to music during ambulatory surgery [23, 24]. Other distraction interventions used are audiovisual distractions. In one case study, Athanassoglou et al. [7] reported that patients undergoing limb microvascular orthoclastic surgery appreciated audiovisual distractions like watching TV or using the internet. They felt relaxed, which was also reported to be beneficial during the recovery.

Furthermore, seminal research on the sense of using colors in health care was performed by Ulrich et al. during the 1990s. Colors are used as distractors because they have different effects on people [25-27] including physiologically positive influences on lowering blood pressure and pulse rate. Green space, in general, has a positive health impact on stressful events in life [25, 28]. Viewing calm green pictures of natural scenery has been used in health care as a way to decrease stress and increase well-being [25, 26, 29] while challenging pictures have had the opposite effect [25, 26].

Patients undergoing bone marrow aspiration and biopsy who viewed pictures of nature scenery filled with green experienced less pain compared to patients who received standard care, although the difference was not statistically significant [29]. Natural scenery has also reduced anxiety about dental procedures and pain [30], and live plants and pictures of plants reduce the patient stress level in the waiting room [31]. The artificial natural scenery is a safe and low-cost distractor that has been used only to a limited extent. To our knowledge, there is no study using natural scenery as a distractor among adult awake patients undergoing elective surgery. The effect of music is however, better documented [4]. Thus, the objective of this study was to investigate whether looking at pictures of natural scenery could reduce anxiety and pain and increase relaxation and well-being being awake during elective surgery.

2. MATERIALS AND METHODS

This three-arm, randomized intervention study to evaluate the effect of looking at pictures of nature being awake during elective surgery was performed at three hospitals in Southern Sweden.

2.2. Intervention

All patients who participated were randomized into the three groups. The randomization was performed through coded questionnaires stating the group the patient belonged to. These questionnaires were placed in coded envelopes. The patients who were randomized to look at pictures of natural scenery viewed the images on an iPad placed on an arm attached to the operating table so that the patient could see the pictures while lying on the operation table Fig. (1). Nature scenery pictures with calm green vegetation of the Swedish landscape without any animals were selected due to earlier study results reporting increased psychological well-being [25, 26]. There were 70 pictures and each picture was shown 45 seconds on the Ipad. Patients randomized to listen to music listened to soft instrumental music, MusiCure, music as medicine, with a rate of about 60-80 beats/minute, which was earlier reported to have positive effects through sensory stimulation on patients in health care. The music is composed from the evidence of patient experience and the CD number 5 (Seasons) from MusiCure collection composed by Niels Eje was used [32]. The patient listened to the music on a CD player using earphones and with the ability to control the volume themselves, meaning that the patient and the physician and nurses did not disturb each other. The patients who were randomized to the control group received care without distraction. There is a routine in Sweden that patients undergoing surgery without general anesthesia, recieve low doses of anesthesia (Propofol) or analgesia (e.g. Fentanyl) as supplement to local anesthesia, if feeling pain or discomfort. The need for this is usually assessed by the anesthetic nurse. All patients received medical drugs as described above when considered in need for this.

3. RESULT

Patients (n = 225) were asked to participate of whom n =174 (53% women) with a mean (SD) age of 58 (±17) years participated in the study. External drop out (n =51) was related to patients did not want to participate, was not interested to listen to music or wanted full anesthesia. More patients had spinal anesthesia compared to the other options (p<0.001), most had had orthopedic surgery (p<0.0001), and 58% (n=102) had previously undergone surgery while being awake (Table 1). Of the participants, 70 were allocated to the intervention group looking at pictures of natural scenery, 56 to the intervention group listening to music, and 41 to the control group receiving routine care.

Sedative and analgesic medical drug treatment was administered to some patients. The control group received a significantly higher dose of propofol compared to the music group, a difference that disappeared when controlling for significance among the three groups (Table 2).

No difference was found between the two intervention groups and the control group with respect to anxiety, well-being, relaxation, or pain after surgery (VAS scales; Table 3), even when controlling for drug treatment with propofol and/or fentanyl. There was, however, a tendency to a difference regarding relaxation when adjusting for propofol (p=0.058), meaning a slightly higher degree of relaxation in the intervention group looking at pictures.

When controlling for the effects of propofol on the difference in anxiety before and after surgery as measured with STAI, patients who received propofol had a significantly higher degree of anxiety after surgery compared to those who did not (p=0.014). For treatment with fentanyl or propofol and fentanyl, no difference was found.

Patients under age 58 years had a higher degree of anxiety (p>0.001) and lower degree of relaxation and well-being (p=0.019 and p=0.003, respectively) compared to patients over 58 years. Women had a higher degree of preoperative anxiety than men (p=0.045).

Of the patients in the intervention group looking at pictures of natural scenery, 79% (n=68) said that they would look at pictures again; of those listening to music, 68% (n=54) preferred to listen to music if undergoing surgery again. For any upcoming surgery, 7% (n=6) preferred bringing their own pictures, and 11% (n=9) preferred bringing their own music.

4. DISCUSSION

Results showed no differences among the three groups regarding anxiety, well-being, relaxation, or pain after surgery. However, both the music intervention and the picture intervention groups received less sedation with propofol during the surgery compared with the control group. This difference may indicate that looking at pictures of natural scenery or listening to soft instrumental music can reduce anxiety during surgery, even if no significant differences could be measured postoperatively in the present study. However, patients who received propofol had a significantly higher degree of anxiety after surgery compared to those who did not, which may suggest that a distracting intervention is as calming as propofol treatment. In a previous study [36] aimed at determining the effectiveness of a photographic display on reducing preoperative anxiety, significant differences between the photographic group and the control group were obtained only for the respiratory rate. A music intervention was not evaluated separately in that study, but anxiety was found to decrease when pictures were combined with music.

A majority of patients in the current study (79% in the picture intervention group and 68% in the music intervention group) stated that they would like to have the same intervention if they had to undergo surgery again. This result could be interpreted as the interventions having had some positive effects, even if differences were not statistically significant using the measurements employed in the study. Experiences and emotions during surgery are individual experiences related to pre-understanding and previous experiences [37]. Music in the operation room has been found to hinder the nurses’ ability to hear the surgeon's speech [38], so the music is often delivered to the patient by earphones. However, some patients would like to know what is going on during the surgery [37]. For those patients, looking at pictures could offer some distraction while still maintaining the opportunity to get information and participate in what is going on in the operation room. A recent interview study revealed that nurse anesthetists assumed that all patients were anxious prior to surgery [39]. Increased work experiences made it easier to handle anxious patients, and more experienced nurses valued nursing interventions and calming conversations prior to administering pharmaceuticals. This possibility has not, to our knowledge, been explored, although such comments were heard during the present study. Insufficient time related to high workloads has also been experienced to affect the first encounter with the patient and how intraoperative anxiety is addressed [39]. If the workload is high, it may be seen as faster and easier to offer sedation than another relaxing alternative, such as looking at pictures or listening to music. One positive effect that occurs when patients are distracted during the surgery may be less patient movement when lying on the operation table, which may be beneficial for the surgeon. This possibility has not, to our knowledge, been explored, although such comments were heard during the present study.

Women had more preoperative anxiety than men, and younger patients showed a higher degree of anxiety compared to older patients, what is in line with earlier reported results [40-42].

However, there are several limitations with this study. One limitation is that a decision was taken to terminate the study before reaching the estimated number of patients. This decision was related to a pronounced high workload at the operating theathers and a problem to perform any task beyond routine care. Despite this, the study involved a relatively large number of patients in comparison with other, similar studies and the result could hopefully be useful for designing future studies in the area.

Lack of difference between groups in the current study may be due to the fact that the effect was not captured by the parameters measured. Further research in the area may therefore, need to include parameters measuring stress during the actual procedure together with self-reported assessments afterward.

Another limitation in this study is related to the randomization procedure that did not work fully, probably because nurses found it difficult to first ask patients about interest in participating in a study about listening to music or watching pictures of nature during the operation and then go back to the patient and tell them that they had been randomized to a control group with either music or pictures. The staff would have needed more information about the importance of following the randomization.

Another limitation was that the included patients were operated in various operation rooms where the iPad with pictures often had to be installed and readjusted for each patient. Because the study was conducted within the context of daily activities involving a large number of staff members, several staff members never had time to become skilled at installing the equipment in a fast and appropriate manner. This situation would probably have been different if the intervention had been managed by fewer staff members or by staff members who were familiar with the equipment. Furthermore, the absence of standardization for sedative medication may be seen as a limit. In Sweden, patient needs always must regulate drug administration, so even if the current purpose was to study patients without sedative medication, some of them asked for or needed it.

Physiological parameters such as signs of pain or anxiety not measured may also be seen as a limit. Moreover, in the future, it would be interesting to evaluate a combination of a picture and music intervention.

CONCLUSION

Looking at pictures of natural scenery being awake during surgery is as relaxing as listening to soft instrumental music. This knowledge could be especially valuable for patients with poor hearing if they need distraction during surgery. Being aware that women, and perhaps also younger patients, have a tendency to heightened anxiety before surgery could also be valuable. Pictures of natural scenery should be studied also in other contexts because looking at natural scenery may have generalizable advantages.

REFERENCES