O R I G I N A L A R T I C LE

Effect of sleep-inducing music on sleep in persons with percutaneous transluminal coronary angiography in the cardiac care unit
Min-Jung Ryu, Jeong Sook Park and Heeok Park

Aim and objective. The study compared the effect of earplug-delivered sleep-inducing music on sleep in persons with percutaneous transluminal coronary angiography in the cardiac care unit. Background. Diverse types of music have been claimed to improve sleeping elsewhere, but relatively little is known in South Korea. Most studies investigating the effect of sleep-inducing music on sleep have involved persons with insomnia, even though many persons with cardiovascular disease in the intensive care unit suffer from sleeping problems. There is a need to investigate the effect of sleep-inducing music on sleep disorders in persons with percutaneous transluminal coronary angiography in the cardiac care unit. Design. An experimental research design was used. Methods. Data collection was conducted in the cardiac care unit of K University Hospital in D city, from 3 September 4 October 2010. Fifty-eight subjects participated and were randomly assigned to the experimental group (earplug-delivered sleep-inducing music for 52 min beginning at 10:00 PM , while wearing an eyeshield, n = 29) and the control group (no music, but earplugs and eyeshield worn, n = 29). The quantity and quality of sleep were measured using questionnaires at 7 AM the next morning for each group. Results. Participants in the experimental group reported that the sleeping quantity and quality were signicantly higher than control group (t = 3181, p = 0002, t = 5269, p < 0001, respectively). Conclusion. Sleep-inducing music signicantly improved sleep in patients with percutaneous transluminal coronary angiography at a cardiac care unit. Offering earplugs and playing sleep-inducing music may be a meaningful and easily enacted nursing intervention to improve sleep for intensive care unit patients. Relevance to clinical practice. Nurses working at cardiac care unit can use music to improve sleeping in clients with percutaneous transluminal coronary angiography. Key words: cardiac care unit, cardiovascular disease, earplugs and eyeshield, insomnia, nurses, nursing, percutaneous transluminal coronary angiography, sleeping, South Korea
Accepted for publication: 21 June 2011

Introduction
The prevalence of cardiovascular disease (CVD) is increasing because of increased life expectancy, obesity and lack of exercise. CVD has been signicantly related with high mortality in South Korea (Statistics Korea, 2010). Most

persons with CVD require coronary angiography as one of the treatments and are supposed to be admitted to the intensive care unit (ICU) for close observation. The environment of a typical ICU is not conducive to sleep. Sleepdepriving inuences include continuous bright light, extreme noises, discomforting smells and frequent medical/nursing

Authors: Min-Jung Ryu, MSN, RN, Nurse, Keimyung University, DongSan Hospital; Jeong Sook Park, PhD, RN, Professor, Keimyung University, College of Nursing; Heeok Park, PhD, RN, Tenure Track - Lecturer, Keimyung University, College of Nursing, Daegu, South Korea

Correspondence: Heeok Park, Tenure Track - Lecturer, Keimyung University, College of Nursing, Deagu, South Korea. Telephone: +82 53 580 3924. E-mail: hopark@kmu.ac.kr

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The effect of sleep-inducing music on sleep

care (Novaes et al. 1997, Kahn et al. 1998, Freedman et al. 1999). Severe sleep disorders can negatively affect physiological parameters including protein synthesis, cell dissolution and immunity and can contribute to increased mortality (Krachman et al. 1995). Sleep disorders in the ICU can cause anxiety, confusion, memory problems and decreased orientation or cognition (Granberg et al. 1996). Especially, persons who receive a percutaneous transluminal coronary angiography (PTCA) suffer from sleeping discomfort in the ICU because they are subject to intense observational scrutiny, which includes a 24-hour electrocardiogram (EKG) in the immediate aftermath of the angiography, despite a relatively short-term ICU stay compared to patients with other serious maladies (Kim 2001). Sleep disorder in persons with CVD cause severe physical emotional changes including increased catecholamine secretion and unstable emotions, which should be addressed by controlling the sleep disorder (Schwab 1994, Schafer et al. 1997, Kim 2001). To improve sleeping in ICU patients, varied forms of nursing care have been tested (Haddock 1994, Fang & Liu 2006, Jang & Choi 2008, OK Park, Korea University, Seoul, unpublished Masters thesis, YJ Koo, Keimyung University, Daegu, unpublished Masters thesis). The use of ear plugs can improve both the quantity and quality of sleep (Haddock 1994, YJ Koo, Keimyung University, Daegu, unpublished Masters thesis). Lessened light intensity attained through diminished light (Fox 1999) or the use of eye bandages (YJ Koo, Keimyung University, Daegu, unpublished Masters thesis) can be helpful. However, these steps did not completely alleviate the sources of sleep deprivation. As well, the studies suffered from lack of randomisation of subjects. Several studies have reported that the positive effects of classical music, religious music and client preferred music on sleep (Johnson 2003, Lai & Good 2005, Park 2008, Chan et al. 2010, OK Park, Korea University, Seoul, unpublished Masters thesis). Levin (1998) applied the term brain music to describe the change in brain wave patterns observed in sleep-deprived subjects during periods of increased musicassisted sleep. Ziv et al. (2008) played relaxing music for older adults to improve sleeping, and the subjects reported reduced anxiety and improved quality of sleep. KK Park (Jeju National University, Jeju, unpublished Masters thesis) reported enhanced sleep using delta (d)-wave music compared with non-d-wave music. Most studies to date concerning the inuence of music on sleep have involved persons with insomnia. There has been no music intervention studies directed at patients with CVD in South Korea. The present study addressed this shortcoming.
2011 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 728735

Background
ICU sleep
Sleep disturbances increase neurosis, anxiety, confusion, attention deciency, emotional discomfort and mortality, but also decrease physical self-defence and sensitivity (Krachman et al. 1995, Pandi-Perumal et al. 2002). There are many factors affecting sleep, and they are generally categorised as physical (illness, discomfort and pain), emotional (anxiety, depression, psychiatric disease, stress and cognitive disorders) and environmental (temperature, humidity, lightness, noises, smell and sound) factors (Kim & Suh 1992, Novaes et al. 1997). Patients with coronary vascular disease are often admitted to the ICU, surrounded by severe noises and impropriate lighting, sleep can suffer (Edell-Gustafsson et al. 1994, Simpson et al. 1996). In one study, over 50% of ICU patients suffered from serious sleeping disorders (Noh et al. 2005). Sleeping problems with ICU patients can include difculty falling asleep, decreased duration of sleep, unsatisfactory sleep and decreased quality of sleep (Yinnon et al. 1992, Schwab 1994, Freedman et al. 1999). Sleeping is signicantly related with cardiovascular conditions (Schafer et al. 1997, Peled et al. 1999). While sleeping, systolic blood pressure decreases by 515% in humans, which reduces cardiac loading and increases cardiac life. On the other hand, sleeping disorders stimulate the sympathetic nerve system and promote the over-secretion of vasoconstrictors that increase cardiac loading. ICU patients report lower quantity and quality of sleeping than healthy persons (Kim & Suh 1992, Krachman et al. 1995, Freedman et al. 1999). Patients receiving a cardio-angiography in the cardiac care unit (CCU) typically require close observation for the rst 24 hours with absolute bed rest (ABR). This may interrupt normal sleep (Kim 2001). To improve sleeping in ICU patients, diverse interventions such as aromatherapy, relaxation therapy, massage and music have been applied (Zimmerman et al. 1996, Fang & Liu 2006, Kim et al. 2006, Park 2008, Jeong 2009, MH Lee, Jeju National University, Jeju, unpublished Masters thesis, OK Park, Korea University, Seoul, unpublished Masters thesis). Generally, the result is increased quantity and quality of sleep. Among the interventions, music intervention is costeffective because it is relatively easy to supply.

Sleep-inducing music
Music therapy is dened as an established allied health profession using music and music activities to address

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physical, psychological, cognitive and social needs of individuals with disabilities (AMTA 1997). The documented positive effects of music on various health problems include anxiety, stress, depression and pain (Kim 2007, Moradipanah et al. 2009, Allred et al. 2010, Hong & Cho 2010, Huang et al. 2010). Music is also effective for ICU patients. Dijkstra et al. (2010) applied music to ventilator-assisted patients and reported a positive inuence on pulse rate, breathing rate and relaxation. Nilsson (2009) offered music to coronary artery bypass graft patients and reported reduced oxytocin levels and increased relaxation. Music interventions have also been applied to control sleeping problems. Ziv et al. (2008) offered relaxation music with muscle relaxation exercise to older adults with sleep disorders and compared the effect of music with relaxation exercise. Anxiety was lower, and the quality of sleep was improved signicantly in the music intervention group compared to the exercise group. Chan et al. (2010) and Lai and Good (2005) also offered music to older adults, and sleep was improved in the music group compared to patients not receiving music. The effect of music on sleep has been studied in South Korea. Park (2008) and OK Park (Korea University, Seoul, unpublished Masters thesis) played music for coronary angiography patients and reported improved sleep after listening to music. Different types of music were offered to improve sleep, and sleep-inducing music (i.e. d-wave music, which stimulates sleep waves in the brain, KK Park, Jeju National University, Jeju, unpublished Masters thesis) has been explored as a means of improving sleep in South Korean subjects experiencing sleeping problems. Sleep-inducing music is played at low volume to promote relaxation and lessen anxiety, stress and sleep problems (KK Park, Jeju National University, Jeju, unpublished Masters thesis). KK Park (Jeju National University, Jeju, unpublished Masters thesis) reported that sleep-inducing music stimulates higher levels of d-wave brain pattern sleep compared to other types of music or no music at all. Alpha-waves, which are antagonistic to sleep, are lessened when listening to sleep-inducing music compared to other types music or no music. Persons who listen to d-wave music report being relaxed by the music and that the music promoted a sound sleep. South Korean studies of the effect of sleep-inducing music have tended to be limited to persons with sleeping disorders, with far less information known of the inuence of sleep-inducing music on patients, in particular those with CVD in the ICU. As PTCA is one

of the most common processes administered to ICA patients with CVD, it becomes of interest to determine the sleep-inducing effects of music to this patient population. The present study investigated the effects of sleep-inducing music on sleep patterns in PTCA recipients in the ICU, with the aim of suggesting practical nursing interventions to improve sleep. The experimental research design was driven by two hypotheses: (1) The quantity scores of sleeping in experimental group (sleep-inducing music) will be higher than in control group (ear plugs) and (2) The quality scores of sleeping in experimental group will be higher than in the control group.

Methods
The research protocol, consent form and potential risks and benets were reviewed and approved by the K University D Hospital Human Subjects Review committee.

Participants
The principal investigator gave a brief presentation to those scheduled for admittance to the CCU a coronary angiography. After the presentation, consent was obtained from 60 of those attending who agreed to participate in this study. The inclusion criteria were 20 years of age, diagnosis of coronary artery disease, admittance to CCU after PTCA and the occurrence of ABR immediately after angiocatheter removal in the CCU. Exclusion criteria were use of ventilators, diagnosed of dementia, neurologic disease, or sensory disorder, use of sleep-inducing drugs or sedative medications, and history of sleeping problem before admittance to CCU. The sample was determined by power calculation based on Cohens (1988) effect size formulas using power 080 and effect size 070. Based on the calculation, 52 subjects for two groups were needed, but 60 subjects enrolled after considering a 10% drop rate. The 60 participants were randomly assigned to experimental group or control group using card number. The participants having an even number were assigned to the experimental group, and those with an odd number were assigned to the control group. During the data collection, two subjects dropped-out. One participant in the experimental group was excluded for having taken a sleepinducing drug taken. One participant in the control group was transferred to another unit. Finally, 29 subjects constituted the experimental group and 29 formed the control group.
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Instruments
Quantity of sleeping Quantity of sleeping questionnaire elicited information concerning the total number of sleeping hours. The questions included the time falling asleep and the awakening time the next morning. The quantity of sleeping was counted as total number of minutes from the time of falling asleep to the time of awakening the next morning. If a subject awoke for a short time during the night, the time of wakefulness was subtracted from the sleeping minutes. For example, if a subject fell asleep at 11 PM and awoke at 4 AM , but was awake for one hour during the night, the sleeping time was recorded as 240 minutes. Quality of sleeping Quality of sleeping was measured using the modied Verran and Synder-Halpern (VSH) sleeping scale (Verran & SynderHalpern 1987, Kim & Kang 1994). The VSH includes eight questions regarding the frequencies of awakening while sleeping, depth of sleep and self-evaluation of sleep. The VSH is a Likert scale that ranged from 010 for each question, with a total possible points ranging from 080. Cronbachs alpha value of the original VSH was 082 in Verran and Synder-Halperns study (1987). The Cronbachs alpha value of the modied VSH was 086 in Kim & Kangs study. Cronbachs alpha value of the modied VSH in this study was 083.

music was developed by Park (2008) and OK Park (Korea University, Seoul, unpublished Masters thesis) and was entitled Koreans brain: Thank you for doing such as great job-stable effect on sleeping: Delta wave Clinic Vol 1. The sleep-inducing music included Nature Sounds (two minutes and eight seconds), Delta Wave Control Music (ve minutes 21 seconds), Goldberg Variations BWV. 988 (27 minutes three seconds), Nature Sounds (four minutes 57 seconds), Goldberg Variations BWV. 988 (11 minutes one second) and Nature Sounds (two minutes 25 seconds). The MP3 music was supplied through earphones to the participants from 10:0010:53. If a subject fell asleep with the music still in progress, the earphone was not removed intentionally until 5 AM the next morning, so as not to disturb sleep. Eye bandage CS-204 (CS Berea Korea) was also applied to the participants at 10 PM and was removed at 5 AM the next morning. The timing of the start of the music (10:00 PM ) and removal of the earphones (5 AM the next morning) coincided with the time of the last daily blood pressure check and the rst blood pressure check of the day, respectively. If participants did not want to continue sleeping any time after 10 PM , the music was terminated and the earphones were removed. The participants answered the questionnaires regarding the quantity and quality of sleeping at 7 AM on the same day. Control group No music was offered to participants, but ear plugs 370 Bilsom No.303 (Bacau-Dalloz Korea) were applied from at 10 PM 5 AM the next morning. The same eye bandage used in the experimental group was also applied to the control participants. The participants in control group also answered the sleeping questionnaires at 7 AM .

Data collection
Data collection was conducted at K University D hospital in D city from 3 September4 October 2010. After consent to participate was obtained, the rst meeting was scheduled at the hospital to check demographic data and sleep characteristics. There were 29 subjects in the experimental and control groups. The principle investigator trained the two research assistants regarding the general information of this study including purpose, method and measurement. The principle investigator played recorded sleep-inducing music at 10 PM , and the research assistants helped subjects to answer the questionnaires concerning the quantity and quality of sleep. The research assistants were nurses having more than two years of experience in the CCU and who were blinded to which subject was assigned to the experimental group or the control group. Experimental group Subjects who were assigned to the experimental group listened to sleep-inducing music in the CCU. The sleep-inducing

Data analysis
Data analysis was conducted using SPSS program version 14.0 (IBM Corporation, Armonk, NY, USA). Descriptive statistics were used to describe demographic and sleeping characteristics. Independent t-test was used to test the two hypotheses.

Results
Sample characteristics
The ndings of sample characteristics are presented in Table 1. Most participants were men (655%), high school educated (414%), Buddhist (345%) and married (862%). Mean age of the participants was 612 years. Most participants were usually satised with their sleep before ICU

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M-J Ryu et al. Table 1 Demographic characteristics (n = 58)

Total f (%) Category Gender Male Female Age <50 5160 6170 7180 Education Less than elementary Middle school High school More than college Religion None Christian Catholic Buddhist Marriage Married None Widowed or divorced Satisfaction on sleeping Generally satised Very satised Usual sleeping hours daily M SD

Experimental group Control group (n = 29) (n = 29) f (%) M SD f (%) M SD v2 or t p

38 (655) 20 (345) 12 15 16 15 (207) (258) (276) (258)

19 (328) 10 (172) 8 5 7 9 (138) (86) (121) (155)

19 (328) 10 (172) 4 (69) 10 (172) 9 (155) 6 (103) 9 (155) 6 (103) 12 (207) 2 (34) 11 (190) 5 (86) 3 (52) 10 (172) 23 (397) 1 (17) 5 (86) 27 (466) 2 (34) 717 075

000

1000

385

0278

15 (259) 15 (259) 24 (414) 4 (69) 20 (345) 15 (259) 3 (52) 20 (345) 50 (862) 2 (34) 6 (103)

6 (103) 9 (155) 12 (207) 2 (34) 9 (155) 10 (172) 0 (00) 10 (172) 27 (466) 1 (17) 1 (17)

120

0753

486

0182

298

0225

51 (879) 24 (414) 7 (121) 5 (86) 712 077 707 079

146 065

0227 0615

Table 2 Difference in quantity of sleeping between groups (n = 58) Experimental group (n = 29) Category Quantity of sleeping (minutes) M SD 27931 4399 Control group (n = 29) M SD 24310 4268 t 318 p 0002

Table 3 Difference in quality of sleeping between groups (n = 58) Experimental group (n = 29) Category Quality of sleeping (minutes) M SD 3614 568 Control group (n = 29) M SD 2941 385 t 526 p <0001

admittance (879%), and mean daily sleeping hours before hospital admittance was 712. There was no signicant difference in demographic and sleeping characteristics between the experimental group and control group.

Hypotheses ndings
Two research hypotheses were tested in this study. An alpha level of 005 was established for acceptance of the hypotheses.

Hypothesis 1: Independent t-test revealed that the quantity of sleeping in the experimental group was signicantly higher than control group (t = 318, p < 005) (Table 2). Therefore, hypothesis 1 was supported. Hypothesis 2: Independent t-test revealed that the quality of sleeping in the experimental group was signicantly higher than control group (t = 526, p < 0001) (Table 3). Therefore, hypothesis 2 was supported.

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Discussion
The current study compared the effect of earphone-delivered sleep-inducing music with the use of noise-mufing ear plugs on the quantity and quality of sleep in ICU patients who had received PTCA in the CCU. Music signicantly increased the quantity and quality of sleep compared to the use of ear plugs. Most studies regarding the effect of music on sleep have been limited to the qualitative effect of music. The current study tested both the qualitative and quantitative effects of music on sleep. The quantitative assessment involved subject responses concerning the number of hours slept. Future studies could be made more robust by including objective tools such as electroencephalography or brain wave testing. KK Park (Jeju National University, Jeju, unpublished Masters thesis) and Levin (1998) tested the effect of music on sleep using brain wave monitoring, and the brain waves showed an improved quality of sleep. On the other hand, Lazic and Ogilvie (2007) tested the effect of music on sleep using polysomnographic and quantitative EKG analysis, but no effect of music on sleep was evident. Therefore, selecting appropriate instruments to measure sleep is required to increase the validity and reliability of the study ndings. Earplugs can improve the quality of sleep by shutting out severe noises (YJ Koo, Keimyung University, Daegu, unpublished Masters thesis). Presently, however, listening to sleep-inducing music using earphones or head phones make it possible to shut noises but also induce the relaxing d-waves. Nurses working in clinical areas might well consider offering earplugs and music to improve patients rest. The current nding of the positive effect of sleep-inducing music on sleeping echoes the ndings of other studies, which reported improved sleep by classical, religious and clientpreferred music. Even though diverse types of music can improved sleep, whether there is one type of music that is superior in South Korea is unknown. There is a need to compare the different types of music on sleep and investigate how the music affects sleep in a different way.

research nding, testing at different points is needed. This study compared the effect of sleep-inducing music with earplugs on sleeping. Many studies also reported the positive effects of music on sleeping and the music are diverse. There is a need to investigate what kind of music is the best for Korean to sleep. Future studies should compare the sleepinducing music with other types of music such as relaxing music or patient-preferred music. Even though the positive effects of music on sleeping have been well established, there is a lack of consistency concerning how music is offered to improve sleep in South Korea. A systematic review or metaanalysis to determine what kind of method is the best to improve sleeping is required.

Conclusion
The current study compared the effect of sleep-inducing music with noise-mufing earplugs on agitation in CCU patients who underwent PTCA. Patients who listened to sleep-inducing music showed signicantly improved quantity and quality of sleep compared to those wearing earplugs. In the CCU, there are many factors that can cause sleeping problems including severe noises, unfamiliar medical tools and bright light. To improve sleep in the CCU, nurses could apply earplugs to block noises, but could also offer sleepinducing music, so that the music could shut noises but also help patients relax and sleep. In future, repetitive studies should be conducted to investigate the effect of sleepinducing music on sleep using different types of measurements and to compare the effect of sleep-inducing music with other types of music on sleeping in the CCU.

Relevance to clinical practice

The clinical signicance of this study is the acknowledgment for nurses that music is effective to improve ICU patient sleep problems. Many ICU patients are medicated to control sleeping problems, and these medications are often addictive and cause undesirable effects. Music may be an efcient alternative.

Contributions Limitations
The current study only investigated ICU patients with PTCA. But, there are other types of CVD. The effect of music on sleep in these patients warrants study. This study tested the quality and quality of sleep only one time after removing angiocatheter. To increase the validity and reliability of the Study design: M-JR, JSP; data collection and analysis: M-JR, JSP, HP and manuscript preparation: M-JR, JSP, HP.

Conict of interest
There is no conict of interests.

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