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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 significantly higher than control group (t = 3Æ181, p = 0Æ002, t = 5Æ269, p < 0Æ001, respectively). Conclusion. Sleep-inducing music significantly 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 significantly 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 influences 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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Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing, 21, 728–735, doi: 10.1111/j.1365-2702.2011.03876.x

noises. unpublished Master’s thesis). 2010. persons who receive a percutaneous transluminal coronary angiography (PTCA) suffer from sleeping discomfort in the ICU because they are subject to intense observational scrutiny. despite a relatively short-term ICU stay compared to patients with other serious maladies (Kim 2001). cell dissolution and immunity and can contribute to increased mortality (Krachman et al. 728–735 Background ICU sleep Sleep disturbances increase neurosis. over 50% of ICU patients suffered from serious sleeping disorders (Noh et al. surrounded by severe noises and impropriate lighting. KK Park (Jeju National University. Simpson et al. stress and cognitive disorders) and environmental (temperature. Park 2008. Pandi-Perumal et al. Jeju. Sleeping problems with ICU patients can include difficulty falling asleep. these steps did not completely alleviate the sources of sleep deprivation. 1995). Ziv et al. discomfort and pain). Especially. unpublished Master’s thesis) can be helpful. Schafer et al. Peled et al. 1994. Sleeping is significantly related with cardiovascular conditions (Schafer et al. Park 2008. Seoul. confusion. unsatisfactory sleep and decreased quality of sleep (Yinnon et al. but also decrease physical self-defence and sensitivity (Krachman et al. and they are generally categorised as physical (illness. The use of ear plugs can improve both the quantity and quality of sleep (Haddock 1994. Patients with coronary vascular disease are often admitted to the ICU. religious music and client preferred music on sleep (Johnson 2003. 1992. The present study addressed this shortcoming. Jeong 2009. which reduces cardiac loading and increases cardiac life. Kim et al. Keimyung University. 1996). Freedman et al. memory problems and decreased orientation or cognition (Granberg et al. massage and music have been applied (Zimmerman et al. Novaes et al. Sleep disorder in persons with CVD cause severe physical emotional changes including increased catecholamine secretion and unstable emotions. Jeju National University. Jeju. sleeping disorders stimulate the sympathetic nerve system and promote the over-secretion of vasoconstrictors that increase cardiac loading. 1999).Original article The effect of sleep-inducing music on sleep care (Novaes et al. 1997. 1995. Freedman et al. 2005). Seoul. Fang & Liu 2006. smell and sound) factors (Kim & Suh 1992. confusion. (2008) played relaxing music for older adults to improve sleeping. In one study. 1999). unpublished Master’s thesis). Daegu. which includes a 24-hour electrocardiogram (EKG) in the immediate aftermath of the angiography. Fang & Liu 2006. Chan et al. Daegu. YJ Koo. Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing. 1996). the result is increased quantity and quality of sleep. unpublished Master’s thesis). 21. Korea University. anxiety. emotional (anxiety. On the other hand. ICU patients report lower quantity and quality of sleeping than healthy persons (Kim & Suh 1992. 1998. psychiatric disease. MH Lee. Keimyung University. depression. Most studies to date concerning the influence of music on sleep have involved persons with insomnia. Kahn et al. Jang & Choi 2008. unpublished Master’s thesis. To improve sleeping in ICU patients. Krachman et al. Lessened light intensity attained through diminished light (Fox 1999) or the use of eye bandages (YJ Koo. Sleep-inducing music Music therapy is defined as ‘an established allied health profession using music and music activities to address 729 . While sleeping. systolic blood pressure decreases by 5–15% in humans. Severe sleep disorders can negatively affect physiological parameters including protein synthesis. OK Park. music intervention is costeffective because it is relatively easy to supply. decreased duration of sleep. humidity. As well. unpublished Master’s thesis) reported enhanced sleep using delta (d)-wave music compared with non-d-wave music. Daegu. There are many factors affecting sleep. Korea University. the studies suffered from lack of randomisation of subjects. 1997). unpublished Master’s thesis. 2006. Keimyung University. Schwab 1994. OK Park. which should be addressed by controlling the sleep disorder (Schwab 1994. Lai & Good 2005. relaxation therapy. sleep can suffer (Edell-Gustafsson et al. diverse interventions such as aromatherapy. 1995. attention deficiency. OK Park. Korea University. lightness. However. unpublished Master’s thesis). 1997. Kim 2001). 2002). To improve sleeping in ICU patients. Among the interventions. Generally. Several studies have reported that the positive effects of classical music. Seoul. 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. Sleep disorders in the ICU can cause anxiety. emotional discomfort and mortality. Patients receiving a cardio-angiography in the cardiac care unit (CCU) typically require close observation for the first 24 hours with absolute bed rest (ABR). 1996. 1997. YJ Koo. varied forms of nursing care have been tested (Haddock 1994. 1999). and the subjects reported reduced anxiety and improved quality of sleep. There has been no music intervention studies directed at patients with CVD in South Korea. This may interrupt normal sleep (Kim 2001). 1999). Freedman et al.

Alpha-waves. and those with an odd number were assigned to the control group. KK Park (Jeju National University. admittance to CCU after PTCA and the occurrence of ABR immediately after angiocatheter removal in the CCU. Park (2008) and OK Park (Korea University. it becomes of interest to determine the sleep-inducing effects of music to this patient population. Jeju National University. 2009. South Korean studies of the effect of sleep-inducing music have tended to be limited to persons with sleeping disorders. As PTCA is one of the most common processes administered to ICA patients with CVD.e. 29 subjects constituted the experimental group and 29 formed the control group. 2010. Sleep-inducing music is played at low volume to promote relaxation and lessen anxiety. Jeju. 52 subjects for two groups were needed. Seoul. or sensory disorder. (2010) applied music to ventilator-assisted patients and reported a positive influence on pulse rate. Jeju. Allred et al. Dijkstra et al. Hong & Cho 2010. Exclusion criteria were use of ventilators. Music is also effective for ICU patients. and history of sleeping problem before admittance to CCU. depression and pain (Kim 2007. Huang et al. Moradipanah et al. are lessened when listening to sleep-inducing music compared to other types music or no music. in particular those with CVD in the ICU. use of sleep-inducing drugs or sedative medications. diagnosis of coronary artery disease.M-J Ryu et al. which are antagonistic to sleep. and sleep was improved in the music group compared to patients not receiving music. KK Park. physical. Nilsson (2009) offered music to coronary artery bypass graft patients and reported reduced oxytocin levels and increased relaxation. Ziv et al. Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing. Finally. Music interventions have also been applied to control sleeping problems. which stimulates sleep waves in the brain. cognitive and social needs of individuals with disabilities’ (AMTA 1997). unpublished Master’s thesis). consent form and potential risks and benefits were reviewed and approved by the K University D Hospital Human Subjects Review committee. with far less information known of the influence of sleep-inducing music on patients. but 60 subjects enrolled after considering a 10% drop rate. Different types of music were offered to improve sleep. neurologic disease. One participant in the control group was transferred to another unit. unpublished Master’s thesis) has been explored as a means of improving sleep in South Korean subjects experiencing sleeping problems. 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. The 60 participants were randomly assigned to experimental group or control group using card number. stress and sleep problems (KK Park. Participants The principal investigator gave a brief presentation to those scheduled for admittance to the CCU a coronary angiography. The present study investigated the effects of sleep-inducing music on sleep patterns in PTCA recipients in the ICU. Jeju National University. and the quality of sleep was improved significantly in the music intervention group compared to the exercise group. After the presentation. Methods The research protocol. diagnosed of dementia. consent was obtained from 60 of those attending who agreed to participate in this study. two subjects dropped-out. and sleep-inducing music (i. The documented positive effects of music on various health problems include anxiety. The participants having an even number were assigned to the experimental group. One participant in the experimental group was excluded for having taken a sleepinducing drug taken. Chan et al. (2010) and Lai and Good (2005) also offered music to older adults. During the data collection. stress. The inclusion criteria were ‡20 years of age. d-wave music. Based on the calculation. The effect of music on sleep has been studied in South Korea. Jeju. unpublished Master’s 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. Persons who listen to d-wave music report being relaxed by the music and that the music promoted a sound sleep. 21. 728–735 730 . psychological. Anxiety was lower. The sample was determined by power calculation based on Cohen’s (1988) effect size formulas using power 0Æ80 and effect size 0Æ70. (2008) offered relaxation music with muscle relaxation exercise to older adults with sleep disorders and compared the effect of music with relaxation exercise. breathing rate and relaxation. 2010). unpublished Master’s thesis) played music for coronary angiography patients and reported improved sleep after listening to music. with the aim of suggesting practical nursing interventions to improve sleep.

0 (IBM Corporation. Experimental group Subjects who were assigned to the experimental group listened to sleep-inducing music in the CCU. Goldberg Variations BWV. 21. the earphone was not removed intentionally until 5 AM the next morning. The VSH includes eight questions regarding the frequencies of awakening while sleeping. high school educated (41Æ4%). The same eye bandage used in the experimental group was also applied to the control participants. Armonk. The principle investigator trained the two research assistants regarding the general information of this study including purpose. but was awake for one hour during the night. 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. the sleeping time was recorded as 240 minutes. if a subject fell asleep at 11 PM and awoke at 4 AM . Goldberg Variations BWV. The sleep-inducing Data analysis Data analysis was conducted using SPSS program version 14. Results Sample characteristics The findings of sample characteristics are presented in Table 1. 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. The Cronbach’s alpha value of the modified VSH was 0Æ86 in Kim & Kang’s study. with a total possible points ranging from 0–80. 728–735 731 . The questions included the time falling asleep and the awakening time the next morning. Most participants were usually satisfied with their sleep before ICU Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing. Data collection Data collection was conducted at K University D hospital in D city from 3 September–4 October 2010. Buddhist (34Æ5%) and married (86Æ2%). Control group No music was offered to participants. NY. Independent t-test was used to test the two hypotheses. The MP3 music was supplied through earphones to the participants from 10:00–10:53. The sleep-inducing music included Nature Sounds (two minutes and eight seconds). 988 (27 minutes three seconds). so as not to disturb sleep.303Ò (Bacau-Dalloz Korea) were applied from at 10 PM –5 AM the next morning. unpublished Master’s thesis) and was entitled Korean’s brain: Thank you for doing such as great job-stable effect on sleeping: Delta wave Clinic Vol 1. Seoul. Most participants were men (65Æ5%). respectively. If participants did not want to continue sleeping any time after 10 PM . Cronbach’s alpha value of the modified VSH in this study was 0Æ83. Kim & Kang 1994). The principle investigator played recorded sleep-inducing music at 10 PM .Original article The effect of sleep-inducing music on sleep Instruments Quantity of sleeping Quantity of sleeping questionnaire elicited information concerning the total number of sleeping hours. and the research assistants helped subjects to answer the questionnaires concerning the quantity and quality of sleep. Cronbach’s alpha value of the original VSH was 0Æ82 in Verran and Synder-Halpern’s study (1987). Delta Wave Control Music (five minutes 21 seconds). method and measurement. music was developed by Park (2008) and OK Park (Korea University. 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 first blood pressure check of the day. 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. USA). 988 (11 minutes one second) and Nature Sounds (two minutes 25 seconds). For example. The VSH is a Likert scale that ranged from 0–10 for each question. Quality of sleeping Quality of sleeping was measured using the modified Verran and Synder-Halpern (VSH) sleeping scale (Verran & SynderHalpern 1987. After consent to participate was obtained. Mean age of the participants was 61Æ2 years. Descriptive statistics were used to describe demographic and sleeping characteristics. If a subject awoke for a short time during the night. There were 29 subjects in the experimental and control groups. Nature Sounds (four minutes 57 seconds). If a subject fell asleep with the music still in progress. the first meeting was scheduled at the hospital to check demographic data and sleep characteristics. but ear plugs 370 Bilsom No. depth of sleep and self-evaluation of sleep. Eye bandage CS-204Ò (CS Berea Korea) was also applied to the participants at 10 PM and was removed at 5 AM the next morning. the time of wakefulness was subtracted from the sleeping minutes. The participants in control group also answered the sleeping questionnaires at 7 AM .

21.M-J Ryu et al. Hypothesis 1: Independent t-test revealed that the quantity of sleeping in the experimental group was significantly higher than control group (t = 3Æ18. There was no significant difference in demographic and sleeping characteristics between the experimental group and control group. p < 0Æ05) (Table 2). p < 0Æ001) (Table 3). An alpha level of 0Æ05 was established for acceptance of the hypotheses. Therefore. hypothesis 1 was supported. and mean daily sleeping hours before hospital admittance was 7Æ12. hypothesis 2 was supported. 728–735 . Hypothesis 2: Independent t-test revealed that the quality of sleeping in the experimental group was significantly higher than control group (t = 5Æ26. Therefore. 732 Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing. Table 1 Demographic characteristics (n = 58) Total f (%) Category Gender Male Female Age <50 51–60 61–70 71–80 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 satisfied Very satisfied 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 (65Æ5) 20 (34Æ5) 12 15 16 15 (20Æ7) (25Æ8) (27Æ6) (25Æ8) 19 (32Æ8) 10 (17Æ2) 8 5 7 9 (13Æ8) (8Æ6) (12Æ1) (15Æ5) 19 (32Æ8) 10 (17Æ2) 4 (6Æ9) 10 (17Æ2) 9 (15Æ5) 6 (10Æ3) 9 (15Æ5) 6 (10Æ3) 12 (20Æ7) 2 (3Æ4) 11 (19Æ0) 5 (8Æ6) 3 (5Æ2) 10 (17Æ2) 23 (39Æ7) 1 (1Æ7) 5 (8Æ6) 27 (46Æ6) 2 (3Æ4) 7Æ17 ± 0Æ75 0Æ00 1Æ000 3Æ85 0Æ278 15 (25Æ9) 15 (25Æ9) 24 (41Æ4) 4 (6Æ9) 20 (34Æ5) 15 (25Æ9) 3 (5Æ2) 20 (34Æ5) 50 (86Æ2) 2 (3Æ4) 6 (10Æ3) 6 (10Æ3) 9 (15Æ5) 12 (20Æ7) 2 (3Æ4) 9 (15Æ5) 10 (17Æ2) 0 (0Æ0) 10 (17Æ2) 27 (46Æ6) 1 (1Æ7) 1 (1Æ7) 1Æ20 0Æ753 4Æ86 0Æ182 2Æ98 0Æ225 51 (87Æ9) 24 (41Æ4) 7 (12Æ1) 5 (8Æ6) 7Æ12 ± 0Æ77 7Æ07 ± 0Æ79 1Æ46 0Æ65 0Æ227 0Æ615 Table 2 Difference in quantity of sleeping between groups (n = 58) Experimental group (n = 29) Category Quantity of sleeping (minutes) M ± SD 279Æ31 ± 43Æ99 Control group (n = 29) M ± SD 243Æ10 ± 42Æ68 t 3Æ18 p 0Æ002 Table 3 Difference in quality of sleeping between groups (n = 58) Experimental group (n = 29) Category Quality of sleeping (minutes) M ± SD 36Æ14 ± 5Æ68 Control group (n = 29) M ± SD 29Æ41 ± 3Æ85 t 5Æ26 p <0Æ001 admittance (87Æ9%). Hypotheses findings Two research hypotheses were tested in this study.

Even though the positive effects of music on sleeping have been well established. Lazic and Ogilvie (2007) tested the effect of music on sleep using polysomnographic and quantitative EKG analysis. whether there is one type of music that is superior in South Korea is unknown. Many studies also reported the positive effects of music on sleeping and the music are diverse. 21. A systematic review or metaanalysis to determine what kind of method is the best to improve sleeping is required. JSP. Conflict of interest There is no conflict of interests. Nurses working in clinical areas might well consider offering earplugs and music to improve patient’s rest. Music may be an efficient alternative. Ó 2011 Blackwell Publishing Ltd Journal of Clinical Nursing. Many ICU patients are medicated to control sleeping problems. Future studies should compare the sleepinducing music with other types of music such as relaxing music or patient-preferred music. Future studies could be made more robust by including objective tools such as electroencephalography or brain wave testing. religious and clientpreferred music. unpublished Master’s thesis). In the CCU. HP and manuscript preparation: M-JR. Even though diverse types of music can improved sleep. 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. Earplugs can improve the quality of sleep by shutting out severe noises (YJ Koo. The effect of music on sleep in these patients warrants study. Most studies regarding the effect of music on sleep have been limited to the qualitative effect of music. however. Therefore. there are other types of CVD. Music significantly increased the quantity and quality of sleep compared to the use of ear plugs. listening to sleep-inducing music using earphones or head phones make it possible to shut noises but also induce the relaxing d-waves. unfamiliar medical tools and bright light. which reported improved sleep by classical. but no effect of music on sleep was evident. research finding. This study tested the quality and quality of sleep only one time after removing angiocatheter. There is a need to investigate what kind of music is the best for Korean to sleep. Daegu. In future. and these medications are often addictive and cause undesirable effects. The quantitative assessment involved subject responses concerning the number of hours slept. The current study tested both the qualitative and quantitative effects of music on sleep. Conclusion The current study compared the effect of sleep-inducing music with noise-muffling earplugs on agitation in CCU patients who underwent PTCA. KK Park (Jeju National University. JSP. data collection and analysis: M-JR. On the other hand. This study compared the effect of sleep-inducing music with earplugs on sleeping. But. Patients who listened to sleep-inducing music showed significantly improved quantity and quality of sleep compared to those wearing earplugs. there are many factors that can cause sleeping problems including severe noises. and the brain waves showed an improved quality of sleep. but could also offer sleepinducing music. To improve sleep in the CCU.Original article The effect of sleep-inducing music on sleep Discussion The current study compared the effect of earphone-delivered sleep-inducing music with the use of noise-muffling ear plugs on the quantity and quality of sleep in ICU patients who had received PTCA in the CCU. unpublished Master’s thesis) and Levin (1998) tested the effect of music on sleep using brain wave monitoring. selecting appropriate instruments to measure sleep is required to increase the validity and reliability of the study findings. To increase the validity and reliability of the Study design: M-JR. Presently. The current finding of the positive effect of sleep-inducing music on sleeping echoes the findings of other studies. testing at different points is needed. Jeju. there is a lack of consistency concerning how music is offered to improve sleep in South Korea. so that the music could shut noises but also help patients relax and sleep. Contributions Limitations The current study only investigated ICU patients with PTCA. HP. 728–735 733 . Relevance to clinical practice The clinical significance of this study is the acknowledgment for nurses that music is effective to improve ICU patient sleep problems. Keimyung University. There is a need to compare the different types of music on sleep and investigate how the music affects sleep in a different way. nurses could apply earplugs to block noises. JSP.

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