effect of sleep inducing music on sleep in persons

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ORIGINAL ARTICLE

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 percu-

taneous 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 PMPM, 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 AMAM 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= 3181,p = 0002, t= 5269,p < 0001, respectively).

Conclusion.Sleep-inducing music significantly improved sleep in patients with percutaneous transluminal coronary angiogra-

phy 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 percu-

taneous 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 ofexercise. 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 environ-

ment of a typical ICU is not conducive to sleep. Sleep-depriving 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: [email protected]

2011 Blackwell Publishing Ltd

728 Journal of Clinical Nursing, 21, 728735, doi: 10.1111/j.1365-2702.2011.03876.x


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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 (Krach-

man et al. 1995). Sleep disorders in the ICU can cause

anxiety, confusion, memory problems and decreased orien-

tation 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 ICUpatients, variedforms 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 thequantityand 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 help-

ful. 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 music-

assisted 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 (JejuNational University, Jeju, unpublished Masters thesis)

reported enhanced sleep using delta (d)-wave music com-

pared with non-d-wave music.

Most studies to date concerning the influence 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.

Background

ICU sleep

Sleep disturbances increase neurosis, anxiety, confusion,

attention deficiency, emotional discomfort and mortality,

but also decrease physical self-defence and sensitivity (Krach-

manet al.1995, Pandi-Perumalet 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,

Simpsonet 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 difficulty

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 significantly related with cardiovascular condi-

tions (Schaferet 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 vasoconstric-

tors 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 first

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, Kimet al.2006, Park 2008, Jeong 2009, MH Lee,

Jeju National University, Jeju, unpublished Masters thesis,

OK Park, Korea University, Seoul, unpublished Mastersthesis). Generally, the result is increased quantity and quality

of sleep. Among the interventions, music intervention is cost-

effective because it is relatively easy to supply.

Sleep-inducing music

Music therapy is defined as an established allied health

profession using music and music activities to address

Original article The effect of sleep-inducing music on sleep


Journal of Clinical Nursing, 21, 728735 729


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physical, psychological, cognitive and social needs of

individuals with disabilities (AMTA 1997). The docu-

mented 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

influence 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 significantly in the music

intervention group compared to the exercise group. Chanet 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 Mas-

ters 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 othertypes 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 influence 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

benefits 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 angiogra-

phy. 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 admit-

tance 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 consider-

ing a 10% drop rate.

The 60 participants were randomly assigned to experi-

mental group or control group using card number. The

participants having an even number were assigned to theexperimental 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 experi-

mental group was excluded for having taken a sleep-

inducing drug taken. One participant in the control group

was transferred to another unit. Finally, 29 subjects consti-

tuted the experimental group and 29 formed the control

group.

M-J Ryu et al.


730 Journal of Clinical Nursing, 21, 728735


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Instruments

Quantity of sleeping

Quantity of sleeping questionnaire elicited information con-

cerning the total number of sleeping hours. The questions in-

cluded the time falling asleep and the awakening time the next

morning. Thequantity of sleeping wascountedas 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 PMPM and awoke at 4 AMAM, but was awake for one hour

during the night, the sleeping time was recorded as 240 min-

utes.

Quality of sleeping

Quality of sleeping was measured using the modified Verran

and Synder-Halpern (VSH) sleeping scale (Verran & Synder-

Halpern 1987, Kim & Kang 1994). The VSH includes eightquestions 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 0 82 in Verran and

Synder-Halperns study (1987). The Cronbachs alpha value

of the modified VSH was 086 in Kim & Kangs study.

Cronbachs alpha value of the modified VSH in this study

was 083.

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 first meeting was scheduled at

the hospital to check demographic data and sleep character-

istics. 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 PMPM,

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 lis-

tened to sleep-inducing music in the CCU. The sleep-inducing

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 (five 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 AMAM the next morning, so as not to disturb sleep. Eye

bandage CS-204 (CS Berea Korea) was also applied to the

participants at 10 PMPM and was removed at 5 AMAM the next

morning.

The timing of the start of the music (10:00 PMPM) and removal

of the earphones (5 AMAM the next morning) coincided with thetime of the last daily blood pressure check and the first blood

pressure check of the day, respectively. If participants did not

want to continue sleeping any time after 10 PMPM, the music was

terminated and the earphones were removed. The participants

answered the questionnaires regardingthe quantity and quality

of sleeping at 7 AMAMon 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 PMPM5 AMAMthe next morning. The same eye bandage used in

the experimental group was also applied to the control par-

ticipants. The participants in control group also answered the

sleeping questionnaires at 7 AMAM.

Data analysis

Data analysis was conducted using SPSSSPSSprogram version 14.0

(IBM Corporation, Armonk, NY, USA). Descriptive statistics

were used to describe demographic and sleeping character-

istics. Independentt-test was used to test the two hypotheses.

Results

Sample characteristics

The findings 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 partici-

pants were usually satisfied with their sleep before ICU





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admittance (879%), and mean daily sleeping hours before

hospital admittance was 712. There was no significant

difference in demographic and sleeping characteristics

between the experimental group and control group.

Hypotheses findings

Two research hypotheses were tested in this study. An alpha

level of 005 was established for acceptance of the hypotheses.

Hypothesis 1:Independentt-test revealed that the quantityof sleeping in the experimental group was significantly 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 significantly higher

than control group (t= 526, p < 0001) (Table 3). There-

fore, hypothesis 2 was supported.

Table 2 Difference in quantity of sleeping between groups (n= 58)

Category

Experimental

group (n= 29)

Control

group (n= 29)

t pM SD M SD

Quantity

of sleeping

(minutes)

27931 4399 24310 4268 318 0002

Table 1 Demographic characteristics

(n = 58)

Category

Total

Experimental group

(n= 29)

Control group

(n= 29)

v2 or t p

f(%) f(%) f(%)

M SD M SD M SD

Gender

Male 38 (65

5) 19 (32

8) 19 (32

8) 0

00 1

000Female 20 (345) 10 (172) 10 (172)

Age


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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. Music significantly 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. Onthe 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 findings.

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 finding of the positive effect of sleep-inducing

music on sleeping echoes the findings of other studies, which

reported improved sleep by classical, religious and client-

preferred 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.

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

research finding, 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 sleep-

inducing 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 meta-

analysis 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-muffling earplugs on agitation in CCU

patients who underwent PTCA. Patients who listened tosleep-inducing music showed significantly 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 sleep-

inducing 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 sleep-

inducing music on sleep using different types of measure-

ments 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 significance 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 efficient

alternative.

Contributions

Study design: M-JR, JSP; data collection and analysis: M-JR,

JSP, HP and manuscript preparation: M-JR, JSP, HP.

Conflict of interest

There is no conflict of interests.





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Ziv N, Rotem T, Arnon Z & Haimov I

(2008) The effect of music relaxation

versus progressive muscular relaxation

on insomnia in older people and

their relationship to personality traits.

Journal of Music Therapy 45,

360380.

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effect of sleep inducing music on sleep in persons

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