According to the American Hospital Association, over 39 million patients are admitted to US hospitals each year. The cost of these stays was over $47 billion, with a median length of stay of 4.6 days and a mean cost per stay of $11,7000, according to the Healthcare Cost and Utilization Project. Patients cared for in the hospital setting can experience physical and psychologic distress and, in many cases, medications are used in patient treatment that can have significant and bothersome adverse reactions. Nonpharmacologic interventions, such as music and art therapy, may be beneficial to mitigate the negative effects of hospitalization. In this article, we discuss the benefits of music and art therapy, as well as the nurse's role in implementing these therapies.
Negative effects of hospitalization
Hospitalized patients spend a significant amount of their day passing the time watching TV or sitting in their bed poorly engaged. The consequences of poor engagement are numerous and may include:
- sleep disturbances
- adverse psychosocial effects
- chronic disease
- adverse physiologic effects.
When in the hospital setting, sleep disturbances are common and can lead to increased pain, inflammation, decreased immune function, and alterations in cognition. Additionally, when patients are anxious, it can lead to an increased work of breathing, cardiovascular stimulation, and increased oxygen consumption. All of these factors can have negative consequences for patients, such as longer stays, reduced motivation, and decreased satisfaction. Patients who are under stress may experience physiologic changes, such as increased respiratory and heart rates, elevated blood glucose levels, decreased BP, and hyperlactatemia (elevated blood lactate without metabolic acidosis).
Research has shown that patients who are critically ill report experiencing anxiety, depression, posttraumatic stress disorder (PTSD), cognitive impairment, and a decline in overall well-being. In fact, as many as 15% of ICU patients will be affected by PTSD and 70% to 80% experience anxiety. It's important to engage patients to prevent complications associated with their stay and recovery. One way to foster patient engagement is through music and art therapy.
Music therapy, involving musical interaction and therapeutic communication, is one of the most widely used nonpharmacologic interventions for patients. Music therapy can include the use of a radio, MP3 player, CD player, or live performance. Additionally, patients can play music themselves. Music therapy can be used for a variety of medical conditions and is an alternative to watching TV or sitting in the room disengaged.
One type of music therapy involves a board-certified music therapist who's educated on the therapeutic process to provide benefits for patients. In some research studies, live music with a music therapist was shown to be more beneficial than listening to music alone, potentially due to the interaction that occurs between the music therapist and patient. The music therapist can respond to a patient's immediate needs, modify music depending on those needs (such as for relaxation or increased energy), and select interventions based on his or her condition. When implementing music therapy, it's important to assess music preferences and provide choices for patients.
Art therapy encompasses a wide range of activities, including active art making, the creative process, applied psychological theory, and the human experience within a therapeutic relationship. Art therapy has been shown to have a positive psychosocial impact on patients and provides them with an outlet for expression. Examples of art therapy activities are coloring, painting, collage making, drawing, and modeling with clay. Art therapy can be used to improve cognitive and sensory motor functions, self-esteem, self-awareness, emotional resilience, personal insight, social skills, and conflict resolution.
When an organization is able, art therapy should be facilitated by a professional art therapist. These professionals are master's-level clinicians who work in hospitals, schools, veterans' clinics, private practice, psychiatric and rehabilitation facilities, community clinics, crisis centers, forensic institutions, and senior communities. When implemented appropriately, art therapy focuses on creating and experiencing, as well as facilitating the expression of memories, feelings, emotions, and self-reflection. When developing art therapy programs for patients, it's important to customize treatment goals and determine the patient's preferred medium.
Music and art therapy are cost-effective and can be implemented with little-to-no cost within a facility. Additionally, these interventions aren't associated with adverse reactions and don't require a healthcare provider's order. When implementing alternative therapies, such as music and art therapy, we may see a decrease in treatment-related symptoms, anxiety, stress, and inflammation and improved cognitive function, sleep quality, restfulness, and patient satisfaction.
Music and art therapy have also been shown to be beneficial for pain management. In the hospital setting, moderate-to-severe pain is often treated with opioid medications, which carry risks. Research has shown that alternative therapies, such as music and art therapy, can be used as a pain management approach, potentially decreasing the use of pain medication among hospitalized patients (post-op patients in particular). In addition to controlling pain, research indicates that when pain is well controlled, anxiety is also decreased. Art therapy has been shown to distract patients from pain, decreasing the need for additional medication.
Music therapy has been shown to decrease stress, anxiety, pain, depression, and feelings of isolation. It can also lead to physical and mental relaxation, as well as improved sleep. Physiologic changes may include decreased BP and heart rate, reduced depression levels in older patients, and an increased ability to cope with feelings. When attempting to address heart rate control, calming music can be played with a rhythm at 60 to 80 beats, matching the desirable heart rate. For patients with dementia, familiar music can be calming and enhance their functional abilities.
Listening to music has been associated with the secretion of dopamine, noradrenaline, enkephalin, and endorphins. Dopamine is a neurotransmitter that plays a role in pleasure; secretion of dopamine may increase pleasure for patients. Noradrenaline is a neurotransmitter associated with increased arousal and alertness; secretion of this neurotransmitter may increase alertness in hospitalized patients. Enkephalin is a peptide associated with pain control; the release of this peptide can result in pain-killing effects. Endorphins are peptides that are also associated with pain control; the release of endorphins has been associated with decreased heart rate and BP, as well as pain. Music listening has also been shown to induce alpha waves in the brain, which are associated with relaxation.
Art therapy can aid in distracting patients from the negative adverse reactions associated with treatment. For example, research has shown that activities such as coloring can help reduce pain. Art therapy can also help patients recognize and understand their emotions and learn to express themselves, as well as manage stress, foster connections, develop healthy self-care practices, and encourage expression of grief. Art therapy has been shown to aid patients with anxiety and help with symptom management. It can also help promote a state of mindfulness, which, in turn, improves self-regulation.
Music and art therapy aren't only beneficial for patients, but for healthcare workers as well. Nurses are prone to stress and burnout, both of which can be detrimental to physical and emotional health. When nurses experience stress and burnout, it can also negatively affect patients/families and colleagues, increasing the risk of decreased patient satisfaction and quality of care. Music and art therapy have been shown to reduce work-related stress, cultivate resilience, promote overall wellness, and enhance emotional health among caregivers. For this reason, nurse managers and educators should look for ways to incorporate these activities into their work environments.
Research has shown that nurses find music and art therapy to be beneficial. However, an identified barrier to the implementation of these interventions is lack of knowledge about alternative therapies. With this in mind, nurses should seek out resources and educational offerings regarding the use of these types of therapies. Additionally, nurse educators should develop and provide educational offerings about alternative therapies.
Nurses can play an important role in the initiation of these therapies, including policy development. In many cases, organizational leaders may be resistant to these interventions because they're afraid of increased cost and difficulty with implementation. However, funding is available in the form of donations or grants, and these interventions are often inexpensive and easy to implement. It may be beneficial for nurses to work directly with music and art therapists to provide guidance and support during implementation.
Both music and art therapy can be effectively used in conjunction with conventional treatments, in some cases improving treatment effectiveness. Nurses must understand the therapy being implemented, how to implement it, and how to educate patients about these therapies.
Body, mind, and spirit
Although both music and art therapy are low-cost, low-risk, easy to implement, and beneficial interventions for patients and healthcare workers, more research on the effectiveness of these therapies and the best way to use them in the healthcare setting is needed. So, what are you waiting for? Create positive changes in your workplace by implementing these alternative therapies and contributing to our body of nursing knowledge.
You're working in a long-term-care facility with patients with cognitive impairment, some of whom become anxious and agitated easily. You decide to implement a music therapy program for this patient population, with the goal of decreasing anxiety and agitation while creating a sense of calm. You purchase music-playing devices (a radio, CD player, and MP3 player) and ask family members about music that's familiar to the patients. When these patients become agitated or anxious, you bring them to a quiet area, such as their room, and play their familiar music, effectively reducing anxiety and agitation.
You're working on an inpatient psychiatric unit and are responsible for group therapy sessions. You're caring for patients who have difficulty understanding their emotions and appropriately expressing themselves. You implement a daily art therapy group where patients are encouraged to express themselves through art. Patients report that the art therapy sessions allow them to express emotions, such as pain, grief, and anger, which, in turn, decreases their anxiety and signs and symptoms of depression.
Nursing assessment and care
- Assess the patient's understanding of music and art therapy.
- Assess the patient's openness to partake in music and/or art therapy.
- After implementation of music/art therapy, assess for improvements in anxiety, reports of stress, sleep quality, and restfulness and physiologic changes, such as decreased BP and heart rate.
- When used for pain relief, determine the patient's pain level before and after implementation of music/art therapy. (When feasible, attempt music/art therapy before the administration of opioid medications.)
- When completing uncomfortable therapies, offer music and/or art therapy as a distraction technique.
- Use music as a calming technique for patients with dementia.
- Use art therapy as a tool for self-exploration and expression.
Abbing A, Ponstein A, van Hooren S, de Sonneville L, Swaab H, Baars E. The effectiveness of art therapy for anxiety in adults: a systematic review of randomised and non-randomised controlled trials. PLoS One
American Art Therapy Association. About art therapy. https://arttherapy.org/about-art-therapy
American Hospital Association. Fast facts on U.S. hospitals, 2020. http://www.aha.org/statistics/fast-facts-us-hospitals
Buchanan V. Art Therapy: Programs, Uses, and Benefits
. New York, NY: Nova Publishers; 2016.
Chlan LL. Engaging critically ill patients in symptom management: thinking outside the box! Am J Crit Care
Freeman WJ, Weiss AJ, Heslin KC. Overview of US hospital stays in 2016: variation by geographic region. Healthcare Cost and Utilization Project. 2018. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb246-Geographic-Variation-Hospital-Stays.jsp
Gök Ugur H, Yaman Aktaş Y, Orak OS, Saglambilen O, Aydin Avci Ï. The effect of music therapy on depression and physiological parameters in elderly people living in a Turkish nursing home: a randomized-controlled trial. Aging Ment Health
Golino AJ, Leone R, Gollenberg A, et al Impact of an active music therapy intervention on intensive care patients. Am J Crit Care
Ho AHY, Tan-Ho G, Ngo TA, et al A novel mindful-compassion art therapy (MCAT) for reducing burnout and promoting resilience for end-of-life care professionals: a waitlist RCT protocol. Trials
Meghani N, Tracy MF, O'Conner-Von S, Hadidi NN, Mathiason MA, Lindquist R. Generating evidence of critical care nurses' perceptions, knowledge, beliefs, and use of music therapy, aromatherapy, and guided imagery. Dimens Crit Care Nurs
Nelson LM. Turn off the TV: benefits of offering alternative activities on medical-surgical units. MedSurg Nurs
Poulsen MJ, Coto J, Cooney MF. Music as a postoperative pain management intervention. J Perianesth Nurs