WSU REPOSITORY MSN/DNP Using Music Therapy to Reduce Anxiety in Preoperative Pediatric Dental Cases Project Title by Alyssa Hedelius Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT April 26, 2024 Date Alyssa Hedelius, BSN, RN, MSN student 04/26/24 Student Name, Credentials Date (electronic signature) Jamie Wankier Randles EdD(c), MSN, RN 04/26/2024 MSN Project Faculty Date (electronic signature) 04/26/2024 Anne Kendrick (electronic signature) DNP, RN, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Using Music Therapy to Reduce Anxiety in Preoperative Pediatric Dental Cases Alyssa Hedelius, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: The purpose/aim of the MSN project is to assist healthcare providers with behavioral management by reducing preoperative dental anxiety in pediatric patients through education and guidelines for music therapy. Rationale/Background: Patient anxiety is a common issue in the dental setting, especially in preoperative cases. Anxiety control is essential to quality patient experience and outcomes. Behavior management is challenging for healthcare providers. Interventions to reduce pediatric preoperative anxiety are vital. Although research has demonstrated the benefits of using music therapy preoperatively, many nurses need further teaching and guidelines on implementing music therapy in the dental setting. Through music interventions, preoperative pediatric patients will learn coping strategies for anxiety and reduce physiological symptoms of distress. Research suggested that standard guidelines for music therapy in the dental setting must be improved. Methods: The methods used in the MSN project aim to explore current literature regarding music therapy interventions to reduce preoperative pediatric anxiety in the dental setting and develop guidelines for the administration of music therapy. The following PICOT question guided this MSN project: Does music therapy before surgical dental procedures decrease anxiety compared to not providing music therapy in pediatric patients? The Star Model was selected to provide a framework and guide the project. Additionally, an intense literature analysis was conducted to find evidence-based practice research that formed the guidelines and education for the MSN project. The MSN project utilized provider education using several deliverables approach for the dental setting. Results: Education was provided to the nurses, anesthesia providers, and dentist to ensure the providers understood the need for and importance of music therapy to reduce pediatric 3 preoperative dental anxiety via staff in-service meeting and an educational pamphlet. Guidelines were developed for the administration of music therapy through research and a thorough literature review. The patients and their families were also given education on preoperative dental anxiety via an educational pamphlet. Conclusions: Despite being a widespread issue, standard guidelines for reducing preoperative dental anxiety in pediatric patients are missing. Physical and psychological effects of dental anxiety, such as increased stress, increased heart rate, and fear of dental procedures, resulting in poor dental health, can have harmful effects on the patient. Music therapy is an effective, noninvasive method for reducing preoperative anxiety in pediatric patients. Therefore, it is vital that nurses and providers are educated on the use of music therapy in the dental setting to reduce pediatric dental anxiety. Proper staff education will ensure the success of the MSN project. Keywords: preoperative anxiety, dental anxiety, music therapy 4 Using Music Therapy to Reduce Anxiety in Preoperative Pediatric Dental Cases On average, 40 million adults suffer from an anxiety disorder, with only 36.9% receiving treatment (Anxiety & Depression Association of America, 2022.) Additionally, individuals facing anxiety issues are three to five times more likely to seek treatment from a doctor and six times more likely to be hospitalized due to an anxiety-related event (Anxiety & Depression Association of America, 2022.). Anxiety in patients is a common issue in the dental setting (Lewis, 2020; Gurcan et al., 2022;). Signs and symptoms of dental anxiety include tachycardia, crying, increased blood pressure, and the secretion of the stress hormone cortisol (Better Health Channel, 2021; Thomasgaard, 2021.). Stress and anxiety in children before dental procedures involving anesthesia can also reduce cooperation and lead to a negative experience (Better Health Channel, 2021; Thomasgaard, 2021). During the preoperative phase, anxiety in children is a common reaction (Abbasi et al., 2021; Lewis, 2020). Traditional methods to reduce preoperative dental anxiety, such as pre-medication, can be effective but potentially lead to a patient's inability to cope with future dental anxiety (Thomasgaard, 2021). Nonpharmacological interventions are non-invasive to prevent or cure certain health conditions (Castellano-Tejedor, 2022). Nonpharmacological interventions such as music have been gaining popularity to reduce anxiety in outpatient and inpatient settings (Wong et al., 2021). Music therapy can benefit children with anxiety in the outpatient setting (Cleveland Clinic, 2023). Music can be a distraction, providing comfort, relaxing patients, and decreasing stress (Redding, 2020; Walden University, 2023). Proper care needs to be given to the issue of pediatric dental anxiety (Gurcan, 2022). While further research is needed, it is clear that nurses 5 can play a critical role in decreasing pediatric anxiety by administering music in the preoperative setting. Statement of Problem Dental procedures can frighten children, causing anxiety and stress (Lewis, 2020). Karbandi et al. (2020) stated that anxiety can cause pain and prolonged recovery in children and induces anxiety for the children's parents or family. Pre-dental procedure anxiety causes increased heart rate and combative or resistant behavior in pediatric patients, leading to a negative patient experience and longer turnover rates (Lewis, 2020; Thomasgaard, 2021). Pediatric anxiety prior to dental procedures can carry into adulthood, leading to avoidance of proper dental care. (Gurcan et al., 2022). Nurses play a crucial role in alleviating patient anxiety (Gurcan et al., 2022; Natale, 2021). Nonpharmacological interventions such as music therapy have been proven effective in reducing anxiety in pediatric patients (Karbandi, 2020). Tan et al. (2023) argued that music therapy decreased heart rate and pain and increased cooperation in preoperative patients. A study by Wong et al. (2021) concluded that music therapy decreased patient stress biomarkers, substances that can be measured to track diseases such as Cortisol. Music can comfort anxious patients and soothe the nervous system (Redding, 2020). For primary caregivers, there is a gap in education on the use of music therapy to reduce anxiety and ease the process for patients (Gurcan et al., 2021). Nurses can advocate for using music preoperatively by demonstrating the success of music interventions to stakeholders such as organizational leaders and patients (Walden University, 2023). Therefore, this MSN project aims to educate nurses on the benefits of music therapy in decreasing anxiety preoperatively in the pediatric dental setting. The goal of this project will be reached by examining current literature to determine the extent of the problem 6 and identifying best practices to develop and implement an educational program for nurses to utilize music therapy interventions to accomplish this goal. Significance of the Project Patient quality outcomes often depend on patient anxiety control (Abbasi et al., 2021). Gurcan et al. (2022) argued that providers must utilize new behavior techniques to improve their patients' dental experience. Behavior management is challenging for healthcare providers, but it plays a vital role in the patient's overall experience and outcomes (Lewis, 2020). Through music interventions, preoperative pediatric patients will receive comfort, learn coping strategies for anxiety, and reduce physiological symptoms of distress (Redding, 2020; Thomasgaard, 2021; Wong et al., 2021). Although research has demonstrated the benefits of using music therapy preoperatively, many nurses still experience barriers to implementing music in this setting (Esplen et al., 2020). Esplen et al. (2020) found that nurses believed music therapy interventions were beneficial and essential. However, research showed that 74.5% of the nurses were not using music therapy to reduce anxiety in their patients (Esplen et al., 2020). Interventions to reduce pediatric preoperative anxiety are essential and necessary (Lewis, 2020). Exploring potential barriers and providing nursing education in the preoperative setting supports positive patient outcomes and can increase the satisfaction of the procedure process. Review of the Literature This literature review aims to explore current literature regarding music therapy interventions to reduce preoperative pediatric anxiety in the dental setting. The following PICOT question guided this MSN project: Does music therapy before surgical dental procedures decrease anxiety compared to not providing music therapy in pediatric patients? The Star Model 7 was selected to provide a framework for this project (Melnyk & Fineout-Overholt, 2019). In addition, an intense literature analysis was conducted to find evidence-based practice research that formed the guidelines for the MSN project. Framework The framework for this MSN project is the Stevens Star Model of Knowledge Transformation (Star model). Dr. Kathleen Stevens developed the Star Model at the University of Texas Health Science Centers San Antonio as a model for nurses to integrate evidence-based research into practice (Brunt & Morris, 2023). The Star Model consists of five points: primary research, evidence summary, translation to guidelines, practice integration, and evaluation (Melnyk & Fineout-Overholt, 2019). The primary research step was utilized through a literature review using the MSN project PICOT question. During the evidence summary step, the research will be summarized from the literature review into education for nursing staff. The third step of the model involves translation to guidelines; this will occur as the MSN project lead reviews the evidence and creates guidelines for nursing staff and other stakeholders. Practice integration, the fourth step of the Star model, will be demonstrated when the plan is implemented. The processoutcome evaluation step will be used to evaluate the effectiveness of music therapy as an intervention for preoperative anxiety. This model was selected for this MSN project because it creates a guide for the project and makes creating evidence-based guidelines more manageable (Melnyk & Fineout-Overholt, 2019). Strengths and Limitations The Star Model will provide a foundation for this MSN project because it provides an easy-to-follow process for obtaining evidence and translating information into guidelines (Melnyk & Fineout-Overholt, 2019). Other strengths of the Star Model include how it highlights 8 the unique needs of nurses, and through the use of the model, many evidence-based therapeutic interventions have been developed (Gulnar & Caliskan, 2021). The Star Model does face some limitations. The Star Model can be viewed as overly simplistic (Dusin et al., 2023). Another limitation of the Star Model is that it needs to consider patient values and preferences (Dusin et al., 2023). Despite these limitations, the Star Model fits the needs of this MSN project. Analysis of Literature An analysis of the literature was conducted to support the PICOT question: Does providing music therapy before surgical dental procedures decrease anxiety compared to not providing music therapy in pediatric patients? Various search strategies were used to research the PICOT question. The literature was synthesized, and three themes were found: dental anxiety is a common challenge, the benefits of music therapy interventions, and nursing education in administering music therapy in the preoperative setting. The results are highlighted in the below sections. Search Strategies A literature search was conducted to identify current evidence using Google Scholar, Weber State University's Stewart Library's OneSearch and Advanced Search (which span multiple databases), and CINAHL to direct initial exploration. Only articles from 2017 through 2023 were included in this literature review to keep information current. The search included keywords derived from the project PICOT question, including preoperative anxiety, pediatric preoperative anxiety, nonpharmacological interventions, behavior management, dental anxiety, nurse interventions, nursing role, music therapy, music interventions, and anxiety prevention. 9 Various Boolean combinations were created with the abovementioned keywords to create a broad search. Synthesis of the Literature Due to the importance of managing pediatric preoperative anxiety, a rigorous literature review was completed to explore the topic of using music therapy in a dental preoperative setting to decrease patient anxiety. The literature identified three themes: 1) dental anxiety is a common challenge, 2) benefits of music therapy interventions, and 3) nursing education for administering music in the preoperative setting. The information within the literature review themes is in the following sections. Dental Anxiety is a Common Challenge Anxiety is a common disorder affecting adults and children (Anxiety & Depression Association of America, 2022; Batty, 2022; Harney et al., 2023). Worldwide, 13% of children are affected by anxiety (Marshman et al., 2023). Additionally, 30% of youth in the United States are affected by some form of anxiety (Batty, 2022). Anxiety symptoms include fear, increased heart rate, visible distress such as crying, decreased cooperation, and behavior issues (Better Health Channel, 2021; Gurcan, 2022; Lewis, 2020; Thomasgaard, 2021). Anxiety can negatively impact an individual's health, increasing the risk of developing chronic illnesses (Batty, 2022). Anxiety before dental procedures is common in all age groups (Better Health Channel, 2021; Dahlander et al., 2019; Gurcan et al., 2022; Lewis, 2020). Children also face dental anxiety due to caregiver separation, fear of the unknown, and unfamiliar medical personnel (Natale, 2021). Because children lack the skills to cope with anxiety, dental anxiety can cause severe distress for the patient and the family (Karbandi, 2021; Natale, 2021). Unmanaged 10 preoperative dental anxiety can result in decreased patient cooperation, the release of the stress hormone cortisol, and a greater need for postoperative care (Thomasgaard, 2021). Childhood dental anxiety often carries into adulthood, leading to avoidance of proper dental treatment (Batty, 2022; Better Health Channel, 2021; Gurcan et al., 2022). When individuals avoid dental care, it can lead to more serious dental issues and a greater need for treatment (Better Health Channel, 2021). Children with dental anxiety may need more significant amounts of anesthesia, which can cause sleep interference and behavioral issues (Thomasgaard, 2021). Moreover, reliance on sedation can hinder a child's ability to learn coping mechanisms (Thomasgaard, 2021). Research showed that reducing patient anxiety is critical to the success of the dental procedure (Gurcan et al., 2022; Lewis, 2020). While pharmacological interventions have a place in dental procedural care, exploring nonpharmacological interventions to manage anxiety is essential in providing best-practice care and improving the patient experience (Batty, 2022; Gurcan et al., 2022; Lewis, 2020; Marshman et al., 2023). Benefits of Music Therapy Interventions Nonpharmacological interventions are science-based nonmedicinal therapies to reduce anxiety and stress in patients (Castellano-Tejedor, 2022). Research showed there is a convincing rationale for using nonpharmacological approaches to managing pediatric preoperative anxiety (Batty, 2022). Nonpharmacological interventions have been gaining popularity due to their effectiveness, low cost, and reduced side effects (Castellano-Tejedor, 2022; Thomasgaard, 2021; Wong et al., 2021). It was found that nonpharmacological interventions reduced anxiety and helped patients have a positive experience, leading to improved attitudes toward dental care 11 (Lewis, 2020). Music therapy is one type of nonpharmacological intervention that is beneficial in alleviating anxiety (James et al., 2021). The technical definition of music therapy is live or recorded music administered by a licensed music therapist (Cleveland Clinic, 2023). Due to the costly nature of using a licensed therapist in a dental outpatient setting, research has shown that nurses can utilize the principles of music therapy interventions to reduce preoperative anxiety in patients (Marshman et al., 2023). Music can have many positive benefits, including improving an individual's well-being (Raglio, 2021; Redding, 2020; Rook, 2023), and it is non-invasive and safe to use (Walden University, 2021). Studies have shown that playing music preoperatively reduced heart rate and cortisol levels and decreased anxiety (Batty, 2022; Bush et al., 2021; Wong et al., 2021). Another benefit of music therapy is that it assists children in developing emotional regulation techniques that can be applied throughout life (Coombs, 2019). In the dental setting, music therapy increased patient cooperation, decreased turnover case time, and decreased postoperative complications related to anxiety and pain leading to improved patient outcomes (Thomasgaard, 2021). Despite research findings supporting music as an effective intervention for reducing pediatric preoperative anxiety, there is little research specific to the dental setting. A study by Bush et al. (2021) found that live music had a more significant effect on heart rate reduction than prerecorded music. However, more research must be completed regarding music therapy in a dental setting to establish evidence-based practice guidelines (Harney et al., 2023). Nursing Education for Administering Music Interventions in a Preoperative Setting Nurses often provide the most hands-on care to patients (Batty, 2022). Establishing positive relationships with patients is crucial to the patient experience (Lewis, 2020; Natale, 2021). Traditional anxiety and pain control methods often have adverse effects on the patient's 12 well-being and experience (Batty, 2022; Gurcan et al., 2022; Lewis, 2020; Thomasgaard, 2021). The use of pre-medication instead of nonpharmacological therapeutic interventions increased patient need for anesthesia and postoperative pain relief (Thomasgaard, 2021). Research showed that nurses who are educated on nonpharmacological methods can have a significant impact on patient anxiety levels preoperatively (Esplen et al., 2020). Despite understanding the benefits of nonpharmacological interventions to reduce patient anxiety, many nurses do not employ them (Esplen et al., 2020). Esplen et al. (2020) found that nurses lacked the education to administer music therapy. Nurses need to take an active role in gaining education on music therapy (Walden University, 2023). Educating stakeholders on the benefits of using music to reduce preoperative patient anxiety is vital to the success of preoperative music administration (Walden University, 2023). Nurses require guidelines on administering music therapy in the preoperative dental setting. Research showed that gaining patient and patient family consent is crucial before administering music therapy (Cleveland Clinic, 2023). Nurses should play familiar, enjoyable music appropriate to the patient's age (Rook, 2023). In addition, the patient's music preference may enhance patient engagement (Redding, 2020). Using music without lyrics may also be beneficial, as music with lyrics may be distracting (Rook, 2023). Despite research providing the above guidelines, there are no specific recommendations on how music should be played. Summary of Literature Review Findings and Application to the Project Preoperative anxiety can have lasting effects on pediatric patients (Lewis, 2020). Reducing patient preoperative anxiety is challenging but essential (Gurcan et al., 2022). Positive patient dental surgical experiences are imperative to proper dental health (Lewis, 2020). 13 Providers and nurses must properly develop strategies to manage pediatric preoperative anxiety (Gurcan et al., 2022). A detailed review of current literature suggested that music therapy effectively reduced preoperative anxiety in pediatric dental patients (James et al., 2021). Music can be used as a distraction technique, allowing the patient to develop coping strategies to manage pain and anxiety (Batty, 2022). The literature also suggested that more research is needed to establish standardized guidelines for using music therapy to decrease anxiety. However, nurses can still advocate for music therapy within their organizations (Walden University, 2023). In addition, research showed that using familiar, enjoyable music, playing music without lyrics, and including patient preferences according to age reduced preoperative anxiety (Rook, 2023). Vargo (2020) found that nurses can use an iPod with headphones and a Spotify playlist to administer music to patients. Using the above guidelines can assist the nurse in administering music preoperatively. The literature review information has helped substantiate this MSN project's potential to improve patient preoperative anxiety by offering guidelines for nursing practice. The evidence reviewed has also suggested future opportunities for this project; this project will use the information from the literature to create an evidence-based education plan for nurses to provide music therapy interventions before dental surgical procedures. Project Plan and Implementation The objective of the MSN project is to reduce preoperative dental anxiety in children. The project plan was guided by the evidence found in the research as discussed above. The success of this plan will rely on the buy-in from the dentist, who is the owner and administrator of the pediatric dental practice. Other key stakeholders include CRNAs/anesthesia providers, 14 nurses, dental assistants, patients, and patient parents/guardians. To implement this plan, the nurse will begin by administering a survey to the nurses, anesthesia providers, and the dentist to gauge understanding of preoperative anxiety and the use of music as an intervention. Using the survey results as a guide, the nurse will develop a pamphlet for patient and family use and present it to the other stakeholders mentioned. After training and approval, patients/patient guardians will be given the choice to listen to music via headphones or speaker and their choice of music using an iPod and Spotify playlist (Vargo, 2020) preoperatively. The effectiveness of reducing anxiety will be evaluated following each case using an anxiety measurement tool. Changes will be made as needed. The project will be evaluated after three months. Plan and Implementation Process The intended recipients of this plan are the pediatric patients receiving dental procedures requiring general anesthesia. The pediatric dental office is a private practice operated and maintained by one dentist and support staff. The office has five treatment rooms and two separate surgical procedures rooms. These cases begin with the nurse performing preoperative care and assisting the CRNA with intubation. The dentist performs the dental procedures with the assistance of the dental assistant while the CRNA monitors the patient. Following the case, the nurse helps the CRNA with postoperative care and extubation. Dental procedures of this type can be scary and overwhelming for young patients (Lewis, 2020). Proper care is needed to reduce fear and anxiety, thus the importance of the MSN project. The owner and administrator must approve the project of the dental practice before it can be initiated. A short survey will be given to the dental practice administrator and other stakeholders to assess the understanding of preoperative anxiety, its effects on pediatric patients and their families, and the use of music as an intervention. Based on these results, a pamphlet 15 will be created to educate the dentist, nurses, anesthesia providers, and other staff on using music therapy to reduce pediatric anxiety and the benefits of reducing patient preoperative anxiety. Following stakeholder approval, the project lead will provide guidelines to administer music preoperatively to at-risk patients and patients via an in-service staff meeting. Prior to surgery, the patient and patient parents/guardians will be given a pamphlet explaining the benefits of music as an intervention to reduce dental anxiety. Parental and patient consent will be gained prior to any music therapy. The preoperative nurse will give the family a written anxiety survey utilizing questions from the Spence Children's Anxiety Scale (SCAS) (Spence, 2021). The nurse will also utilize the anxiety measurement tool to assess the patient's preoperative anxiety. Based on the survey results and nurse observation, the nurse will offer the patient/patient parent preoperative music therapy. The patient will select music based on a playlist. Music will be played via headphones or speaker based on patient preference using an iPod before any preoperative care begins. The nurse will assess the patient for signs of anxiety and the effectiveness of music therapy. Following the dental procedure, the patient or their family will be given a short survey to assess the effectiveness of the music therapy in reducing their anxiety. The music selection and administration changes will be given according to feedback from the patients, patient families, and the healthcare team. After three months, the effectiveness of the project will be evaluated using results from the patient surveys. Changes to the clinical guidelines and project implementation will be made based on feedback received. These changes will then be reevaluated after three months. 16 Interdisciplinary Team The interdisciplinary team is small at the dental practice. The team comprises the dentist/owner of the practice, one anesthesia provider, one nurse, and two dental assistants daily. Due to the size of the team, the team must work together with open communication and feedback. Dentist/Administrator. The pediatric dental office is owned and operated by the dentist. Because it is a private practice, the dentist is the organization's administrator with ultimate decision-making authority regarding patient practices and policies. Providing excellent and compassionate care is the core mission of the dentist and dental practice. This project will align with the mission by providing better patient outcomes and overall experience. Anesthesia Providers. The dentist performs dental procedures requiring anesthesia with a CRNA managing the anesthesia and airway. The care provided by the CRNA significantly impacts patient outcomes. The CRNA makes the patient feel calm and comfortable before anesthesia (Thomasgaard, 2021). Anxious and fearful children are often uncooperative, delaying the induction of anesthesia and overall case time (Thomasgaard, 2021). The MSN project will make the anesthesia process more manageable for the entire dental team, including the patient and the patient's family. Nurses. The nurse is often the first person the patient encounters at the dental office. The nurse is responsible for preoperative and postoperative care. According to the MSN project, the nurse would assess the patient for dental anxiety using the preoperative dental anxiety survey and 17 administer music therapy based on the survey results and feedback from the patient family. Patient outcomes are impacted by the nurse's ability to act promptly (Batty, 2021). Project Leader. The developer of the MSN project will act as the project leader. After developing the project and gaining approval, the project leader will implement the MSN project by ensuring that staff and patients are given proper education, resources, and training to ensure the best patient outcomes. The project leader will provide education and training to all staff via an in-service staff meeting using deliverables such as the educational pamphlet and guidelines for music therapy implementation. The nurse will assist in carrying out the music therapy guidelines established by the project leader. The project leader will evaluate the project following the timeline (see Appendix J). Dental Assistant. Dental assistants are another part of the interdisciplinary team. Most dental cases are performed with one or two dental assistants who assist the dentist. The dental assistants would not provide music therapy or have decision-making power. However, dental assistants impact patient outcomes and, therefore, need to understand the need to reduce preoperative dental anxiety. Patients and Patient Families. The intended target of the MSN project is pediatric patients and their families. Providing safe and effective care is vital to practice and patient experience. The implementation of this project will positively impact patients and their families. The patients will provide critical feedback via postoperative feedback surveys. The information gathered from the postoperative 18 surveys will be used to evaluate the success of the MSN project and guide changes that need to be made. Description and Development of Project Deliverables This section will describe the deliverables used in this project to facilitate learning and evaluation. The MSN project will utilize nine deliverables: a stakeholder education assessment survey, in-service agenda, educational pamphlet, music therapy guidelines, preoperative anxiety survey, anxiety measurement tool, music selection playlist, and postoperative evaluation survey. A detailed review of all the deliverables is listed below. Stakeholder Education Assessment Survey. The stakeholder education assessment survey (see Appendix A) will be given to stakeholders such as the dentist, nurses, anesthesia providers, and dental assistants to gauge their understanding of the adverse effects of preoperative anxiety and the importance of nonpharmacological interventions such as music therapy. This brief survey contains six questions answered by circling yes, somewhat, and no. This deliverable is essential because it will illustrate to the project leader the amount of education the stakeholders need to ensure the MSN project's success. Inservice Agenda. An in-service agenda (see Appendix B) will be used to organize the in-service meeting where the music therapy guidelines and education will be presented to the dental staff, nurses, anesthesia providers, and dentist. The in-service agenda will be influential in documenting the in-service meeting and identifying gaps in the information presented. 19 Educational Pamphlet. The educational pamphlet (see Appendix C) will be given to all stakeholders listed above, including patients and their families, to educate them on preoperative dental anxiety and the effectiveness of music therapy in reducing anxiety. Educational pamphlets are an effective and straightforward method of educating healthcare providers and patients (Rowzie, 2022). The pamphlet is written in simple, easy-to-understand language, without medical jargon so that anyone can understand the information. This pamphlet is crucial to the success of the MSN project. The pamphlets will also be placed in the waiting area for patients and their families to view. Music Therapy Guidelines. The music therapy guidelines (see Appendix D) are crucial to the success of the MSN project. The guidelines will provide the framework for music therapy administration in the dental practice. These guidelines will be posted in the treatment room to be referenced by the nurse. Preoperative Anxiety Survey. The following deliverable utilized by the MSN project is the written preoperative anxiety survey (see Appendix E, F). Before the procedure, the patient or family will be given a written anxiety survey utilizing questions from the Spence Children's Anxiety Scale (SCAS) (Spence, 2021). In the case of children under the age of eight, the parent version of the anxiety survey will be given. The Spence Anxiety scale is designed for children to gauge their level of anxiety and is an effective tool for assessing anxiety in children (Spence, 2021). This anxiety will allow the nurse to identify at-risk patients. It will also help the patients and their families assess the need for music therapy. 20 Anxiety Measurement Tool. The anxiety measurement tool (see Appendix G) is a list of signs and symptoms of dental anxiety that the nurse can utilize to assess the patient's anxiety level before, during, and after music therapy initiation. This tool is a simple way to evaluate the effectiveness of music therapy on patients. Evaluation is an essential component of the growth and success of the MSN project (Marquis & Huston, 2021). Music Selection Playlist. To ensure a timely selection of music for music therapy, the patient and their family will be given a playlist of available songs (see Appendix H). The playlist will be short and ageappropriate, featuring songs with and without lyrics. Familiar, age-appropriate music can reduce pediatric dental anxiety (Raglio, 2021). Allowing patients to select song preferences can also help ease anxiety (Redding, 2021). This list will be posted in the treatment room for the patients and their families to view. Evaluation Survey. The patient evaluation survey is the last deliverable in the MSN project (see Appendix I). This survey will be given to patients using a face scale to assess their experience and ask for feedback. This survey is simple and can be given postoperatively directly to the patient or via the patient family. One survey will be given to patients who received music therapy, and the other will be given to patients without music therapy to assess the effect of music therapy on the overall patient experience. Timeline Following project approval from the appropriate stakeholders, the project timeline (see Appendix J) begins with the healthcare stakeholder educational assessment survey. The project 21 leader will give this survey within one month to allow sufficient time for the survey to be administered to all staff and to evaluate common themes within the survey results. An in-service meeting will educate staff about music therapy and establish guidelines. During the in-service meeting, the project leader will answer the stakeholder's questions and share the educational pamphlet with attendees. The project leader will implement the MSN project after the in-service meeting. During this time, technology will be secured to play the music, and the music playlist will be posted in the treatment room. The nurses will utilize the music therapy guidelines to ensure consistent administration and implementation. After three months, the project will be evaluated based on patient postoperative surveys and nurse/provider feedback. Based on these results, changes to the program will be determined and implemented for three months. During the second evaluation, the project leader will again utilize the patient postoperative surveys and nurse/provider feedback. The project leader will analyze the results of these findings, and changes will be made to the music therapy guidelines as needed. If the project proves successful, the project will continue. Project evaluations will be completed bi-annually to assess effectiveness and implement necessary changes. The project timeline is adaptable to the needs of the patients and the dental clinic. The project timeline will act as a guide for the project implementation and is essential to realizing the goal of the MSN project. Project Evaluation The MSN project aims to add value to the lives of the patients and their families through postoperative anxiety reduction. Evaluation is essential for any project to gauge its value (Brown University, 2024). Through evaluation, the project lead can assess whether the project's intended 22 outcomes were accomplished (Bronw University, 2024). The MSN project will utilize evaluation as a crucial component of the project's success. The project leader will rely on feedback to improve practices and provide positive patient outcomes (Marquis & Huston, 2021). The MSN project will utilize surveys and verbal feedback to evaluate the project's success. The postoperative patient survey will be vital to gain feedback on the use of music therapy and the potential reduction of preoperative anxiety to assess the ' project's effectiveness. A review of the surveys will occur every three months, assessing common themes in the feedback, which will guide project changes. Oral feedback from the nurses and anesthesia providers will be crucial to understanding the effect of music therapy on anxiety from the clinical perspective, as seen in a reduction of physical signs of anxiety. In addition, feedback from the dentist will be essential to maintain stakeholder buy-in for the continued implementation of this project. Ethical Considerations It is essential to assess the ethical concerns when implementing the MSN project. Ethical quality improvement advancements such as this MSN project are the responsibility of healthcare providers (Melnyk & Fineout-Overholt, 2019). There are some ethical considerations for the MSN project. Because the target population for the MSN project is children, special considerations will need to be made, such as parental permission and patient consent. The nurse must ask the patient's parent/guardian for permission before using music therapy. All patients and their families will have the choice to utilize music therapy and can decline the treatment. These actions will ensure that the rights of the minor are protected. Patient consent is always an essential ethical consideration (Melnyk & Fineout-Overholt, 2019). 23 Another ethical consideration is the privacy of individuals. All surveys given to patients and their families will be anonymous. The nurse will also explain the privacy rights to the patients and their families. Patients and families will have the right to refuse any surveys or treatment. Personal bias from the project lead and other healthcare providers may also influence the project's outcomes. The lead must assess personal bias toward music therapy to avoid conflicting project results. Bias from other team members, especially the nurses providing the music therapy, may also affect the project results. Through the educational assessment survey and proper education, the project leader will strive to establish the need to remain unbiased during the project implementation and evaluation. Discussion As discussed in the literature review, preoperative dental anxiety is an ongoing challenge (Anxiety & Depression Association of America, 2022; Batty, 2022; Harney et al., 2023). Preoperative dental anxiety negatively impacts the dental procedure's success and the patient's health (Batty, 2022). Dental anxiety in pediatrics can lead to lifelong dental anxiety and avoidance of care (Lewis, 2020). Dental anxiety also negatively affects the patient's family (Karbandi et al., 2020). The MSN project was developed using music therapy to reduce pediatric preoperative dental anxiety. The project lead will provide education and guidelines to staff and evaluate the project's success using patient and nurse feedback via surveys and observation. Music therapy effectively manages preoperative dental anxiety and improves the patient's overall experience (James et al., 2021). Music therapy is simple, cost-effective, and non-invasive (Marshman et al., 2023; Walden University, 2021). This section will review evidence-based 24 solutions for dissemination, their significance to advanced nursing practice, their implications, and practice recommendations. Evidence-based Solutions for Dissemination Evidence suggested that music therapy can reduce preoperative dental anxiety in pediatric patients (Batty, 2022; James et al., 2021; Marshman et al., 2023; Natale, 2021). Because music therapy is cost-effective and straightforward to organize, any organization can share and implement these findings into standard practice (Batty, 2022). The MSN project will utilize a project poster to disseminate the findings and recommendations of the project. The project poster will be presented to healthcare professionals via Zoom. The project poster can also be presented in conferences and staff meetings to educate dental and other healthcare providers on the benefits of music therapy in reducing anxiety. This poster can be easily shared, making the dissemination of information efficient and effective. The final project poster will be presented to the Annie Dee Taylor School of Nursing at Weber State University. Significance to Advanced Nursing Practice Nurses provide hands-on patient care and can significantly impact patient outcomes (Natale, 2021). Fundamental to the nursing field is the desire to improve the quality of care given to patients (Melnyk & Fineout-Overholt, 2019). Reducing patient pain and anxiety is vital to the patient experience in any setting (Lewis, 2020). Through the MSN project, nurses can gain a greater understanding and education on how music therapy can improve the patient's experience by reducing preoperative dental anxiety. While most nurses understand the benefit of nonpharmacological approaches to reducing patient preoperative stress and anxiety, they may lack education on how to implement these practices (Epslen et al., 2020). There is much research on the benefits of using 25 nonpharmacological approaches to reduce preoperative anxiety, but few standard guidelines have been developed (Esplen et al., 2020). Using current research and literature reviews, the MSN project has developed guidelines for implementing music therapy in the dental setting. While these guidelines have been developed specifically for the dental setting, the concepts can adapt quickly to any healthcare setting. Research demonstrated that playing familiar music to patients using a playlist and an iPod with headphones can reduce pediatric preoperative anxiety (Raglio, 2021; Rook, 2023; Vargo, 2020). These simple guidelines can assist nurses in providing quality patient care and improve the patient experience. Implications Improving the patient's experience is paramount to this MSN project. The strengths of the MSN project are that it can be easily implemented in any practice. The MSN project does not require expensive equipment or lengthy training to implement. Music therapy is cost-effective, simple, and non-invasive (Walden University, 2021). Music is universal and has positive psychological effects (Raglio, 2021; Redding, 2020; Rook, 2023). Music therapy will significantly improve patient experience (Marshman et al., 2023). Despite the simplicity of the MSN project, there are some limitations. One of this project's limitations is that it relies heavily on patient participation and patient evaluation via surveys. Due to psychological development, children cannot always communicate feelings, which may limit the evaluation results. Another project limitation is that it relies heavily on nurse buy-in and compliance with the guidelines. The nursing staff must feel the importance of the MSN project and adhere to the project guidelines for the project to be successful (Walden University, 2021). Education and follow-up will be vital to addressing the limitations of the 26 MSN project. Additionally, the small sample size is also a limitation to the MSN project. More research will need to be done to increase the sample size and reliability of outcomes. Recommendations Using available research and literature reviews, the MSN project has developed guidelines for administering music therapy preoperatively in the dental setting to reduce anxiety (see Appendix D). However, more research is needed to be specific to the use of music therapy in the dental setting. Further research on using music therapy in the preoperative dental setting would increase standard guidelines, understanding, and evaluation of patient outcomes. Standard guidelines would provide grounding for the recommended guidelines of the MSN project. Therefore, the MSN project must be presented and implemented in more facilities to gauge its actual effects. Conclusion Despite being such a prevalent issue, there are no standard guidelines for reducing preoperative dental anxiety in pediatric patients (Esplen et al., 2020). Dental anxiety can have harmful physical and psychological effects, such as increased stress, increased heart rate, and fear of dental procedures, resulting in poor dental health (Gurcan et al., 2022; Karbandi et al., 2020; Lewis, 2020). Music therapy is a practical, nonpharmacological approach to reducing preoperative anxiety (James et al., 2021). The MSN project has provided specific guidelines on how to implement music therapy into standard practice in the dental setting. 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The role of music in healthcare: What nurses should know. https://www.waldenu.edu/online-masters-programs/master-of-science-innursing/resource/the-role-of-music-in-healthcare-what-nurses-should-know Wong, M. M., Tahir, T., Wong, M. M., Baron, A., & Finnerty, R. (2021). Biomarkers of Stress in Music Interventions: A Systematic Review. Journal of Music Therapy, 58(3), 241– 277. https://doi.org.hal.weber.edu/10.1093/jmt/thab003 Vargo, K. (2020). Nurse's DNP project examines preoperative music listening interventions. Conuslt QD. Cleveland Clinic. https://consultqd.clevelandclinic.org/nurses-dnp-projectexamines-preoperative-music-listening-interventions/ 32 Appendix A Stakeholder Education Assessment Survey 1. What is your role in the dental office? 2. How long have you worked in pediatric dentistry? 3. Can you identify the signs and symptoms of anxiety? Yes No Somewhat 4. Do you understand the negative impacts of anxiety on both patients and their dental experience? Yes No Somewhat 5. Are you familiar with nonpharmacological approaches to manage anxiety? Yes Somewhat No 6. Do you use nonpharmacological methods to reduce anxiety in patients? Yes No Somewhat 7. Are you familiar with the effects music has on anxiety? Yes No Somewhat 8. Would you like additional information on the benefits of music therapy for our patients? Yes No 33 Appendix B INSERVICE AGENDA Location: Dental Office Date: June 2024 Time: 6:00 PM Agenda details Introduction Review educational assessment survey Introduce MSN project Educational pamphlet Review pamphlet Answer questions Guidelines Share guidelines for music therapy Open forum Share deliverables, answer questions, gain feedback 34 Appendix C Educational Pamphlet 35 36 Appendix D Music Therapy Guidelines Check-in ✓ Ensure patient has not eaten ✓ Obtain height and weight ✓ Administer anxiety questionnaire ✓ Give patient family educational brochure to read and ask for permission to administer music therapy Pre-op ✓ Bring patient to treatment room ✓ Ask patient what song they would like to begin with (see Music Playlist) ✓ Place headphones and start music ✓ Monitor for s/s anxiety (see anxiety measurement tool) ✓ Obtain vital signs ✓ Assist with anesthesia Post-Op ✓ Following PACU care, administer post-op evaluation survey (you may need to assist patient) 37 Appendix E Anxiety Questionnaire Patient version How old are you?_______________ Circle the answer that best describes you 1. I feel afraid. Always Sometimes Never 2. I worry about being away from my parents. Always Sometimes Never 3. I worry that something bad will happen to me. Always Sometimes Never 4. I am scared of going to the doctors or dentists. Always Sometimes Never Sometimes Never 5. I feel happy. Always (Adapted from Spence Children's Anxiety Scale, 2021) 38 Appendix F Anxiety Questionnaire Parent version What is your child’s age:___________ Do they have a history of anxiety:________________ Circle the answer that best describes your child My child states they feel afraid even when there is nothing to be afraid of. Always Sometimes Never My child worries about being away from parents. Always Sometimes Never My child worries something bad will happen to them. Always Sometimes Never My child is scared of going to the doctors or dentists. Always Sometimes Never My child is happy. Always Never Sometimes (Adapted from Spence Children's Anxiety Scale, 2021) 39 Appendix G Healthcare Provider Anxiety Measurement Tool (If the patient is experiencing two or more of these signs, utilize music therapy) ✓ Increased heart rate/tachycardia ✓ Increased respiratory rate ✓ Shaking/trembling ✓ Sweating ✓ Crying ✓ Panic ✓ GI problems ✓ Uncooperative/combative (Mayo Clinic, 2018) 40 Appendix H Patient Music Playlist __Title 1. Trick Rider 2. Fairy Tale Lullaby 3. Peace Like a River 4. Hello Night 5. Across the Sea 6. The Rainbow Connection 7. Hush 8. Lullaby 9. Boat Song 10. Here Comes the Sun 11. Yoga Song 12. Moon River 13. I Will 14. Edelweiss 15. Over the Rainbow 16. You are My Sunshine 17. Calm Like a Tree 18. Love, Peace & Light 19. Fuzzy Kitten 20. Time For Sleep Meditation 21. Sleepy DreamyKid Meditation 22. Pink Bubble Meditation 23. Breathe In, Breathe Out 24. Just Be 25. Colors Artist_________ the 'Wailin' Jennys Elizabeth Mitchell Elizabeth Mitchell Kesang Marstrand the 'Wailin' Jennys Sarah McLachlan Kesang Marstrand Jack Johnson & Matt Costa JJ Heller JJ Heller Stephanie Leavell JJ Heller JJ Heller JJ Heller JJ Heller Elizabeth Mitchell DreamyKid Meditation DreamyKid Meditation DreamyKid Meditation Sleepy DreamyKid Meditation Sleepy DreamyKid Meditation Sleepy DreamyKid Meditation Nancy Kopman Kira Willey Kira Willey https://open.spotify.com/playlist/3WODQdsroQzWjDYetVfHwV?si=fe465fbbcef84e7f 41 Appendix I Postoperative Patient Survey (For patients receiving music therapy) Name: ___________________________________ Date: ____________________________________ Procedure: _________________________ How did the music make you feel? What could have made it better? (For patients not receiving music therapy) Name: ___________________________________ Date: ____________________________________ Procedure: _________________________ How did you feel the procedure went? What could have made it better? 42 Appendix J PROJECT TIMELINE APRIL 2024 MAY 2024 JUNE 2024 SEPT 2024 Project Implementation Assessment survey Inservice Training Evaluate JAN 2025 BiAnnual check Evaluate & make additional changes Program evaluation & compliance