Document8

Research Article

Music as a nursing intervention: Effects of music listeningon blood pressure, heart rate, and respiratory rate inabdominal surgery patientsnhs_633 412..418

Anne Vaajoki, MNSc, rn, Päivi Kankkunen, phd, rn, Anna-Maija Pietilä, phd, rn andKatri Vehviläinen-Julkunen, phd, rnDepartment of Nursing Science, University of Eastern Finland, Kuopio, Finland

Abstract Contradictory results have been presented on how music listening affects patients’ blood pressure, heart rate,and respiratory rate. The aim of the present study was to evaluate the effects of music listening on bloodpressure, heart rate, and respiratory rate on operation day, and on the first, second, and third postoperativedays in abdominal surgery patients. Using a quasi-experimental pretest–post-test design, 168 abdominalsurgery patients were assigned every second week to the music group (n = 83) or to the control group (n = 85)for 25 months. In the music group, the respiratory rate was significantly lower after intervention on both thefirst and second postoperative days compared with the control group. A significant reduction in systolic bloodpressure was demonstrated in the group that received music compared with the control group on both the firstand second postoperative days. Evaluation of the long-term effects of music on physiological factors showedthat the respiratory rate in the music group was significantly lower compared with the control group. Nursesshould offer music listening to surgery patients because of its potential benefit.

Key words abdominal surgery, non-pharmacological method, music intervention, postoperative pain, quasi-experimentaldesign.

INTRODUCTION

Postoperative pain and surgery are both physiological andpsychological stressors that activate the sympathetic nervoussystem by increasing heart rate, blood pressure, and periph-eral vascular resistance. Surgery, especially in the abdominalregion of the body, can produce postoperative moderate tosevere pain and result in respiratory dysfunction, because anupper abdominal surgery wound is in the breathing area andinterferes with abdominal muscle use for deep breathing,coughing, and moving (Ashburn et al., 2004).

The theoretical background for music intervention can beexplained by gate control theory.The gate can be closed frominside using cognitive–behavioral methods, such as musiclistening, so that stimulus of pleasant music distracts thoughtsfrom pain, relaxes muscles, evokes an affective response, andvia a descending inhibitory system, closes the gate. Postop-erative pain can be assessed on the basis of the patient’sbehavior and by rating their intensity of pain or recognizingpain from physiological factors, such as blood pressure, heartrate, respiratory rate, peripheral thermal stimuli, and com-plexion (Melzack & Katz, 2006).

Music listening is a non-pharmacological method that canfocus attention (Kwekkeboom, 2003), facilitate breathing,and stimulate the relaxation response (McCaffrey & Locsin,2002). Music elicits unique experiences in the listener at dif-ferent times, and depends on an individual’s physiology, mindstate, and mood. It is essential to identify the types of musicthat the listener prefers (Leardi et al., 2007).

Music listening used in nursing practice should be distin-guished from music therapy, because most nurses have nomusic therapy education nor are they usually present whilepatients listen to music. Moreover, a nurse does not evaluatea patient’s psychological and physiological entity in relationto rhythm, melody, and harmony (Masuda et al., 2005;Nilsson, 2009). The present study concentrates on the effectsof music listening on blood pressure, heart rate, and respira-tory rate in pain management. An earlier article (Vaajokiet al., in press) discusses music and its effects on pain intensityand pain distress.

METHODS

Literature review

This literature review focuses on the effect of music listeningstudies on patients’ postoperative blood pressure, heart rate,and respiratory rate. In the last 6 years, there have been no

Correspondence address:Anne Vaajoki, PO Box 1627, 70211 Kuopio, Finland. Email:[email protected] 2011 May 03; accepted 2011 July 03.

Nursing and Health Sciences (2011), 13, 412–418

© 2011 Blackwell Publishing Asia Pty Ltd. doi: 10.1111/j.1442-2018.2011.00633.x

studies that have evaluated the effects of music on respira-tory rate after surgery. The research results of listening tomusic and its effects on blood pressure and heart rate aftersurgery are contradictory. Interventions were conductedduring (Nilsson et al., 2005) and/or after surgery (Masudaet al., 2005; Tse et al., 2005; Sendelbach et al., 2006; Nilsson,2009).

Six studies did not show significant differences betweenthe music group and the control group in blood pressure orheart rate (Masuda et al., 2005; Nilsson et al., 2005; Sendel-bach et al., 2006; Nilsson, 2009; Allred et al., 2010). Nilssonet al. (2005) did not obtain any differences in vital signsbetween the groups of open hernia repair patients. Masudaet al.s (2005) sample consisted of orthopedic patients, and theintervention was done on the third postoperative day. Therewere no differences in blood pressure and heart rate betweenthe music and control groups.

In cardiac surgery patients, the effects of listening to musicon blood pressure and heart rate have been investigated bySendelbach et al. (2006) and Nilsson (2009). Cardiac surgerypatients listened to music between the first and third pos-toperative days. Neither study found differences in bloodpressure or heart rate between the two groups.

Tse et al. (2005) obtained contradictory results withpatients who listened to music after nasal surgery. Musicgroup patients had lower systolic blood pressure and heartrates than patients in the control group. Participantslistened to music both on the operation day and on the firstpostoperative day.

In summary, previous studies on patients’ music listeningafter surgery have used different methodological approachesthat impact reliability and the appropriateness of genera-lizing findings. Music interventions used in these studieswere different types of surgeries at different times during theperioperative period.

Study

Aim

The aim of this study was to evaluate the effects of musiclistening on blood pressure, heart rate, and respiratory ratein postoperative abdominal surgery patients. The followinghypothesis was tested: Patients in the music group will havesignificantly lower systolic and diastolic blood pressure, heartrate, and respiratory rate than those in the control group.

Study design

A quasi-experimental pretest–post-test design was used,with one music group and one control group. A repeated-measures design was used, in which each patient’s systolicand diastolic blood pressure, heart rate, and respiratory ratewere measured before and after intervention between theoperation day and the second postoperative day. Physiologi-cal parameters were measured only once every time to avoidstressing the patient too much, and thus affecting thoseparameters. Music was played in the evening of the operationday and on the first and second postoperative days in the

morning (8.00–9.00 hours), at midday (13.00–15.00 hours),and in the evening (18.00–20.00 hours). On the third postop-erative day, blood pressure, heart rate, and respiratory ratewere measured once.

Sample and setting

A calculation of the required sample size was based on thepower analysis with respect to Visual Analogue Scale pain,because this is an intervention study concerning posto-perative pain management. A mean of 3.5 and standarddeviation (SD) of 2.4 were expected. A clinically-significantdifference of 30% and statistically-significant level of 0.05were expected. With a power of 80%, a sample size of 83patients for each group (n = 166) was calculated as beingappropriate (Burns & Grove, 2005). A pilot study was con-ducted with 10 patients. After the pilot study, changes weremade to the pain assessment so that patients assessed bothpain intensity and pain distress while resting, during deepbreathing, and when shifting position.

The patients in the study sample (n = 280) were adults(21–85 years) undergoing elective abdominal surgery inKuopio University Hospital (Kuopio, Finland) over a periodof 25 months. Patients eligible for the study had epiduralanalgesia after surgery; their estimated hospital stay was atleast 4 days, and the anesthesia physical status classification(ASA) was 1–3. Patients suffering from drug abuse, psychi-atric disorders, hearing impairment, dementia, or chronicpain problems, or patients admitted to other departments,were excluded.

In the main study, 22 patients refused to participate. Fifteenpatients withdrew after surgery because they were very tiredor the surgeon had given them bad news after the operation.Nineteen patients were excluded for research reasons; forexample, patients did not get epidural analgesia, despite theanesthesia plan, or surgery was delayed or cancelled. Forty-six patients did not meet the inclusion criteria. The finalsample comprised 168 participants, with 83 in the musicgroup and 85 in the control group.

Measurements

Blood pressure and heart rate were measured with an auto-matic OMRON M5-I or OMRON M6 (Dalian, China) byone researcher (AV). The same machines, which were cali-brated once a year by an equipment maintenance engineer,were used throughout the research. The respiratory rateis the number of respirations per minute and was obtainedby counting the number of times the patient’s chest rose andfell for 1 min. After the final measurements on day 3, theresearcher conducted a structured interview if patients hadnot completed a questionnaire by themselves. Participantswere asked about music-exposure frequency, musical back-ground, and their favorite music. Moreover, there was anopen question: “What else would you like to say?”

Music as an experimental intervention

The patients chose their favorite music out of 2000 songs.Thealternatives were domestic or foreign hit songs, dance, pop,

Music as a nursing intervention 413

© 2011 Blackwell Publishing Asia Pty Ltd.

rock, soul and blues, spiritual, or classical music. The partici-pants were given their favorite music. This procedure wasbased on data from an earlier study (Leardi et al., 2007) anddiscussions with the music therapist. There were two head-phones (HD 555; Sennheiser,Tullamore, Ireland and K28NC;AKG, Vienna, Austria) and two MP3 players (AppleiPod 8GB; Apple, Cupertino, CA, USA), on which differentkinds of music were recorded. Selections of music wereadded according to participants’ wishes during the study. Theresearcher talked with the participants about music theyliked, and showed a music list prior to the day of surgery.

The intervention started in the evening of the operationday, if patients were discharged from the post-anesthesia careunit. Before intervention, the researcher measured patients’systolic and diastolic blood pressure, heart rate, and respira-tory rate. After the measurements were taken, patients in themusic group listened to their choice of music via headphonesfor approximately 30 min. After the intervention, the samemeasurements were repeated. In the control group, systolicblood pressure, heart rate, and respiratory rate were mea-sured at half-hour intervals, but the patients did not listen tomusic. The intervention was repeated seven times during theoperation day and second postoperative days. All partici-pants were provided epidural analgesia, which was adjustedaccording to patients’ pain scoring and intravenous paraceta-mol 1 g¥ three/day after surgery.When needed, parental oxy-codone was provided as rescue analgesia.

Ethical considerations

The Research Ethics Committee Hospital of the Districtof Northern Savo approved the study. All participants weregiven a written, informed consent form, and they had oppor-tunity to ask about it. Participation was voluntary, and refusalto participate did not affect the care received during hospi-talization. It was also possible to stop participation withoutany specific reason.

Procedure

Before the pilot study, it was determined that electiveabdominal surgery patients would be assigned to the musicgroup or the control group via an alternate-week arrange-ment according to a yearly calendar. For example, patientsadmitted to hospital in one week were assigned to the experi-mental group, and patients admitted in the next week wereassigned to the control group.This process was repeated untileach group had 83 patients.

Participants were screened from departments’ opera-tion plan lists every week, and the researcher countedpatients who potentially met the inclusion criteria. Prior tothe day of surgery, the researcher familiarized herself withthe patients’ paper and estimated exclusion and inclusioncriteria, and checked the final operation and anesthesiaplan.The researcher interviewed and informed patients priorto the day of surgery. All the patients were told about thepurpose of the study and they were told whether theywere assigned to the music or the control group before anydecision to participate was required.

The intervention was repeated seven times. The researchermet the participants a total of nine times: prior to the day ofsurgery, in the evening of the operation day (if the patientarrived on the ward), on the first and second postoperativedays in the morning (8.00–9.00 hours), at midday (13.00–15.00 hours), in the evening (18.00–20.00 hours), and once onthe third postoperative day. Intervention was carried out inthe patient’s room alongside normal care.

Data analysis

The computer program SPSS 16.0 for Windows (SPSS,Chicago, IL, USA) was used for all statistical analyses. Com-plete data were obtained for 168 of the 280 abdominalsurgery patients. The data were presented as frequencies,percentages, mean values, and SD. Descriptive statisticswere computed, and c2-tests were used to test independenceof treatment group assignment. The parametric test usedwas ANOVA for repeated measurement in order to analyzethe systolic and diastolic blood pressure, heart rate, and res-piratory rate over time between the groups. On the first andsecond postoperative days, systolic and diastolic blood pres-sure, heart rate, and respiratory rate measurements werepresented as means and SD. Because of missing data total-ing over 50%, the operation day was dropped from theanalysis. The main reason for this was that most of theoperations were major abdominal cancer surgeries. Patientswere discharged from the post-anesthesia care unit late inthe evening or even the next day. They were also extremelytired because of the operation, anesthesia, and analgesia.One patient in the control group suffered from delirium onthe third postoperative day and could not complete thequestionnaire, and the researcher could not measure physi-ological parameters on that day. The long-term effect ofmusic on systolic and diastolic blood pressure, heart rate,and respiratory rate was analyzed by the non-parametricMann–Whitney U-test for independent groups (Burns &Grove, 2005).

RESULTS

Demographic data

In the music group, the mean age was 60 years (range:47–73 years), and in the control group, the mean age was63 years (range: 51–75 years). Most of the participants weremarried/common-law marriage (74%), retired (61%), andhad completed vocational school or had no education(67%).

Participants had a variety of diagnoses for laparotomy:ventral hernia (n = 6, 4%), diverticulitis (n = 13, 8%), andcolitis ulcerous/Morbus Crohn (n = 21, 13%). The majorityunderwent surgery for a diagnosis of cancer (n = 110, 65%).

The sample for this study consisted of 168 individuals intwo groups undergoing elective abdominal surgery. Thegroups did not differ in terms of age, sex, education, occupa-tion, marital status, diagnosis, type of surgery, ASA, or dosesof analgesia. (Table 1). Participants’ musical background,

414 A. Vaajoki et al.


music exposure frequency, and favorite music did not differbetween the two groups. Nearly half (46%) of the partici-pants said they had no interest in music. The majority ofparticipants in both groups were exposed to music at a fre-quency of once a day or more often. Of those who listened tomusic, nearly half (47%) liked domestic hit/dance music(Table 2).

The means and SD of respiratory rate, systolic and dias-tolic blood pressure, and heart rate scores on the first andsecond postoperative days for the two groups at each of thepretests and post-tests are shown in Tables 3 and 4. Thelong-term effects of music on systolic and diastolic bloodpressure, heart rate, and respiratory rate were evaluated onday 3. For systolic and diastolic blood pressure or heart rate,no statistically-significant differences were found. In themusic group, the respiratory rate (15/min-1) was significantlylower (P = 0.001) than in the control group (18/min-1).(Table 5).

In the music group, 47 of 83 (57%) patients answered theopen question. Participating in the study and music listeningwere a positive experience for 18 of 47 (38%) patients. Out ofa total of 47, 21 patients (45%) mentioned that they weresatisfied with the postoperative care. In the control group, 44of 84 (52%) patients answered the open question, and par-

ticipating in the study was a positive experience for 13 of 44(30%). Out of a total of 44 patients, 23 (52%) mentioned thatthey were satisfied with the postoperative care.

Hypothesis testing

The hypothesis that music listening results in significantlylower systolic and diastolic blood pressure, respiratory rate,and heart rate than in the control group was partly sup-ported. ANOVA for repeated measurements indicated thaton days 1 and 2, the postoperative patients in the music grouphad lower respiratory rates and systolic blood pressure levelscompared with the control group.

On the first postoperative day, the post-test mean for res-piratory rate in the music group (16/min-1) was significantlylower (P = 0.001) than in the control group (18/min-1). Thepost-test mean for systolic blood pressure on day 1 in themusic group was significantly lower (P = 0.05) compared withthe control group (Table 3).

On the second postoperative day, the pretest mean forrespiratory rate in the music group (17/min-1) was signifi-cantly lower (P < 0.001) than in the control group (18/min-1).In addition, the post-test mean for respiratory rate in themusic group (16/min-1) was significantly lower (P < 0.001)

Table 1. Background data of the abdominal surgery patients in the music and control groups

Background variables Music group (n = 83), n, % Control group (n = 85), n, % c2-test d.f. P-value

Age (mean, SD) 60 (13) 63 (12) 0.149Sex (male/female) 42/41 48/37 0.58 1 0.466Education 0.04 5 0.998

No education 20 (24)† 20 (24)Vocational school 35 (43)† 37 (43)College 14 (17)† 15 (18)Polytechnic/university or other 13 (16)† 13 (15)

Employment status 0.85 6 0.652Higher/lower office worker 12 (14) 9 (11)

Employee/entrepreneur 22 (27) 18 (21)Student/other 2 (2) 3 (3)Retired 47 (57) 55 (65)

Marital status 1.00 3 0.801Married/common-law marriage 60 (72) 65 (77)Single 8 (10) 7 (8)Widow 8 (10) 5 (6)Divorced/separated 7 (8) 8 (9)

Diagnosis for laparotomy 10.48 6 0.106Ventral hernia 3 (4) 3 (4)Diverticulitis 5 (6) 8 (10)Carsinoma intestinal 39 (47) 35 (41)Carsinoma ventriculi 7 (8) 7 (8)Carsinoma pancreas 10 (12) 12 (14)Colitis ulcerosa/Morbus Crohn 15 (18) 6 (7)Other 4 (5) 14 (17)

ASA 1.39 2 0.4991 5 (6) 2 (2)‡2 33 (40) 34 (41)‡3 45 (54) 48 (57)‡

*P < 0.05. †n = 82, missing data of education. ‡n = 84, missing data of anesthesia physical status classification (ASA). SD, standard deviation.



than in the control group (18/min-1). The post-test mean forsystolic blood pressure on day 2 in the music group wassignificantly lower (P = 0.04) compared with the controlgroup (Table 4).

There were no statistically-significant differences in dias-tolic blood pressure or heart rate on the first (Table 3)or second postoperative day (Table 4) between the twogroups.

Table 2. Patients’ music preferences in music group and control group

Music preferencesMusic group (n = 83) Control group (n = 84)†

c2-test P-valuen % n %

What is your music interest? 0.052 0.97Only listen to music 25 30 26 31Listen, play, sing 20 24 19 23No interest 38 46 39 46

Music exposure frequency 0.724 0.39Once a day or more often 73 88 70 83Once a week, rarely or never 10 12 14 17

What is your favorite music 1.520 0.68Hit/dance music 39 47 32 39

Domestic/foreign pop, rock 10 12 11 13Classical/religious music 14 17 14 17All kinds of music/not mentioned above 20 24 26 31

†One missing data item.

Table 3. Patients’ physiological parameters on the first postoperative day before and after music intervention between the two groups

First postoperative dayMusic group (n = 83)

Mean (�SD)Control group (n = 85)

Mean (�SD) P-value

PrevalueRespiratory rate 17/min (3) 18/min (3) 0.33Heart rate 78/min (12) 75/min (14) 0.23Systolic Bp 126 mmHg (16 mmHg) 128 mmHg (18 mmHg) 0.52Diastolic Bp 69 mmHg (9 mmHg) 69 mmHg (11 mmHg) 0.89

Post valueRespiratory rate 16/min (2) 18/min (3) 0.001*Heart rate 77/min (13) 78/min (15) 0.62Systolic Bp 124 mmHg (15 mmHg) 126 mmHg (18 mmHg) 0.05*Diastolic Bp 68 mmHg (9 mmHg) 68 mmHg (11 mmHg) 0.13

*P � 0.05. Repeated-measures ANOVA. Bp, Blood pressure; SD, standard deviation.

Table 4. Physiological parameters on the second postoperative day before and after intervention between the two groups

Second postoperative dayMusic group (n = 83)


Mean (�SD) P-value

PrevalueRespiratory rate 17/min (2) 18/min (3) 0.001*Heart rate 77/min (13) 78/min (15) 0.34Systolic Bp 134 mmHg (17 mmHg) 140 mmHg (21 mmHg) 0.32Diastolic Bp 75 mmHg (9 mmHg) 78 mmHg (11 mmHg) 0.95

Post valueRespiratory rate 16/min (3) 18/min (3) 0.001*Heart rate 77/min (13) 77/min (14) 0.79Systolic Bp 132 mmHg (17 mmHg) 138 mmHg (20 mmHg) 0.04*Diastolic Bp 75 mmHg (8 mmHg) 77 mmHg (10 mmHg) 0.14




DISCUSSION

Study limitations

There are certain methodological issues related to this studythat need to be addressed. First, only one researcher (AV)collected the data. This has advantages and disadvantages.The researcher has extensive experience in working on asurgical ward. Physiological measures were always taken inthe same way and in the same order. Blood pressure andheart rate were measured with an automatic OMRON M5-Ior OMRON M6 by one researcher (AV). These machineswere also used on the ward. The presence of the researcherthroughout the procedure might have influenced the partici-pants to have a more positive response. In both groups, thosewho answered the open question said that participating inthe study was a positive experience. The researcher was notblinded to the group assignment. Second, the sample size wasbased on a power analysis, and the data were collected over a25-month period. Third, all data were collected in only onehospital, so the results cannot be generalized.

Main findings

The aim of the study was to evaluate the effects of musiclistening on blood pressure, heart rate, and respiratory ratein postoperative abdominal surgery patients as part of anintervention study of pain management. The findings indi-cated that music listening resulted in a significantly lowerrespiratory rate and systolic blood pressure on both the firstand second postoperative days. There were no differencesbetween the two groups in diastolic blood pressure or heartrate. This result is different from that of previous studies byNilsson (2009), Sendelbach et al. (2006) and Masuda et al.(2005), in which there were no differences in blood pressureor heart rate. The results of this study are partially consistentwith those of Tse et al. (2005), in which both blood pressureand heart rate levels were lower in the music group than inthe control group. Although the results of these studies arenot completely comparable, it has been reported that bothcardiac and upper abdominal surgeries are painful and havean effect on breathing. Lower respiratory rate levels in themusic group might be as a result of well-managed analgesia,but also because of the possibility of patients listening to themusic they preferred (Mitchell et al., 2006). Favorite andfamiliar music possibly makes patients relaxed (Nilsson,

2009), so muscle tension is reduced and their respirationbecomes deeper and steadier. Usually, people like music thatevokes positive, or reduces negative, emotions. In this study,patients were pleased because they were allowed to selecttheir preferred music. Another explanation might be thatafter surgery, patients felt relief and gratitude, because theoperation was over, regardless of a cancer diagnosis (Worster& Holmes, 2009).

In this study, systolic blood pressure and respiratory ratelevels in the music group were lower before intervention.The reason remains somewhat unclear, because there wereno significant differences in socioeconomic status, age, sex,ASA classification, diagnosis, or analgesia between the twogroups, nor were there any significant differences in musicalpreferences.

On the third postoperative day, the music group patients’respiratory rate levels were significantly lower comparedwith the control group, even though they were no longerlistening to music. Good et al. (2002), who studied the effectsof music, relaxation, and the combination of relaxation andmusic in postoperative settings, obtained the same result, butafter intervention. Physiological indicators, such as changesin blood pressure, heart rate, and respiratory rate, might beassociated with pain and with the drugs used to treat it, butpain is also affected by disease and other sources of distress(Herr et al., 2006; Arbour & Gélinas, 2010). In this study,music intervention was organized in patients’ rooms duringnormal care. Patients were occasionally disrupted during theintervention because of a doctor’s round, nursing action, tele-phone calls, or visits by close relatives. These interruptionssometimes disturbed and irritated patients, and they mighthave had an influence on physiological parameters.Althoughsystolic blood pressure and respiratory rate levels weresignificantly lower in the music group, variations in allphysiological factors were normal in both groups.

Conclusions

This study has provided statistical support for the notion thatmusic listening is associated with significantly lower systolicblood pressure and respiratory rate on the first and secondpostoperative days. Moreover, music might have a long-termeffect on respiratory rate. Additionally, the study found thatmusic listening is a positive experience.

To verify these results, we need to conduct further studies.There is a need to study the effect of music on respiratory

Table 5. Systolic and diastolic blood pressure, heart rate, and respiratory rate on the third postoperative day

Third postoperative dayMusic group (n = 83)


Mean (�SD) Mann–Whitney U-test P-value

Systolic Bp 140 mmHg (23 mmHg) 147 mmHg (24 mmHg) 2814.0 0.31Diastolic Bp 81 mmHg (10 mmHg) 82 mmHg (11 mmHg) 3120.5 0.24Heart rate 75/min (16/min) 74/min (14/min) 3391.5 0.76Respiratory rate 15/min ( 4/min) 8/min ( 3/min) 1760.0 0.001*




rate after surgery. It is also important to evaluate the effectsof music in other surgery patient groups in several hospitalsat the same time. Further studies are also needed to examinethe effect of music and other non-pharmacological interven-tions on postoperative pain, such as relaxation, imagery, anddistraction (by arranging some meaningful activities, such aswatching television/films or reading) using qualitativemethods. Further studies are also needed of the nurses’ viewsof using the non-pharmacological methods.

Nurses should be encouraged to strengthen theirknowledge of the benefits of music listening as a non-pharmacological intervention. This would ensure that musicbecomes part of the healing environment to support surgicalpatients during their recovery period.

This study indicates that music listening might be anacceptable, low-risk intervention in clinical practice, and italso indicates that music has positive effects on patients’experiences while they are in hospital.

ACKNOWLEDGMENTS

The authors wish to thank Mr Vesa Kiviniemi, statistician,University of Eastern Finland, for sharing his expertise inthe statistical analysis. The study was financially supportedby Kuopio University Hospital EVO funding, the FinnishAssociation of Caring Sciences, and the Foundation of NurseEducation.

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