Dr. Kami Kloster earned her DNP from Aspen in August 2024. She has a background as an operating room nurse who focused primarily on patient advocacy, and is currently a nursing faculty member at a local community college, working to improve nursing education. Her doctoral research focused on non-pharmacological music interventions to reduce agitation in long-term care facility residents. She presented her project during Aspen’s 2024 Fall Research Colloquium and the video recording can be found here.
Harmonizing Minds: A Music Approach for Reducing Agitation – A Quality Improvement Project
By Kamala L. Kloster, DNP, MSN, RN
Understanding the Need
Approximately 20% of adults in the U.S. grapple with psychiatric disorders, often accompanied by comorbid conditions that lead to increased healthcare utilization, higher costs, and poorer health outcomes (Haight et al., 2023). Within skilled nursing facilities (SNFs), the use of antipsychotic medications has emerged as a critical concern for regulatory compliance, significantly impacting the quality of care provided to residents (Posar et al., 2023). The Centers for Medicare and Medicaid Services (CMS) stress the importance of stewardship in reducing psychotropic medication use in long-term care settings to enhance residents’ quality of life (Centers for Medicare and Medicaid Services, 2023). However, some residents, especially those exhibiting behavioral and psychological symptoms of dementia (BPSD), may genuinely require antipsychotic medications for safety (Cerejeira et al., 2021). Thus, it is essential to ensure that every resident maintains some degree of autonomy in their care.
Project Site
The rural Tennessee long-term care facility (LTCF) selected for this quality improvement project faces a higher-than-acceptable rate of residents requiring antipsychotic medications according to CMS guidelines. These guidelines often do not account for the unique demographics of individual LTCFs. While antipsychotics can be beneficial, their usage is frequently linked to heightened risks of falls and adverse drug events (Harrison & Sluggett, 2021). This LTCF specializes in caring for residents with behavioral disturbances and has initiated a psychotropic stewardship program in 2024, focusing on implementing non-pharmacological interventions to alleviate agitation before resorting to antipsychotic medications. The primary goal is to enhance residents’ autonomy and decrease agitation, ultimately improving their overall quality of life.
Project Purpose
This Doctor of Nursing Practice (DNP) quality improvement project aimed to implement a music intervention to reduce agitation among residents aged 30 to 60, utilizing the Practice Question, Evidence, and Translation (PET) Process from the Johns Hopkins Evidence-Based Practice Model. Music has been recognized as a non-pharmacological intervention that is quick to administer, low-cost, and easy to replicate (D’Aniello et al., 2021). Research shows that music can significantly decrease the need for PRN medications (Scudamore et al., 2021) and is associated with reduced psychotropic medication use and improved mood (Bakerjian et al., 2020). Furthermore, music interventions have been shown to effectively lower agitation in individuals with Alzheimer’s disease (Hill-Wilkes et al., 2023) and promote stress reduction for both residents with dementia and caregiving staff (Isaac et al., 2021). The link between anxiety and agitation is crucial, as subtle stress cues can escalate into intense behaviors; even listening to a single song can effectively mitigate agitation.
Research Question
Guiding this project is the PICOT question:
In long-term care residents aged 30-60 showing signs of agitation, does adding a music intervention to their treatment reduce these symptoms more effectively than using no nonpharmacological intervention over a calendar month?
P (Population): Long-term care residents aged 30-60
I (Intervention): Adding a music intervention to their treatment
C (Comparison): No nonpharmacological intervention
O (Outcome): Reduction of agitation symptoms
T (Timeframe): Over a calendar month
Sample Studied
The music intervention involved several key components: a care provider would first identify agitation in a resident and then complete the Pittsburgh Agitation Scale (PAS) pre-intervention assessment. Residents listened to music from a predetermined playlist tailored to their age, using Bluetooth-connected headphones in shared spaces or a small speaker in private areas. This approach adapted a previous intervention used by Belenchia (2023) but simplified the process by omitting personalized playlists to maintain the integrity and efficacy of the quality improvement implementation.
To minimize distractions in shared spaces, residents wore headphones to help drown out background noise (B. Gaither, personal communication, November 28, 2023). Each resident’s room was equipped with a smart television to facilitate music playback (W. Hall, personal communication, November 18, 2023). The goal was to document instances of agitation among the 15 participating residents using the PAS survey before the intervention. After each music session, a post-survey was conducted to evaluate the impact of the intervention over the project’s one-month duration.
Predetermined Playlists via Apple Music
For the quality improvement project, predetermined playlists were loaded by the project leader onto two iPhones and distributed to interdisciplinary teams for use throughout the implementation month. The decision to focus on generational playlists was informed by a study by McCreedy et al. (2021), which highlighted the effectiveness of selecting music preferred by residents during their formative years (ages 16-26). This approach helps to standardize testing across influential decades and genres, particularly since many residents lack family involvement in their care. The playlists were tailored to different age groups as follows:
Residents aged 30-34: 00’s Hits
Residents aged 35-39: 90’s Hits
Residents aged 40-44: 80’s or 90’s Hits
Residents aged 45-49: 80’s Hits
Residents aged 50-54: 70’s or 80’s Hits
Residents aged 55-59: 60’s or 70’s Hits
Residents aged 59-60: 60’s or 70’s Hits
Instrumentation
The instrument utilized for this quality improvement project was the Pittsburgh Agitation Scale (PAS), developed by Rosen et al. in 1994. The PAS categorizes agitation behaviors into four groups: aberrant vocalizations, motor agitation, aggressiveness, and resisting care. It also includes an intensity scale for each behavior group, allowing providers to assess and rate the observed behaviors’ severity. Additionally, the scale inquires about any interventions employed in response to the behaviors, such as seclusion, PRN medications, restraints, or other measures (Rosen et al., 1994).
Project Design
This quality improvement project utilized the Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) approach.
- It began by defining the opportunity for improvement, outlining the project’s goals, and identifying key stakeholders.
- The measurement phase involved assessing agitation levels among residents using the PAS through pre- and post-intervention surveys.
- During the analysis phase, data was collected by the interdisciplinary team members to evaluate the music intervention’s effectiveness in reducing agitation.
- The improvement step showcased the implementation of the music intervention while continuing data collection and evaluating outcomes.
- Finally, the control phase focused on developing a long-term plan to sustain the quality improvements achieved.
The opportunity for improvement was established by determining whether the addition of a music intervention effectively reduced agitation signs and symptoms in long-term care residents aged 30-60 compared to no nonpharmacological intervention. The project’s goal was to reduce agitation symptoms through this music intervention, with key stakeholders including the resident population, multidisciplinary care providers, and facility leadership.
Data on pharmacologic and nonpharmacologic interventions were compiled from the facility, which has a capacity of 70 residents; 15 were included in this project. The immersion site administrator evaluated residents on antipsychotic medication, and following an understanding of current interventions, the multidisciplinary team was introduced to the music intervention, utilizing the PAS as the pre-and post-survey tool to measure effectiveness over a calendar month.
Theoretical Framework
The theoretical framework for this project was Dorothea Orem’s Self-Care Deficit Nursing Theory, which emphasizes the significance of patient care while prioritizing patient autonomy (Devi et al., 2023). Orem’s theory offers a systematic approach for nurses to assess and prioritize care for residents, fostering their independence by supporting self-care activities. This framework ensures that care practices enhance residents’ abilities to manage their own health, ultimately promoting their well-being and autonomy.
Change Model
The change model for this project employed the DMAIC (Define, Measure, Analyze, Improve, Control) process, a problem-solving method within the Six Sigma framework. This model is linked to Deming’s Plan-Do-Study-Act (PDSA) cycle (Wayne, n.d.). The quality improvement project aimed to achieve success within a limited timeframe by leveraging the structured approach of DMAIC. This systematic methodology enhances efficiency, minimizes defects, and fosters continuous improvement, making it an effective framework for quality improvement initiatives commonly associated with Doctor of Nursing Practice projects.
Data
Data collection for this quality improvement project involved self-reporting through surveys and direct observation, as well as real-time data tracking via sheets or logs. At the immersion site, multidisciplinary team members were briefed on the project plan, completed the PAS survey during a defined pre-intervention period, implemented the music intervention, and then conducted the PAS as a post-intervention survey. The project leader analyzed the collected data, which did not contain any patient-identifying information. Data collection commenced following project approval from the Institutional Review Board (IRB) at Aspen University and permission from the site administrator. All data was securely stored and devoid of identifiable patient information.
The data analysis plan focused on comparing the pre- and post-intervention PAS results. The independent variable was the music intervention, consisting of a predetermined generational playlist played through Bluetooth headphones or an MP3 player, depending on residents’ locations when agitation occurred. The dependent variable, agitation, was assessed using the PAS, which evaluates four behavior groups: aberrant vocalizations, motor agitation, aggressiveness, and resisting care. The aggregate score for each resident before and after the intervention was recorded to assess the intervention’s impact on agitation levels.
Understanding the Pittsburgh Agitation Scale Results
The project analyzed data from 15 residents, with 14 completing evaluations using the Pittsburgh Agitation Scale (PAS). This scale assesses four key behavior groups: aberrant vocalization, motor agitation, aggressiveness, and resisting care. Each resident was assigned a unique identifier to maintain confidentiality, and detailed information regarding interventions used during the assessment period was collected.
- Aberrant Vocalization
Aberrant vocalizations encompass repetitive requests, complaints, or nonverbal vocalizations like moaning or screaming. The pre-intervention score for this behavior group was 21, which significantly decreased to 7 post-intervention. This represents a remarkable 66.66% reduction (a decrease of 14 points).
- Motor Agitation
Motor agitation includes behaviors such as pacing, wandering, or disrobing. The pre-intervention score was 17, which dropped to 6 following the intervention, reflecting a 66% reduction (an 11-point decrease).
- Aggressiveness
Aggressiveness is assessed through verbal threats, threatening gestures, or physical actions. Interestingly, the score for aggressiveness remained unchanged at 3 for both pre- and post-intervention assessments, indicating no significant impact from the music intervention.
- Resisting Care
Resisting care includes avoidance of care activities such as washing or eating. The score in this category decreased from 5 to 1, marking an 80% reduction (a decrease of 4 points) post-intervention.
Overall, these results suggest that the music intervention was effective in reducing agitation in three of the four behavior categories, particularly notable were the 66% reductions in both aberrant vocalization and motor agitation, alongside the 80% reduction in resisting care.
Impact on Medication Usage
In addition to behavioral assessments, the project analyzed medication usage among residents based on monthly consultant pharmacist reports. The findings from March to April revealed a decrease in the percentage of residents using various classes of medications:
Psychotropic Medications: Decreased from 97.1% in March to 95.7% in April (1.4% reduction).
Antipsychotics: Reduced from 76.5% in March to 75.7% in April (0.8% reduction).
Anxiolytics: Decreased from 52.9% in March to 51.4% in April (1.5% reduction).
Antidepressants: Reduced from 75% in March to 72.9% in April (2.1% reduction).
Anticonvulsants: Decreased from 47.1% in March to 42.9% in April (4.2% reduction).
These findings highlight a significant decrease in the use of psychotropic medications across all categories, echoing findings from existing literature. Notably, the sample of 15 residents represented 20% of the total population, suggesting that broader implementation of music interventions could lead to even greater reductions in medication usage across multiple facilities.
Conclusion
This quality improvement project holds promise for significantly reducing agitation levels among long-term care residents, fostering improved patient autonomy, and potentially diminishing reliance on pharmacologic interventions. The successful implementation of a music intervention based on the PAS offers a structured, evidence-based approach to enhancing care quality in skilled nursing facilities. Ongoing data analysis and evaluation will provide further insights into the sustainability of these improvements and the potential for scaling similar interventions in other long-term care settings.
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