Intensive & Critical Care Nursing xxx (xxxx) xxx

Contents lists available at ScienceDirect

Intensive & Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Research article

Effects of progressive muscle relaxation combined with music on stress,

fatigue, and coping styles among intensive care nurses
Bugse Ozgundondu a, Zehra Gok Metin a,b,⇑
a
University of Health Sciences, Ankara Gulhane Training and Research Hospital, Internal Medicine Intensive Care Unit, Turkey
b
Hacettepe University Faculty of Nursing, Internal Medicine Nursing Department, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Aim: To examine the effects of progressive muscle relaxation combined with music on stress, fatigue and
Received 19 May 2019 coping styles amongst intensive care unit (ICU) nurses.
Revised 13 June 2019 Design: A randomised controlled trial of 56 nurses aged 18 years and older, with at least three months
Accepted 16 July 2019
experience. The intervention group (n = 28) received a 20 minute session comprising progressive muscle
Available online xxxx
relaxation combined with music for a total of eight weeks in the form of group sessions, while the control
group (n = 28) received only a single-time face-to-face attention-matched education (20 minutes). The
Keywords:
data collection tools were administered at baseline, at week four, eight and twelve.
Coping styles
Intensive care nurses
Setting: Internal Medicine, Anaesthesia, and Coronary Intensive care Unit of a training and research hos-
Music therapy pital.
Progressive muscle relaxation Main outcome measures: Primary outcome: Stress level. Secondary outcome: Fatigue severity and coping
Stress styles.
Results: Stress scores in the intervention group decreased significantly at week 8 and week 12 (p < 0.05).
Similarly, the fatigue scores were observed to be significantly lower in the intervention group at week 8
and week 12 in comparison to those in the control group (p < 0.05). The scores of coping styles, obtained
for the acceptance sub-dimension were significantly higher in the intervention group compared to the
control group at week 4, 8, and 12 (p < 0.05). The use of instrumental support, venting and the emotional
support scores were observed to be significantly higher in the intervention group compared to the control
group at week 12 (p < 0.05).
Conclusion: The results indicated that progressive muscle relaxation combined with music appears to be
effective in decreasing stress and fatigue, and in improving the coping styles amongst intensive care
nurses. Future studies should be conducted on a larger scale to make conclusions with higher probability.
Ó 2019 Elsevier Ltd. All rights reserved.

Implications for clinical practice

 This study highlights the beneficial effects of progressive muscle relaxation combined with music therapy on stress, fatigue, and cop-
ing styles amongst intensive care nurses.
 The progressive muscle relaxation combined with music therapy indicated positive effects on perceived stress and fatigue scores and
coping styles.
 Results generated from this study shed light on how intensive care nurses are provided support with mind-body based interventions
including progressive muscle relaxation and music therapy.
 Future research integrating additional home exercises should be conducted on a larger scale, and for a longer period.

⇑ Corresponding author at: Hacettepe University, Faculty of Nursing, 06000

Sihhiye, Ankara, Turkey.
E-mail address: zehragok85@hotmail.com (Z. Gok Metin).

https://doi.org/10.1016/j.iccn.2019.07.007
0964-3397/Ó 2019 Elsevier Ltd. All rights reserved.

Please cite this article as: B. Ozgundondu and Z. Gok Metin, Effects of progressive muscle relaxation combined with music on stress, fatigue, and coping
styles among intensive care nurses, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.07.007
2 B. Ozgundondu, Z. Gok Metin / Intensive & Critical Care Nursing xxx (xxxx) xxx

Introduction et al., 2018; Pahlavanzadeh et al., 2016; S ß ahin and Dayapoğlu,

2015; Zhou et al., 2015). Additionally, a few reports have indicated
Intensive care units (ICUs) are an essential part of hospital- that PMR and music therapy exert promising effects of stress relief
based healthcare in order to provide rapid resuscitative and sup- amongst ICU nurses (Pahlavanzadeh et al., 2016; Ploukou and
portive care to critically ill patients (Kıraner et al., 2016; Yılmaz Panagopoulou, 2018; Steele, 2018). Just one study is available in
and Vermisßli, 2016). ICUs are also stressful atmospheres because the literature that has highlighted the effect of performing music
of the complexity and the dynamic nature of their environment. therapy in reducing the severity of perceived stress in oncology
The different ICU stressors include working relationship with nurses (Steele, 2018). On the other hand, previous studies applying
nurses and the other healthcare team members, communication only progressive muscle relaxation, or music therapy, or combining
and conversations with the patients, the high levels of knowledge both of them, generally conducted with small number of partici-
and skills required to work in this ward, use of sophisticated pants, as single centered, non-randomised, and had variations in
technical equipment in ICUs, high workload, the necessity of assessment times and follow-up procedures (Choi, 2010; Liao
responding swiftly and promptly to situations that demand et al., 2018; Ploukou and Panagopoulou, 2018; Zhou et al., 2015).
urgent care and heavy responsibility regarding the care of the No clinical study has so far investigated the effects of PMR in com-
patients (Cengiz, 2017; Dede, 2013; Günüsßen, 2017; Nursen bination with music therapy on stress, fatigue and coping styles
et al., 2016; Sßengül et al., 2015). Nurses, who are the indispens- amongst nurses working in ICUs. In consideration of the long-
able members of ICU team, hold important duties and responsi- term exposure to stress, chronic fatigue, and the lack of coping
bilities such as providing 24 hour care, high concentration, close styles among ICU nurses, studies that assess the effects of PMR
monitoring of the patients, early recognition of complications and music therapy become essential. In this regard, the present
and maintenance of strong communication with the other health- randomised controlled trial aimed at examining the effects of
care providers. A Swedish study conducted previously indicated PMR in combination with music therapy on stress, fatigue, and
that greater than 80% of ICU nurses reported higher levels coping styles amongst ICU nurses. The present study hypothesised
of stress compared to the other professional groups (Gelsema that PMR combined with music as a supportive therapy could
et al., 2005). reduce (1) stress, (2) fatigue levels and (3) also improve coping
In addition to higher stress levels, the other most common styles amongst nurses working in ICUs.
problems experienced by ICU nurses are physical and mental fati-
gue (Akyol and Kankaya, 2017; Kesgin and Kublay, 2011). Fatigue Materials and methods
is a subjective symptom, which is defined as burnout or exhaustion
and prevents nurses from continuing the practices in their lives Study design and setting
and decreases their efficiency (Altuntasß et al., 2014; Jenkins and
Warren, 2012; Troxel et al., 2010). The levels of fatigue among The present study was designed as a prospective, attention-
120 nurses were evaluated and it was reported that 68% of the matched education, controlled, randomised trial, and was con-
nurses felt tired and exhausted (Altuntasß et al., 2014). Moreover, ducted in University of Health Sciences, Ankara Gulhane Training
because of exposure to chronic stress and fatigue, nurses may and Research Hospital. The study was conducted with the nurses
experience headache, sleep disorder, mental problems such as anx- working in Internal Medicine, Anaesthesia, and Coronary ICUs.
iety and depression, low performance at work and even burn-out The nurses who were grouped in the intervention group were pro-
syndrome (Oktay, 2005). As a result of high stress and chronic fati- vided with a booklet containing the definition, purpose, benefits,
gue, the coping abilities of ICU nurses decrease over time (Andolhe and application techniques of PMR and the music therapy. The ses-
et al., 2014). Considering the outcomes of previous studies avail- sion of PMR combined with music was conducted by the principal
able in the literature, mind-body practices such as breathing exer- investigator (PI), who had work experience in relaxation and music
cises, yoga, meditation, progressive muscle relaxation (PMR) and therapy, through group sessions, which composed of 10–15 partic-
music therapy have been utilised in recent years to help reduce ipants; each session was 20 minutes long and was conducted once
stress and fatigue in the individuals and improve their coping each week for a total of eight weeks. The participants in the inter-
styles (Steinberg et al., 2017; Troxel et al., 2010). vention group were asked to not perform additional PMR and
PMR is one of the mind-body practices that involves voluntary music therapy sessions independently at home until the comple-
stretching and relaxation of all the muscle groups in the body, from tion of follow-up assessment. The nurses in the control group
head to foot (Genç and Oğuz, 2018b). PMR allows reduction of the received a single-time face-to-face attention-matched educational
effects of chronic stress on the body and assists in attracting the session, for a total of 20 minutes, on the first day of the study and
individuals’ attention on their skeletal muscles (Li et al., 2015; no additional intervention was conducted for this group during the
ß ahin and Dayapoğlu, 2015). Similar to PMR, music therapy is
S whole study period. Like the intervention group, the control group
another mind–body practice, which uses rhythm, melody, har- session (attention-matched education) which composed of 10–15
mony and other elements of music to cause improvements in the participants was performed with a booklet containing the causes,
individuals’ neuroendocrine system, to bring significant changes negative effects of stress and fatigue on the body, and techniques
in the structure of their feelings and thoughts (Liu et al., 2016; for coping with stress in a silent room located in the hospital.
Robb et al., 2018). Previous studies have reported that music ther- The participants in the intervention group continued to receive
apy causes a decrease in the pulse rate, respiratory rate, group sessions comprising PMR combined with music, once a
systolic/diastolic blood pressure and body temperature, provides week, for a total of eight weeks. The PMR combined with music
relaxation, directs attention to different thoughts, reduces stress sessions were finalized at week 8. The intervention was applied
levels and improves the quality of life (QOL) by providing sensorial neither to the intervention nor the control group post the comple-
and mental well-being (Meriç and Kaya, 2018; Warth et al., 2015). tion of the weekly sessions (week 8) until the follow-up assess-
So far, the use of PMR and music therapy has remained limited to ment (week 12). The follow-up assessment was performed only
reducing acute or chronic pain, improving QOL in chronic diseases, once at week 12 (four weeks post the last session of PMR combined
managing chemotherapy-related side effects such as pain, nausea, with music). The 2017 CONSORT Statement for Randomised Trials
vomiting, and fatigue and changing the attitudes and behaviours of of Non-Pharmacological Treatments was used as a guide while
_
the individuals (Genç and Oğuz, 2018a; Ibrahimoğlu, 2015; Liao reporting the present study.

Please cite this article as: B. Ozgundondu and Z. Gok Metin, Effects of progressive muscle relaxation combined with music on stress, fatigue, and coping
styles among intensive care nurses, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.07.007
 B. Ozgundondu, Z. Gok Metin / Intensive & Critical Care Nursing xxx (xxxx) xxx 3

Sample size through lottery method (A: Control; B: Intervention) by the second
author of the present report who was not involved in the interven-
G* Power 3.1 software was used to calculate the sample size for tion procedures, and the PI informed the nurses about the randomi-
the study. The power of the study was calculated on the basis of sation results. As a result of the assignment to a different hospital
our data which included comparisons between the study groups (n = 1) and annual leave (n = 2), a total of three participants in the
in terms of mean differences at the baseline and week 8 in the Fati- intervention group could not begin the sessions. In the control
gue Severity Scale (FSS) scores. The corresponding scores obtained group, a total of four participants could not receive the attention-
for the intervention group and control group were 30.86 ± 10.41 matched education either due to assignment to a different hospital
and 42.82 ± 9.66, respectively. Considering a two-sided a of 5%, (n = 2) or due to change of unit (n = 2). The study was finally com-
with a medium effect size (0.60), the power of the study was pleted with a total of 56 ICU nurses, 28 in the intervention group
determined to be 98.9. and 28 in the control group (Fig. 1). The PI collected all data of the
study. All the sessions comprising PMR combined with music were
also conducted by the PI who was not blinded to the study groups
Randomisation, allocation and blinding
due to the nature of PMR. Hence, the current study was conducted
as non-blinded. The data obtained in the study were analysed by
The potential participants (n = 75) were listed and assessed in
an independent statistician.
terms of the eligibility criteria established by the PI. Subsequently,
the PI explained the study protocol to the participants. The partici-
pants eligible for the present study were recruited from 1 July Eligibility criteria and study sample
2018 to 15 January 2019. A total of 12 nurses were excluded from
the study as they either did not meet the inclusion criteria (n = 4) The eligible nurses included those who (a) were 18 years old,
or declined to participate in the study (n = 8). Subsequent to obtain- (b) had an experience of at least three months in ICUs, and (c) had
ing informed consent from the eligible participants, these 63 nurses no documented history of chronic obstructive pulmonary disease,
were assigned randomly into two groups (Group A: 31; Group B: 32) heart failure and asthma. The exclusion criteria were as follows:

Fig. 1. Flow diagram of the study sample.

Please cite this article as: B. Ozgundondu and Z. Gok Metin, Effects of progressive muscle relaxation combined with music on stress, fatigue, and coping
styles among intensive care nurses, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.07.007
4 B. Ozgundondu, Z. Gok Metin / Intensive & Critical Care Nursing xxx (xxxx) xxx

(a) history of severe psychiatric disorder, (b) ICU experience of less 3. Take a deep breath through your abdomen, hold for 3 sec-
than three months, and (c) not currently using any complementary onds, and exhale slowly. Again, as you breathe, notice
therapy modalities such as acupuncture, massage therapy, relax- your stomach rising and your lungs being filled with air.
ation techniques, and yoga that can be influential on perceived 4. As you exhale, imagine all the tension in your body
stress and fatigue or coping styles. being released and flowing out of your body. Again,
inhale and exhale. Feel that your body has relaxed.
Progressive muscle relaxation combined with music: procedure 5. As you go through each step, continue breathing in the
manner instructed earlier.
The nurses were required to reach the amphitheater of the 6. Now, please tighten your forehead muscles by raising
Ankara Gulhane Training and Research Hospital, which dimly lit, your eyebrows as high as you are able to. Hold for 5 s
in order to receive the group sessions of PMR combined with and then lose the tension, and wait for the next
music. Training on PMR combined with music was conducted in 10 seconds.
face-to-face sessions. The participants were first taught the 7. Next, tighten your eye muscles. Hold for 5 seconds and
description, using fields and effects on the body of the PMR plus release. Wait for 10 seconds.
music therapy. Subsequently, step-by-step instructions on PMR 8. Now smile widely, feel the tension in your mouth and
were provided by the PI. After the demonstration by PI, all the cheeks. Hold for 5 seconds and release; appreciate the
PMR steps were practiced by the participants under the supervi- softness in your face. Wait for 10 seconds.
sion of PI within the duration of 20 minutes, following which, 9. Gently pull your head back as if you were looking at the
PMR booklets prepared by the researchers were delivered to the ceiling. Hold the position for 5 seconds and release; feel
nurses in the training session itself. The PI prepared the amphithe- the tension melting away. Wait for 10 seconds.
ater prior to each group session, and the preparations included 10. Now, feel the weight of your relaxed head and neck.
placement of a laptop on a small table in the middle of amphithe- Breathe in and breathe out. Let go of all the stress in
ater and insertion of a flash memory card (USB) for relaxing music your body. Breathe in and breathe out.
developed by Daniel Kobialka. The aforementioned music piece 11. Now, tightly, but without forcing, clench your hands.
was selected because it contains elements such as rhythm, melody, Hold this position for 5 seconds and release. Wait for
and harmony, has a fluid melody and a tempo that does not 10 seconds.
increase the resting heart rate (Liao et al., 2018; Zhou et al., 2015). 12. Now, flex your forearms to tighten the biceps muscles.
The intervention group continued with the 20-min PMR accom- Feel the tension in your muscles. Hold for 5 seconds and
panied by music group sessions once a week, each week, for a total release; enjoy the relaxing effect. Breathe in and
of eight weeks. The nurses in the CG were invited to a silent room, breathe out.
where they received a single-time attention-matched education on 13. Now spread your arms and position your elbows in
the effects of stress on the body. The attention-matched education front of you to tighten the triceps muscles. Hold for
was conducted face to face and lasted for 20 min, following which 5 seconds and release. Wait for 10 seconds.
training booklets designed by researchers were distributed 14. Now lift your shoulders up as if they could touch your
amongst the participants. ears. Hold for 5 seconds and release quickly; feel the
The nurses in the intervention group selected their places in the weight of your shoulders. Wait for 10 seconds.
amphitheater based on where they felt comfortable sitting on the 15. Tense your upper back by pulling your shoulders back.
chairs. Deep breathing technique was demonstrated by the PI to Hold for 5 seconds and release. Wait for 10 seconds.
all the nurses when the latter had settled in comfortable positions. 16. Tighten your chest by taking a deep breath. Hold for
After the demonstration, the nurses were asked to take a deep 5 seconds and exhale deeply.
breath, focus on the music, and wear the black-colored cotton 17. Now tighten your stomach muscles by pulling into your
eye patch provided to them in order to achieve a dimly lit environ- belly. Hold for 5 seconds and release. Wait for
ment, just prior to the commencement of the session. After com- 10 seconds.
pleting the PMR session, the music was turned off. The PMR 18. Gently lean forward to tighten your low back. Feel your
intervention comprised 20 min sessions, which involved tensing upper body letting go of the tension and stress; hold for
and relaxing the body along with deep breathing. The participants 5 seconds and relax. Wait for 10 seconds.
performed PMR for each body part in a particular order, beginning 19. Tighten your buttocks. Hold for 5 seconds and release.
with the face muscles and head, followed by neck, shoulders, chest, Imagine that your hips have become light. Wait for
abdomen, legs, and feet. All the muscle tensing and relaxing proce- 10 seconds.
dures were performed in accompaniment with deep breathing. The 20. Touch your knees with each other, and then press your
participants were instructed to tense a specified group of muscles patellae in a manner as if you are holding a penny or a
for 5 s while breathing in, and then relax the same muscles for 10 s thin paper between them. Hold the position for 5 sec-
while breathing out. While performing this exercise, the partici- onds and release. Wait for 10 seconds.
pants visualized a wave of relaxation flowing through their body 21. Now flex your feet, pull your toes toward you, and feel
by using the deep-breathing technique. the tension in the muscles at the back of your lower leg.
The steps for the PMR session are listed below: Hold for 5 seconds and release; feel that the weight of
your legs is sinking. Wait for 10 seconds.
1. Wear comfortable clothes, sit on a chair in a comfortable 22. Bend your toes, and feel the tension in the muscles at
position, and use the black-coloured cotton eye patch the front of your lower leg. Hold for 5 seconds and
provided to you until the completion of the intervention. release. Wait for 10 seconds.
2. Bring your attention specifically to your body. If you 23. Now imagine a wave of relaxation slowly spreading
begin to notice that your mind is wandering, bring through your body, beginning at your head and reach-
your attention back to the muscle you are currently ing your feet. Feel the light weight of your relaxed body.
working on. Breathe in and breathe out. In and out.

Please cite this article as: B. Ozgundondu and Z. Gok Metin, Effects of progressive muscle relaxation combined with music on stress, fatigue, and coping
styles among intensive care nurses, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.07.007
 B. Ozgundondu, Z. Gok Metin / Intensive & Critical Care Nursing xxx (xxxx) xxx 5

Outcome measurements and study instruments venting, positive reframing, planning, humor, acceptance, religion
and self-blame. The sub-dimensions in Brief COPE are classified
The primary outcome of this study was the perceived stress into three categories: problem-focused coping strategies,
level. The secondary outcomes were fatigue severity and change emotion-focused coping strategies and ineffective coping strate-
in coping styles findings. Personal Information Form was used to gies (Bacanlı et al., 2013). While the sub-dimensions of active cop-
collect the sociodemographic and working characteristics of the ing, planning, self-distraction, and use of instrumental support
nurses included in the present study. Perceived Stress Scale (PSS) constitute problem-focused coping strategies, use of emotional
for stress levels, Fatigue Severity Scale (FSS) for fatigue scores, support, positive reframing, acceptance, humor, and religion sub-
and Brief COPE for coping style were also utilized for data dimensions constitute emotion-focused coping strategies. Venting,
collection. denial, behavioral disengagement, self-blame and substance use
sub-dimensions are placed in the category of ineffective coping
Personal information form strategies (Bacanlı et al., 2013). The reliability and validity of the
This form contained 12 questions inquiring about age, gender, Turkish version of Brief COPE were established by Bacanlı et al.
educational level, marital status, number of children, income sta- (2013), who obtained a Cronbach’s alpha value of 0.79 for the Turk-
tus, comorbid conditions, living alone or living with a family or ish version. The higher score obtained in Brief COPE represents bet-
friend, name of ICU, total experience in ICUs, working hours per ter coping strategies used by the participants.
week, and level of satisfaction with ICU (Eren and Öztunç, 2016).
Data collection
Perceived stress scale (PSS)
The scale was developed by Cohen et al. (1983) and represents a
The baseline data were collected using the personal information
global measure of stress that assesses the extent to which the
form, PSS, FSS and Brief COPE in the first interview conducted with
respondents perceive life to be unpredictable, uncontrollable, and
the nurses. PSS, FSS, and Brief COPE interviews were repeated at
overloaded. The PSS contains general rather than event-specific
week 4, week 8 and week 12. All the data collection tools were
items and is sensitive to background extraneous stressors as well
applied through face-to-face interviews by the PI.
as to existing stressful circumstances. The PSS originally developed
contained 14 items. However, subsequent scrutiny produced a
modified 10-item version (PSS–10) that possessed superior psy- Statistical analysis
chometric properties. Consequently, Cohen (1988) recommended
that researchers should use PSS–10 rather than the original version The data obtained in the present study were analysed using IBM
of PSS. The PSS scale is a 5-point Likert type (1 = never, 2 = almost SPSS Statistics 23.0 (IBM Corp., Armonk, New York). The variables
never, 3 = sometimes, 4 = fairly often, 5 = very often) scale. The of the study were evaluated for conformity to a normal distribution
validity and reliability tests for the Turkish version of this scale using the Shapiro-Wilk test. Mean (±standard deviation) was used
were conducted by Erci (2006); the item-total score correlation for expressing the data exhibiting normal distribution, while med-
was determined to be in the range of 0.32–0.66, and the Cronbach’s ian and 25th and 75th quartile values were used for the data that
alpha coefficient obtained was 0.70. PSS scores were obtained by were not normally distributed. The baseline variables including
reversing the responses (e.g. 0 = 4, 1 = 3, 2 = 2, 3 = 1, and 4 = 0) to age, marital status, educational level, income level, etc., were com-
the four positively stated items (items 4, 5, 7, and 8), followed by pared using the chi-squared test. Comparisons between the study
summing across all the scale items. Higher scores obtained in the groups in terms of PSS, FSS, and Brief COPE scores were performed
PSS indicate a high level of perceived stress (Erci, 2006). In the pre- by using one-way ANOVA and Mann-Whitney U test. The statistical
sent study, the PSS Cronbach’s alpha coefficient was calculated to significance threshold for the two-tailed test and the analyses was
be 0.74. set at p < 0.05.

Fatigue severity scale (FSS) Ethical considerations

The scale was originally developed by Krupp et al. (1989) and
assesses the individuals’ fatigue severity. This scale contains nine The study was approved by the clinical trials ethics committee
items and allows the selection of scores from 1 (strongly disagree) of the University of Health Sciences, Ankara Gulhane Training and
to 7 (strongly agree) to indicate the agreement level to each item. Research Hospital (decision number: 18/167–05.06.18), and was
The Turkish validity and reliability of this scale were studied by performed in accordance with the Declaration of Helsinki. After
Armutlu et al. (2007), who obtained a Cronbach’s alpha coefficient obtaining permission from the related ICU units, PI approached
of 0.94 and an item-total correlation coefficient was in the range of the eligible nurses at ICUs. All the eligible participants were
0.64–0.67. The total score is the mean of scores of the nine items, requested to submit a written informed consent for participation
and a higher score obtained on this scale indicates a higher degree in the study. The participants were informed that they could with-
of fatigue. A score of four or higher implies fatigue. In the present draw from the study at any point of time without stating a reason
study, the FSS Cronbach’s alpha coefficient was calculated to be and that there was no cost for participating in the study. All data
0.81. were collected and recorded in a manner that protected the anon-
ymity of the participants.
Brief COPE
Brief COPE is a 28-item multi-dimensional measure of the
strategies used for coping in response to stressors. Carver (1997) Results
originally developed a 53-item scale, which was later translated
into a 28-item short form known as Brief COPE. Brief COPE contains Participants’ adherence to PMR combined with music sessions
14 sub-dimensions and is scored as a four-point Likert scale, rang-
ing from ‘‘I have not been doing this at all” (score 1) to ‘‘I have been In the weekly sessions, no participants dropped out of the study,
doing this a lot” (score 4). The fourteen sub-dimensions are self- and all of them attended the weekly sessions in line with the study
distraction, active coping, denial, substance use, use of emotional protocol. Moreover, no participant dropouts were observed due
support, use of instrumental support, behavioural disengagement, to unexpected adverse effects of PMR combined with music,

Please cite this article as: B. Ozgundondu and Z. Gok Metin, Effects of progressive muscle relaxation combined with music on stress, fatigue, and coping
styles among intensive care nurses, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.07.007
6 B. Ozgundondu, Z. Gok Metin / Intensive & Critical Care Nursing xxx (xxxx) xxx

indicating that this intervention was safe to practice and well- participants in the intervention group were working for
tolerated amongst ICU nurses. 40–48 hour per week, 53.6% of the participants were working for
more than 48 h per week in the control group. Greater than
Participants’ demographic and working characteristics 60.0% of the participants in both the groups reported being satis-
fied with working in ICUs. The study groups were homogeneous
Sociodemographic and working characteristics of the nurses are in terms of age, gender, marital status, educational level, income
presented in Table 1. The mean age of the nurses was 24.61 ± 2.61 status, living with either their family or friends, comorbid condi-
years in the intervention group and 27.75 ± 4.75 years in the con- tions, experience in ICU, working hours per week and satisfaction
trol group. All the participants (100.0%) in the present study were levels with ICUs (p > 0.05).
female. Majority of the participants (78.6%) in the intervention
group and 53.6% of those in the control group were single. A great
majority of participants (92.8%) in the intervention group and all Effects of PMR combined with music therapy on PSS scores of
the participants (100.0%) in the control group had graduated from participants
university. A big majority of participants in the study groups had
moderate income levels. A huge proportion of participants (92.9% The median total PSS scores of the participants in the interven-
in the intervention group and 89.3% in the control group) reported tion group were as follows: 31.0 at the baseline, 29.0 at week 4,
having no comorbid condition. In both of the groups, more than 27.0 at week 8 and 30.0 at week 12 of the study. The corresponding
half of the participants were living with their families. scores obtained for the control group were 29.0, 30.5, 29.0, and
In regard to working characteristics, 71.4% of the participants in 31.0, respectively. In regard to the comparison of the total PSS
the intervention group and 75.0% in the control group were work- scores between the study groups, statistical testing revealed no
ing in the internal medicine ICU. More than half of the participants significant difference for the baseline and week 4 assessments,
(57.1%) in the intervention group and 64.3% in the control group while a significant reduction was observed in favor of the interven-
were working in ICU for more than two years. While 53.6% of the tion group (p < 0.05) at weeks 8 and 12 of the study (Table 2).

Table 1
Socio-demographics characteristics of the participants (N = 56).

Characteristics Intervention Group Control Group (n = 28) Test statistic* p-value

(n = 28)
Age (X ± SD) 24.61 ± 2.61 27.75 ± 4.75 3.063 0.060
n % n %
Gender
Female 28 100.0 28 100.0 ** **
Male 0 0 0 0
Educational level
High school 2 7.2 0 0.0 ** **
University 26 92.8 28 100.0
Marital status
Single 22 78.6 15 53.6 3.903 0.051
Married 6 21.4 13 46.4
Having Children
No 26 92.9 23 82.1 1.469 **
Yes 2 7.1 5 17.9
Income status
Low 3 10.7 3 10.7 0.422 **
Moderate 19 67.9 24 85.7
High 6 31.4 1 3.6
Comorbid diseases
Not present 26 92.9 25 89.3 0.220 1.000
Present 2 7.1 3 10.7
Living with together
Family 15 53.6 17 60.7 1.125 0.557
Alone 10 35.7 10 35.7
Friend 3 10.7 1 3.6
ICU
Internal medicine 20 71.4 21 75.0 1.691 0.422
Coronary 6 21.4 3 10.7
Anesthesia 2 7.1 4 14.3
Total experience in ICU
6–23 months 16 57.1 10 35.7 1.788 0.285
>2 year 12 42.9 18 64.3
Working hours per week
40–48 h 15 53.6 13 46.4 1.143 0.285
>49 h 13 46.4 15 53.6
Satisfaction with ICU
Yes 18 64.3 19 67.9 0.080 0.778
No 10 35.7 9 32.1

X = Mean, SD: Standard deviation, *Chi-square test p < 0,05, **No Chi-square analysis could be conducted due to the values being less than 5.

Please cite this article as: B. Ozgundondu and Z. Gok Metin, Effects of progressive muscle relaxation combined with music on stress, fatigue, and coping
styles among intensive care nurses, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.07.007
 B. Ozgundondu, Z. Gok Metin / Intensive & Critical Care Nursing xxx (xxxx) xxx 7

Table 2
Comparison of PSS scores between the groups (N = 56).

PSS Intervention Group (n = 28) Control Group (n = 28) Test statistic* p-value
Median (25th–75th) Median (25th–75th)
Baseline 31.00 (25.50–36.00) 29.00 (26.25–33.75) 364.0 0.646
Week 4 29.00 (5.00–34.50) 30.50 (28.00–32.00) 356.0 0.554
Week 8 27.00 (25.00–29.75) 29.00 (27.00–31.75) 260.0 0.030
Week 12 30.00 (28.00–32.00) 31.00 (29.25–32.75) 197.0 0.001

PSS: Perceived Stress Scale, *Mann-Whitney U test.

Effects of PMR combined with music therapy on FSS scores of therapy, and relaxation to reduce the perceived levels of stress
participants amongst ICU nurses (Mehrabi et al., 2012; Pahlavanzadeh et al.,
2016). This study combined PMR and music therapy and became
The mean total FSS scores of the participants in the intervention the pioneer study to investigate the effects of these interventions
group were as follows: 42.4 at the baseline, 41.1 at week 4, 30.8 at on the stress levels amongst nurses working in ICUs. At the end
week 8 and 22.6 at week 12 of the study. The corresponding scores of the monitoring period, data analysis revealed that the perceived
for the control group were 45.3, 43.6, 42.8, and 41.7, respectably. In stress scores had significantly reduced in the intervention group,
regard to the comparison of the total FSS scores between the study and the beneficial effects of PMR combined with music continued
groups, statistical testing revealed no significant difference for the until the follow-up assessment at week 12 of the study. This find-
baseline and week 4 assessments, while a significant reduction was ing supported the first hypothesis established by us, and also coin-
observed in favour of the intervention group (p < 0.05) at weeks 8 cided with the previous studies focusing on the effects of PMR on
and 12 of the study (Table 3). nurses. Steele (2018) studied the effect of one session of PMR com-
bined with music on stress levels amongst oncology nurses in a
recent randomised controlled study and reported a significant
Effects of PMR combined with music therapy on Brief COPE scores of
decrease in the perceived stress scores immediately after the inter-
participants
vention. Ploukou and Panagopoulou (2018) also reported similar
findings from their randomised controlled study conducted in the
In regard to Brief COPE scores, at the end of the monitoring per-
oncology ward, according to which, music therapy that lasted for
iod, the scores of the acceptance sub-dimension obtained for the
one month, with 60-min per week sessions, significantly reduced
intervention group were significantly higher than those obtained
the anxiety, depression and somatic scores, and improved the
for the control group at week 4, week 8 and week 12 (p < 0.05).
well-being of the participants. Lai and Li (2011) reported consis-
The intervention group also yielded significantly higher scores for
tent findings in their randomised controlled crossover trial, reveal-
coping styles in terms of the use of instrumental support, use of
ing that soothing music decreased the self-perceived stress levels
emotional support, and venting sub-dimensions, in comparison
amongst the first-line nurses. When the outcomes of all these stud-
to those observed for the CG in the 12th week of the study
ies are taken together, PMR combined with music therapy appears
(p < 0.05). Besides, the scores for the self-distraction sub-
to exert both short-term and long-term effects of reducing per-
dimension were observed to be significantly higher (p < 0.05) in
ceived stress. Additionally, Steinberg et al. (2017) revealed that a
the intervention group compared to the CG at week 4 (Table 4).
mindfulness-based intervention that included yoga, meditation,
and mindfulness developed for surgical ICU personnel decreased
Discussion the stress levels of participants in their feasibility study. Significant
decrease in the stress scores of ICU nurses observed in the present
The present study was designed as a prospective, randomised, study could be attributed to the relaxation effects of PMR and
controlled trial that examined the effects of well-established 8- music interventions which included energy restoration in the body
week interventions of PMR combined with music on stress, fatigue, and reduction of autonomic stimulation (Benson, 1975).
and coping styles among ICU nurses. Although reports exploring In addition to stress, another problem evident amongst ICU
the effects of PMR or different mind–body practices on the nurses nurses is commonly experienced fatigue. Fatigue impairs the QOL
working in different units are available in the literature, it is possi- of the nurses and also causes stress. It is noteworthy that only a
ble to state based on our knowledge that no study has been con- few trials have been conducted in the nursing population to inves-
ducted to date investigating the effects of PMR combined with tigate the effects of non-pharmacological interventions on fatigue
music on ICU nurses. severity (Anderson et al., 2017; Duarte and Pinto-Gouveia, 2016;
High stress is a major problem amongst nurses working in ICUs. Hür, 2018). Moreover, to the best of our knowledge, no study so
The literature review revealed that to date, limited studies have far has investigated the effects of PMR combined with music on
used various non-pharmacological approaches such as yoga, music fatigue severity amongst nurses working in ICUs. It was difficult

Table 3
Comparison of FSS scores between the study groups (N = 56).

FSS Intervention Group (n = 28) Control Group (n = 28) Test statistic* p-value
(XSD) (XSD)
Baseline 42.43 ± 11.83 45.36 ± 12:20 0.831 0.366
Week 4 41.18 ± 11.07 43.68 ± 10:40 0.758 0.388
Week 8 30.86 ± 10.41 42.82 ± 9:66 19.843 <0.001
Week 12 22.64 ± 6.64 41.79 ± 8:19 101.954 <0.001

FSS: Fatigue Severity Scale, X = Mean, SD: Standard deviation, *One-way ANOVA.

Please cite this article as: B. Ozgundondu and Z. Gok Metin, Effects of progressive muscle relaxation combined with music on stress, fatigue, and coping
styles among intensive care nurses, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.07.007
8 B. Ozgundondu, Z. Gok Metin / Intensive & Critical Care Nursing xxx (xxxx) xxx

Table 4
Comparison of Brief COPE scores between the study groups (N = 56).

Brief COPE Sub-dimensions Measurement time Intervention Group (n = 28) Control Group (n = 28) Test statistic* p
Median (25th–75th) Median (25th–75th)
Use of instrumental support Baseline 6.0 (5.0–7.0) 6.0 (5.0–6.0) 372.00 0.733
Week 4 6.0 (4.0–6.7) 6.0 (5.0–6.0) 350.50 0.485
Week 8 5.5 (4.0–7.0) 6.0 (5.0–6.0) 390.50 0.980
Week 12 6.5 (6.0–7.0) 6.0 (4.0–6.0) 214.00 0.003
Humour Baseline 5.0 (3.0–5.7) 4.0 (3.0–5.0) 368.00 0.689
Week 4 4.0 (3.0–5.0) 4.0 (3.0–5.0) 379.50 0.834
Week 8 4.0 (3.0–4.7) 4.0 (3.0–5.0) 344.50 0.425
Week 12 4.0 (4.0–5.0) 4.0 (3.0–5.0) 351.00 0.488
Active coping Baseline 6.5 (5.2–8.0) 6.0 (6.0–7.0) 344.50 0.420
Week 4 6.0 (6.0–7.0) 6.0 (5.2–6.0) 296.00 0.096
Week 8 6.0 (6.0–7.0) 6.0 (5.2–6.7) 323.50 0.237
Week 12 6.0 (5.2–7.0) 6.0 (6.0–6.0) 342.50 0.372
Substance use Baseline 2.0 (2.0–2.0) 2.0 (2.0–2.0) 362.00 0.461
Week 4 2.0 (2.0–2.0) 2.0 (2.0–2.0) 384.50 0.864
Week 8 2.0 (2.0–2.0) 2.0 (2.0–2.7) 371.00 0.631
Week 12 2.0 (2.0–2.0) 2.0 (2.0–2.7) 348.50 0.477
Acceptance Baseline 6.0 (5.0–7.0) 6.0 (5.0–6.7) 317.50 0.208
Week 4 6.0 (5.0–7.0) 5.0 (4.0–6.0) 250.50 0.017
Week 8 6.0 (5.0–7.0) 5.0 (4.0–6.0) 268.50 0.038
Week 12 6.0 (5.0–6.0) 5.0 (4.0–5.0) 200.00 0.001
Venting Baseline 6.0 (5.0–6.0) 5.5 (5.0–6.0) 390.00 0.973
Week 4 6.0 (5.0–6.0) 5.0 (4.2–6.0) 319.00 0.216
Week 8 6.0 (5.0–6.0) 5.0 (5.0–6.0) 323.00 0.235
Week 12 6.5 (5.2–7.0) 5.0 (5.0–6.0) 199.50 0.001
Religion Baseline 6.0 (4.5–7.0) 5.5 (4.0–7.0) 317.00 0.209
Week 4 6.0 (4.2–6.7) 5.5 (4.0–6.7) 347.00 0.446
Week 8 6.0 (6.0–6.7) 6.0 (4.2–6.0) 300.00 0.108
Week 12 6.0 (5.0–7.0) 6.0 (5.0–7.0) 360.00 0.753
Denial Baseline 4.0 (2.0–4.0) 3.5 (2.0–4.7) 377.00 0.798
Week 4 3.0 (2.2–4.0) 3.5 (3.0–4.0) 368.00 0.682
Week 8 3.5 (3.0–5.0) 3.5 (2.2–4.0) 331.00 0.302
Week 12 3.0 (3.0–4.0) 3.0 (3.0–4.0) 389.50 0.964
Behavioural disengagement Baseline 3.0 (2.0–4.0) 2.5 (2.0–4.0) 367.50 0.670
Week 4 2.0 (2.0–3.0) 2.0 (2.0–3.0) 370.50 0.697
Week 8 2.0 (2.0–3.0) 3.0 (2.0–3.0) 346.00 0.413
Week 12 2.0 (2.0–3.7) 2.0 (2.0–3.0) 351.50 0.460
Self-distraction Baseline 6.0 (5.0–7.0) 6.0 (5.0–7.0) 385.00 0.906
Week 4 6.0 (6.0–7.0) 6.0 (5.2–6.0) 272.50 0.036
Week 8 6.0 (6.0–7.0) 6.0 (5.2–7.0) 321.50 0.224
Week 12 6.0 (6.0–7.0) 7.0 (6.0–7.0) 340.00 0.361
Self-blame Baseline 5.0 (5.0–6.7) 5.0 (4.0–6.0) 320.50 0.222
Week 4 5.0 (4.0–6.0) 5.0 (4.0–5.0) 340.00 0.370
Week 8 4.0 (4.0–6.0) 4.5 (4.0–5.0) 374.00 0.758
Week 12 4.0 (4.0–5.0) 5.0 (4.0–5.0) 349.50 0.467
Positive reframing Baseline 6.0 (5.0–7.0) 6.0 (6.0–7.0) 387.00 0.932
Week 4 6.0 (5.2–7.0) 6.0 (5.0–6.7) 352.50 0.497
Week 8 6.0 (6.0–7.0) 6.0 (6.0–7.0) 332.00 0.295
Week 12 7.0 (6.0–8.0) 6.0 (6.0–7.0) 303.50 0.126
Use of emotional support Baseline 5.5 (4.2–6.0) 5.5 (4.2–6.0) 379.50 0.834
Week 4 5.0 (4.0–6.0) 6.0 (5.0–6.0) 329.00 0.288
Week 8 6.0 (5.0–7.0) 5.0 (4.0–6.0) 294.50 0.101
Week 12 6.0 (6.0–7.0) 5.0 (5.0–6.0) 233.50 0.012
Planning Baseline 7.0 (6.0–7.0) 6.0 (6.0–7.7) 342.00 0.396
Week 4 6.0 (6.0–7.0) 6.0 (5.2–6.0) 328.00 0.262
Week 8 6.0 (6.0–7.0) 6.0 (5.0–7.0) 311.00 0.160
Week 12 6.0 (6.0–7.0) 6.0 (5.2–7.0) 351.00 0.484
*
Mann-Whitney U test.

to make a direct comparison between the study findings. The anal- terms of considerable reductions in the fatigue scores. Another pre-
ysis conducted following the PMR combined with music sessions vious report stated that a 6-week awareness meditation program
revealed that fatigue severity scores were significantly reduced at conducted for oncology nurses resulted in relief from fatigue
week 8 and this beneficial effect continued until the follow-up (Duarte and Pinto-Gouveia, 2016). Taken together, all these find-
assessment at week 12 of the study, supporting our second ings indicate that non-pharmacological interventions such as
hypothesis. In line with the findings of the present study, Hür PMR, music, and meditation may exert similar beneficial effects
(2018) examined the effects of stress management training on fati- on fatigue scores in nurses. It is suggested that PMR combined
gue levels amongst ICU nurses and reported similar findings in with music approach adopted in the present study could play an

Please cite this article as: B. Ozgundondu and Z. Gok Metin, Effects of progressive muscle relaxation combined with music on stress, fatigue, and coping
styles among intensive care nurses, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.07.007
 B. Ozgundondu, Z. Gok Metin / Intensive & Critical Care Nursing xxx (xxxx) xxx 9

important role in decreasing the feeling of fatigue by providing a study evidenced benefits of PMR combined with music, and it is
pleasurable stimulus, thereby creating arousal which increases recommended that nurses integrate PMR and music interventions
nurses’ engagement during PMR. It is also suggested that music into clinical setting after participating in the related specific train-
may enhance PMR, as the movements of the relaxation technique ing programs. Future studies should examine the results using lon-
could be entrained with music, which may have ultimately gitudinal designs in nurses working in multiple settings. This study
decreased fatigue in the participants (Choi, 2010). suggests that PMR, and music therapy can provide a low-cost, fea-
In support of our third hypothesis, PMR combined with music sible, and attractive way to alleviate some of the stressors of nurses
significantly improved the coping styles in the intervention group working in high intensity settings. The authors suggest that future
in comparison to those in the CG. On the basis of the outcomes of research should explore PMR combined with music therapy for
the present study, one of the problem-focused coping strategies, other problems such as burn out syndrome, sleep disturbance,
the use of instrumental support significantly improved in the inter- and depression to provide more comprehensive support for ICU
vention group at week 12, as observed in the follow-up assess- nurses.
ment. In regard to the emotion-focused coping strategies, In conclusion, the present randomised control trial provided
acceptance was significantly used by the participants in the inter- sufficient evidence that PMR combined with music exerts benefi-
vention group at weeks 4, 8 and 12. Additionally, the self- cial effects of decreasing perceived stress and fatigue severity as
distraction sub-dimension obtained a significantly higher score in well as improving the coping styles amongst ICU nurses. According
the intervention group at week 4. Similar to the findings of the pre- to the results of the present study, it is possible to safely integrate
sent study, Mehrabi et al. (2012) reported that yoga improved PMR combined with music into clinical practice, for the manage-
problem-focused coping strategies in ICU nurses. It may, therefore, ment of stress and fatigue and to support the coping strategies of
be concluded that PMR combined with music or yoga exert posi- ICU nurses.
tive effects on improving the coping styles in ICU nurses. These
parallel findings in relation to coping style strategies could be par- Funding
tially attributed to the nature of PMR and music interventions both
of which belong to the category of non-pharmacological, relaxation The author(s) received no financial support for the research,
approaches, and have similar therapeutic components. In the liter- authorship, and/or publication of this article.
ature, problem-focused coping strategies have been frequently
used to alter or modify the fundamental cause of stress. In this con-
Ethical approval
text, nurses in the PMR combined with music intervention group
obtained greater coping scores compared to the nurses in the CG,
The study was approved by the clinical trials ethics committee
implying that they were able to cope better with their daily lives
of the University of Health Sciences, Ankara Gulhane Training and
or with ICU related stressors by following the weekly practice of
Research Hospital (decision number: 18/167–05.06.18), and was
the PMR combined with music sessions conducted in the present
performed in accordance with the Declaration of Helsinki.
study. Emotion-focused coping strategies have also been demon-
strated to take control over the individuals’ emotions (Contrada
and Baum, 2011). In this context, with improvements in the Authors’ note
emotion-focused coping strategies in the PMR combined with
music group in the present study, ICU nurses may gain certain abil- This study was master dissertation of B.O. and Z.G.M. was the
advisor.
ities in terms of self-reflection, self-expression, and processing of
their own emotions in order to achieve reappraisal of the
unchangeable stressors (Baldacchino and Draper, 2001; Stanton Declaration of Competing Interest
et al., 2000).
The authors declare they have no conflict of interest.

Limitations Acknowledgement

The findings of the present study must be interpreted in the The authors would like to thank all the nurses working in the
context of certain limitations. The PI collected the data for both ICU units of Ankara Gulhane Training and Research Hospital. With-
the control and intervention groups and administered all the inter- out the nurses’ voluntary participation, this study would not have
ventions. This could be a potential inherent bias. The study proto- been possible. The authors sincerely express their heartiest thank
col occurred over 8 weeks with only a single time follow-up, so the for receiving continuous encouragement and wholehearted sup-
long-term effects are unknown. Therefore, a study identifying the port provided by Hacettepe University, Education, Practice and
long-term effects would be better able to describe the full impact Research Center in Nursing.
of the interventions. Finally, the present study was conducted in
a single center, and the sample was confined to female nurses only,
Appendix A. Supplementary data
which makes findings difficult to generalise to all nurses working
in ICUs.
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.iccn.2019.07.007.
Conclusion
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styles among intensive care nurses, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.07.007
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Please cite this article as: B. Ozgundondu and Z. Gok Metin, Effects of progressive muscle relaxation combined with music on stress, fatigue, and coping
styles among intensive care nurses, Intensive & Critical Care Nursing, https://doi.org/10.1016/j.iccn.2019.07.007